CHAPTER 32: NEUROLOGICAL ALTERATIONS My Nursing Test Banks

CHAPTER 32: NEUROLOGICAL ALTERATIONS

MULTIPLE CHOICE

1.The nurse assessing an infant finds the following signs and symptoms: sun setting eyes with sclera seen above the iris, a high-pitched cry, a bulging fontanel, dilated scalp veins, slight alteration in consciousness, and vomiting. The nurse is aware that these signs and symptoms are most consistent with:

a.

increased intracranial pressure

c.

encephalitis caused by a virus

b.

spinal cord trauma

d.

severe hypoxia

ANS: A

Feedback

A

Correct. For the child with increased intracranial pressure, the common presenting signs and symptoms may include vomiting, alteration in level of consciousness, sun setting eyes with the sclera seen above the iris, high-pitched cry, bulging fontanel, and dilated scalp veins.

B

Incorrect. These signs and symptoms are not associated with spinal cord trauma.

C

Incorrect. These signs and symptoms are not associated with encephalitis caused by a virus.

D

Incorrect. These signs and symptoms are not associated with severe hypoxia.

PTS:1REF:p. 1194 Seizures

OBJ: Cognitive Level: Application

2.An infants brain is what portion of the weight of an adults brain?

a.

one-fourth

c.

one-half

b.

one-third

d.

two-thirds

ANS: D

Feedback

A

Incorrect. An infants brain weight that is one-fourth the weight of an adults brain would warrant further evaluation.

B

Incorrect. An infants brain weight that is one-third the weight of an adults brain would warrant further evaluation.

C

Incorrect. An infants brain weight that is one-half the weight of an adults brain would warrant further evaluation.

D

Correct. At birth, the infants brain weight is approximately two-thirds the weight of an adults brain.

PTS:1REF:p. 1198 Seizures

OBJ: Cognitive Level: Comprehension

3.The nurse reporting on duty learns that the nursing unit is using the AVPU scale on one of the nurses assigned clients. The nurse recalls that the AVPU scale is used for:

a.

determining the level of pain of an intubated child

b.

measuring the weight of a child who cannot stand

c.

obtaining a measure of the level of consciousness

d.

obtaining a gross measure of intracranial pressure

ANS: C

Feedback

A

Incorrect. The AVPU scale is not used for determining pain status.

B

Incorrect. The AVPU scale is not used for determining the weight of the child.

C

Correct. The AVPU scale is used to evaluate the childs level of consciousness. AVPU is a mnemonic which represents A=alert and awake, V=responsive to verbal stimuli, P=responsive to painful stimuli, U=unresponsive.

D

Incorrect. The AVPU scale is not used in obtaining a gross measure of intracranial pressure.

PTS:1REF:p. 1199 Seizures

OBJ: Cognitive Level: Comprehension

4.You are the nurse reporting on duty. You learn during report that one of the children assigned to your care has been in status epilepticus. You will recall that status epilepticus refers to:

a.

a chronic seizure condition that is not well controlled and usually lasts for years or a lifetime

b.

a prolonged seizure or a series of convulsions there loss of consciousness occurs for at least 30 minutes

c.

an unconscious state induced by medication to keep seizures under control and give the brain a chance to rest

d.

being diagnosed with epilepsy in the past, but not having seizures for 5 or more years

ANS: B

Feedback

A

Incorrect. Status epilepticus is not typically referred to as a chronic seizure disorder.

B

Correct. Status epilepticus is a prolonged seizure or series of convulsions there loss of consciousness occurs for at least 30 minutes.

C

Incorrect. Status epilepticus is not characterized as an unconscious state induced by medications.

D

Incorrect. Status epilepticus is not defined as having a history of epilepsy without seizure activity for 5 or more years.

PTS:1REF:p. 1201 Seizures

OBJ: Cognitive Level: Comprehension

5.Refractory seizures last more than how many minutes?

a.

30

c.

50

b.

40

d.

60

ANS: D

Feedback

A

Incorrect. Refractory seizures are not characterized by seizures lasting 30 minutes.

B

Incorrect. Refractory seizures are not characterized by seizures lasting 40 minutes.

C

Incorrect. Refractory seizures are not characterized by seizures lasting 50 minutes.

D

Correct. Refractory seizures last longer than 60 minutes.

