Chapter 28: The Child with a Neurological Alteration My Nursing Test Banks

Chapter 28: The Child with a Neurological Alteration

Test Bank

MULTIPLE CHOICE

1. A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences?

a.

The infant has 150 milliliters of cerebrospinal fluid compared with 50 milliliters in the adult.

b.

Papilledema is a common manifestation of increased intracranial pressure in the very young child.

c.

The brain of a term infant weighs less than half of the weight of the adult brain.

d.

Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

ANS: D

Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the childs coordination and fine muscle movements. An infant has about 50 milliliters of cerebrospinal fluid compared with 150 milliliters in an adult. Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of increased intracranial pressure. The brain of the term infant is two-thirds the weight of an adults brain.

DIF: Cognitive Level: Comprehension REF: p. 733

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

2. A nurse is assessing a 1-year-old child for increased intracranial pressure (ICP). Which sign should the nurse assess for with this age of child?

a.

Headache

b.

Bulging fontanel

c.

Tachypnea

d.

Increase in head circumference

ANS: A

Headaches are a clinical manifestation of increased ICP in children. A change in the childs normal behavior pattern may be an important early sign of increased ICP. A bulging fontanel is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP.

DIF: Cognitive Level: Comprehension REF: p. 740

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

3. The nurse should give a child who is to have magnetic resonance imaging (MRI) of the brain which information?

a.

Your head will be restrained.

b.

You will have to drink a special fluid before the test.

c.

You will have to lie flat after the test is finished.

d.

You will have electrodes placed on your head with glue.

ANS: A

To reduce fear and enhance cooperation during the MRI, the child should be made aware that his head will be restricted to obtain accurate information. Drinking fluids is usually done for gastrointestinal procedures. A child would lie flat after a lumbar puncture, not during an MRI. Electrodes are attached to the head for an electroencephalogram.

DIF: Cognitive Level: Application REF: p. 737

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

4. A child with spina bifida is being admitted to the hospital for a shunt revision? The nurse admitting the child anticipates which type of precautions to be ordered for the child?

a.

Latex

b.

Bleeding

c.

Seizure

d.

Isolation

ANS: A

Children with spina bifida are at high risk for developing latex allergies because of frequent exposure to latex during catheterizations, shunt placements, and other operations. The child with spina bifida does not have a risk for bleeding. Not all children with spina bifida are at risk for seizures and isolation would not be indicated in a child being admitted for a shunt revision.

DIF: Cognitive Level: Application REF: p. 744

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

5. Nursing care of the infant who has had a myelomeningocele repair should include which intervention?

a.

Securely fastening the diaper

b.

Measurement of pupil size

c.

Measurement of head circumference

d.

Administration of seizure medications

ANS: C

Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Head circumference measurement is essential because hydrocephalus can develop in these infants.

DIF: Cognitive Level: Application REF: p. 745

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

6. When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with an observable distended scalp vein, the nurse recognizes these signs as indicative of which condition?

a.

Hydrocephalus

b.

SIADH (syndrome of inappropriate antidiuretic hormone)

c.

Cerebral palsy

d.

Reyes syndrome

ANS: A

The combination of signs is strongly suggestive of hydrocephalus. SIADH would not present in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reyes syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurological deterioration occurs.

DIF: Cognitive Level: Comprehension REF: p. 746

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

7. A child is admitted to the hospital with spastic cerebral palsy. The nurse will assess for which manifestations associated with this disorder?

a.

Tremulous movements at rest and with activity

b.

Sudden jerking movement caused by stimuli

c.

Writhing, uncontrolled, involuntary movements

d.

Clumsy, uncoordinated movements

ANS: B

Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The childs muscles are very tight and any stimuli may cause a sudden jerking movement. Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy. Slow, writhing, uncontrolled, involuntary movements occur with athetoid or dyskinetic cerebral palsy. Clumsy movements and loss of coordination, equilibrium, and kinesthetic sense occur in ataxic cerebral palsy.

DIF: Cognitive Level: Comprehension REF: p. 747

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

8. Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis?

a.

CSF appears cloudy.

b.

CSF pressure is decreased.

c.

Few leukocytes are present.

d.

Glucose level is increased compared with blood.

ANS: A

In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually deceased compared with the serum glucose level.

DIF: Cognitive Level: Analysis REF: p. 760

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

9. Which would be an appropriate nursing intervention for the child with a tension headache?

a.

Assess for an aura.

b.

Maintain complete bed rest.

c.

Administer pharmacological headache relief measures.

d.

Assess for nausea and vomiting.

ANS: C

Administration of pharmacological techniques is appropriate to assist in the management of a tension headache. An aura is associated with migraines but not with tension headaches. Complete bed rest is not required. Nausea and vomiting are associated with a migraine but not with tension headaches.

DIF: Cognitive Level: Application REF: p. 766

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

10. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child?

a.