PTS:1REF:p. 1201 Seizures

OBJ: Cognitive Level: Comprehension

6.The nurse assigned to work with a child who has simple partial seizures (also called focal seizures) will most expect to find that this child has which of the following signs and symptoms before, during, or immediately after a simple partial seizure?

a.

an aura

b.

loss of consciousness for several minutes

c.

alterations in sensory perception

d.

movements involving both sides of the body

ANS: C

Feedback

A

Incorrect. Simple partial seizures, also referred to as focal seizures, are characterized by having no aura.

B

Incorrect. A loss of consciousness is not typical in a focal seizure.

C

Correct. The typical symptoms include a loss of motor or sensory function. This may include numbness, tingling, or painful sensations that begin in one area of the body and may spread out to other areas of the body.

D

Incorrect. In a simple partial seizures movements may involve one extremity and, therefore, do not necessarily involve both sides of the body.

PTS:1REF:p. 1202 Seizures

OBJ: Cognitive Level: Application

7.You are caring for a child who has a seizure that begins with tonic contractions of the fingers of the left hand. You notice the spasms progressing into tonic/clonic movements that proceed up the muscles of the left side of the body. Which of the following types of seizures will you report that this child experienced?

a.

Jacksonian

c.

sylvian

b.

Rolandic

d.

complex partial

ANS: A

Feedback

A

Correct. Jacksonian seizures are motor episodes that begin with tonic contractions of either the fingers of one hand, toes of one foot, or one side of the face. The spasms progress into tonic/clonic movements that extend up adjacent muscles of the affected extremity or side of the body.

B

Incorrect. These physical presentations are not consistent with Rolandic or sylvian seizures, which are manifested as tonic/clonic movements of the face with increased salivation and arrested speech that often occurs during sleep.

C

Incorrect. These physical presentations are not consistent with Rolandic or sylvian seizures, which are manifested as tonic/clonic movements of the face with increased salivation and arrested speech that often occurs during sleep.

D

Incorrect. Complex partial seizures are characterized by a change in mental status, followed by purposeless behaviors or assuming an unusual posture.

PTS:1REF:p. 1202 Structural Abnormalities

OBJ: Cognitive Level: Application

8.Which of the following will the nurse teach the family of a child who has tonic/clonic seizures to do then their child begins to have a seizure?

a.

Put a padded tongue blade between the childs teeth.

b.

Perform a jaw thrust and, if available, administer oxygen.

c.

Hold the child down in the bed or restrain the child.

d.

Administer a benzodiazepine by intramuscular (IM) method.

ANS: B

Feedback

A

Incorrect. A padded tongue blade should not be inserted between the childs teeth.

B

Correct. For the child with tonic/clonic seizures, it is necessary to ensure a patent airway. This is best accomplished by performing the jaw thrust. If available, oxygen should be administered because of the impaired gas exchange associated with diaphragmatic muscle rigidity.

C

Incorrect. It would not be indicated to restrain or hold the child down.

D

Incorrect. The benzodiazepines should be administered by intravenous method.

PTS:1REF:p. 1202 Structural Abnormalities

OBJ: Cognitive Level: Application

9.If you are walking with a child who begins to have a seizure, you will ease the child to the floor to prevent injury. Which of the following additional actions will you most need to take?

a.

Get the child onto a stretcher.

c.

Obtain a set of baseline vital signs.

b.

Place the child on his or her side.

d.

Put a pillow under the childs head.

ANS: B

Feedback

A

Incorrect. Getting the child onto a stretcher would not be the safest action.

B

Correct. When ambulating a child who begins to have a seizure, it is necessary to ease the child to the floor and to turn the child onto his or her side. Turning the head to the side prevents secretions from pooling in the mouth.

C

Incorrect. While obtaining a set of baseline vitals should be initiated once the child is stabilized, it would be most important to protect the childs airway.

D

Incorrect. Putting a pillow under the childs head would not prevent the pooling of secretions in the mouth and, therefore, is not recommended.

PTS:1REF:p. 1204 Structural Abnormalities

OBJ: Cognitive Level: Application

10.You are to administer phenytoin (Dilantin) IV to a child who is having a series of seizures. Which of the following things is most important for you to do?

a.

Hold the medication if the apical pulse is below 60.

b.

Administer the medication as quickly as possible.

c.

Push the medication between seizures or wait for a mild seizure.

d.

Administer at a rate no greater than 0.5-1 milligram per kilogram (mg/kg) per minute.

ANS: D

Feedback

A

Incorrect. Assessment of the apical rate is not a parameter for Dilantin administration.

B

Incorrect. Dilantin should be administered slowly, according to the recommended rate.

C

Incorrect. Dilantin administration should not be prolonged until the client is between seizures or has a mild seizure.