You will be on your knees with your head down on the table.

b.

You will be able to sit up with your chin against your chest.

c.

You will be on your side with the head of your bed slightly raised.

d.

You will lie on your side and bend your knees so that they touch your chin.

ANS: D

The child should lie on her side with knees bent and chin tucked into the knees. This position exposes the area of the back for the lumbar puncture. The knee-chest position is not appropriate for a lumbar puncture. An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurses body. A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture.

DIF: Cognitive Level: Application REF: p. 737

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

11. A mother reports that her child has episodes in which he appears to be staring into space. This behavior is characteristic of which type of seizure?

a.

Absence

b.

Atonic

c.

Tonic-clonic

d.

Simple partial

ANS: A

Absence seizures are very brief episodes of altered awareness. The child has a blank expression. Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms.

DIF: Cognitive Level: Comprehension REF: p. 755

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

12. What is the best response to a father who tells the nurse that his son daydreams at home and his teacher has observed this behavior at school?

a.

Your son must have an active imagination.

b.

Can you tell me exactly how many times this occurs in one day?

c.

Tell me about your sons activity when you notice the daydreams.

d.

He is probably getting tired and needs a rest.

ANS: C

The daydream episodes are suggestive of absence seizures and data about activity associated with the daydreams should be obtained. Suggesting that the child has an active imagination does not address the childs symptoms or the fathers concern. The number of times the behavior occurs is consistent with absence seizures, which can occur one after the other several times a day. Determining an exact number of absence seizures is not as useful as learning about behavior before the seizure that might have precipitated seizure activity. Blaming the seizures on rest ignores both the childs symptoms and the fathers concern about the daydreaming behavior.

DIF: Cognitive Level: Application REF: p. 755

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

13. The nurse teaches parents to alert their healthcare provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures?

a.

Weight loss

b.

Bruising

c.

Anorexia

d.

Drowsiness

ANS: B

Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. Weight gain, not loss or anorexia, is a side effect of valproic acid. Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications.

DIF: Cognitive Level: Comprehension REF: p. 756

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

14. A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. Which term corresponds to this childs level of consciousness?

a.

Disoriented

b.

Obtunded

c.

Lethargic

d.

Stuporous

ANS: B

Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to the lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

DIF: Cognitive Level: Comprehension REF: p. 740|p. 742

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

15. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure?

a.

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

b.

Turn the childs body on his side.

c.

Place a padded tongue blade between the teeth.

d.

Quickly slip soft restraints on the childs wrists.

ANS: B

Positioning the child on his side will prevent aspiration. The child should be placed on a soft surface if he is not in bed; however, it would be inappropriate to leave the child during the seizure. Nothing should be inserted into the childs mouth during a seizure to prevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

DIF: Cognitive Level: Application REF: p. 759

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

16. After a tonic-clonic seizure, it would not be unusual for a child to display which symptom?

a.

Irritability and hunger

b.

Lethargy and confusion

c.

Nausea and vomiting

d.

Nervousness and excitability

ANS: B

In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. Neither irritability nor hunger is typical of the period after a tonic-clonic seizure. Nausea and vomiting are not expected reactions in the postictal period. The child will more likely be confused and lethargic after a tonic-clonic seizure.

DIF: Cognitive Level: Comprehension REF: p. 755

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

17. What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures?

a.

The child should use a soft toothbrush and floss his teeth after every meal.

b.

The child will require monitoring of his liver function while taking this medication.

c.

Dilantin should be taken with food because it causes gastrointestinal distress.

d.

The medication can be stopped when the child has been seizure free for 1 month.

ANS: A

A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child receiving Depakene (valproic acid) should have liver function studies because this anticonvulsant may cause hepatic dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

DIF: Cognitive Level: Comprehension REF: p. 756

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

18. What is the most appropriate nursing response to the father of a newborn infant with myelomeningocele who asks about the cause of this condition?

a.

One of the parents carries a defective gene that causes myelomeningocele.

b.

A deficiency in folic acid in the father is the most likely cause.

c.

Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele.

d.

There may be no definitive cause identified.

ANS: D

The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. The exact cause of most cases of neural tube defects is unknown. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.

DIF: Cognitive Level: Application REF: p. 742

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

19. Which assessment noted in an infant 1 day after placement of a ventriculoperitoneal shunt is indicative of surgical complications?

a.

Hypoactive bowel sounds

b.

Congestion in upper airways

c.

Increasing lethargy

d.

Mild incisional pain

ANS: C

A decreasing level of consciousness indicates a problem with shunt function and should be reported immediately to the neurosurgeon. Peristalsis is depressed during surgery. Hypoactive bowel sounds may be evident after surgery as peristalsis returns to its preoperative function. Congestion in the upper airways may be evident after surgery. Mild incisional pain is a normal finding in the postoperative period.

DIF: Cognitive Level: Analysis REF: p. 740

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

20. Which change in vital signs should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

a.

Rapid, shallow breathing

b.

Irregular, rapid heart rate

c.

Increased diastolic pressure with narrowing pulse pressure

d.

Confusion and altered mental status

ANS: D

The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhage, hemiparesis, and papilledema. Respiratory changes occur with increased intracranial pressure. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by an increasing rate and depth, then a decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with increased intracranial pressure. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

DIF: Cognitive Level: Comprehension REF: p. 740

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

21. The nurse should expect a child who has frequent tension-type headaches to describe his headache pain with which statement?

a.

There is a rubber band squeezing my head.

b.

Its a throbbing pain over my left eye.

c.

My headaches are worse in the morning and get better later in the day.

d.

I have a stomachache and a headache at the same time.

ANS: A

The child who has tension-type headaches may describe the pain as a band-like tightness or pressure, tight neck muscles, or soreness in the scalp. A common symptom of migraines is throbbing headache pain, typically on one side of the eye. A headache that is worse in the morning and improves throughout the course of the day is typical of increased intracranial pressure. Abdominal pain may accompany headache pain in migraines.

DIF: Cognitive Level: Application REF: p. 764

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

22. A nurse is performing a Glasgow Coma Scale assessment. Which assessment should the nurse not include?

a.

Eye opening

b.

Verbal response

c.

Sensory response

d.

Motor response

ANS: C

Sensation is not a component of the Glasgow Coma Scale. The nurse would assess eye opening, verbal response, and motor response.

DIF: Cognitive Level: Application REF: p. 741

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

23. Which statement made by an adolescent indicates an understanding about factors that can trigger migraine headaches?

a.

I should avoid loud noises because this is a common migraine trigger.

b.

Exercise can cause a migraine. I guess I wont have to take gym anymore.

c.

I think Ill get a migraine if I go to bed at 9 PM on week nights.

d.

I am learning to relax because I get headaches when I am worried about stuff.

ANS: D

Stress can trigger migraines. Relaxation therapy can help the adolescent control stress and headaches. Other precipitating factors in addition to stress include poor diet, food sensitivities, and flashing lights. Visual stimuli, not auditory stimuli, are known to be a common trigger for migraines. Exercise is not a trigger for migraines. The adolescent needs regular physical exercise. Altered sleep patterns and fatigue are common triggers for migraine headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue.

DIF: Cognitive Level: Application REF: p. 764|p. 766

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

24. What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barr syndrome (GBS)?

a.

Immunosuppressive medications

b.

Respiratory assessment

c.

Passive range-of-motion exercises

d.

Anticoagulant therapy

ANS: B

Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention, but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This would not be the priority nursing intervention.

DIF: Cognitive Level: Application REF: p. 763

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

25. A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation?

a.

Clorazepate dipotassium (Tranxene)

b.

Fosphenytoin (Cerebyx)

c.

Phenobarbital

d.

Lorazepam (Ativan)

ANS: D

Lorazepam or diazepam is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes. Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally. Fosphenytoin and phenobarbital can be given intravenously as a second round of medication if seizures continue.

DIF: Cognitive Level: Application REF: p. 759

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

26. What should be the nurses first action when a child with a head injury complains of double vision and a headache and then vomits?

a.

Immobilize the childs neck.

b.

Report this information to the physician.

c.

Darken the room and put a cool cloth on the childs forehead.

d.

Restrict the childs oral fluid intake.

ANS: B

Any indication of increased intracranial pressure should be promptly reported to the physician. Stabilizing the childs neck does not address the childs symptoms. Darkening the room and putting a cool cloth on the childs forehead may facilitate the childs comfort. It would not be the nurses first action. The childs episode of vomiting does not necessitate a fluid restriction.

DIF: Cognitive Level: Application REF: p. 750

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

MULTIPLE RESPONSE

1. Which interventions should the nurse perform if a child is having a tonic-clonic seizure? Select all that apply.

a.

Place a padded tongue blade in the childs mouth.

b.

Place the child in a supine position.

c.

Time the seizure.

d.

Restrain the child.

e.

Stay with the child.

f.

Loosen the childs clothing.

ANS: C, E, F

As a seizure begins the nurse should look at his or her watch and time the seizure. The nurse should protect the child from injury by loosening clothing at the neck and turning the child gently onto the side, removing any obstacles in the childs environment. Do not restrain the child or insert any object into the childs mouth.

DIF: Cognitive Level: Application REF: p. 759

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

2. A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply.

a.

Elevated white blood count (WBC).

b.

Decreased protein

c.

Decreased glucose

d.

Cloudy in color

e.

Increase in red blood cells (RBC).

ANS: A, C, D

The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

DIF: Cognitive Level: Analysis REF: p. 736

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

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