D

Correct. Dilantin should not be administered at a rate greater than 0.5-1 mg/kg per minute.

PTS:1REF:p. 1204 Structural Abnormalities

OBJ: Cognitive Level: Application

11.Older children and adolescents who develop hydrocephalus usually have hydrocephalus due to which of the following causes?

a.

aqueductal stenosis

b.

meningomyelocele

c.

various congenital malformations

d.

intracranial tumors, infection (meningitis), or head injury

ANS: D

Feedback

A

Incorrect. In the neonatal period and early infancy, hydrocephalus is regarded as a primary dysfunction, and aqueductal stenosis is one of the causes.

B

Incorrect. In the neonatal period and early infancy, hydrocephalus is regarded as a primary dysfunction, and meningomyelocele is one of the causes.

C

Incorrect. Noncommunicating or obstructive hydrocephalus, responsible for most occurrences in children, is secondary to various congenital malformations.

D

Correct. Older children and adolescents usually have hydrocephalus due to intracranial tumors, infection (meningitis), or head injury.

PTS:1REF:p. 1206 Structural Abnormalities

OBJ: Cognitive Level: Comprehension

12.Which of the following signs and symptoms will the nurse most likely find then assessing an infant with Arnold-Chiari malformation?

a.

difficulty sleeping, hypervigilant, and an arching of the back

b.

weakness of the leg muscles, loss of sensation in the legs, and restlessness

c.

difficulty swallowing, diminished or absent gag reflex, and respiratory distress

d.

paradoxical irritability, diarrhea, and vomiting

ANS: C

Feedback

A

Incorrect. The signs and symptoms seen in an infant with Arnold-Chiari malformation do not include difficulty sleeping, hypervigilant, and an arching of the back.

B

Incorrect. The signs and symptoms seen in an infant with Arnold-Chiari malformation do not include weakness of the leg muscles, loss of sensation in the legs, and restlessness.

C

Correct. The signs and symptoms seen in an infant with Arnold-Chiari malformation include difficulty swallowing, diminished or absent gag reflex, and respiratory distress.

D

Incorrect. The signs and symptoms seen in an infant with Arnold-Chiari malformation do not include paradoxical irritability, diarrhea, and vomiting.

PTS:1REF:p. 1206 Neurological Alterations

OBJ: Cognitive Level: Application

13.You are the nurse assigned to work with a child who has just returned from the recovery room postoperatively for placement of a shunt as a treatment for hydrocephalus. Which of the following positions will you place this child in?

a.

elevated 45 degrees in a supine position

c.

flat and lying on the operated side

b.

flat and lying on the unoperated side

d.

elevated 30 degrees and prone

ANS: B

Feedback

A

Incorrect. This child will not be elevated 45 degrees in a supine position.

B

Correct. A child who has just returned from the recovery room postoperatively for placement of a shunt as a treatment for hydrocephalus will be placed flat and lying on the unoperated side to prevent rapid CSF drainage and pressure on the valves. If CSF is drained too quickly, the child is at risk for a subdural hematoma caused by tears in the vessels secondary to the cerebral cortex pulling away from the dura.

C

Incorrect. This child will be positioned flat, but not on the operated side.

D

Incorrect. This child will not be elevated 30 degrees and prone.

PTS:1REF:p. 1209 Structural Abnormalities

OBJ: Cognitive Level: Application

14.The nurse assessing a newborn baby finds that the baby has spina bifida with the lesion located high on the spinal column. The nurse realizes that this location often means which of the following?

a.

The higher locations are often associated with additional neurological defects, especially hydrocephalus.

b.

It is easier to correct spina bifida that is higher on the spinal column.

c.

Higher lesions are less likely to involve respiratory difficulties.

d.

Higher lesions seldom involve bladder or bowel problems.

ANS: A

Feedback

A

Correct. A lesion located high on the spinal column means that the higher locations are often associated with additional neurological defects, especially hydrocephalus. The lower extremities may be partially or completely paralyzed, and the bowel and bladder may or may not be affected.

B

Incorrect. The location of the lesion is not a factor in the ease or difficulty of surgery.

C

Incorrect. Higher lesions are more likely to involve respiratory difficulties.

D

Incorrect. With higher lesions there may be renal impairment secondary to faulty kidney innervation.

PTS:1REF:p. 1210 Structural Abnormalities

OBJ: Cognitive Level: Comprehension

15.The nurse is answering questions for the parents of a newborn who has spina bifida. The parents ask then surgery can be done. Which of the following responses by the nurse is most accurate?

a.

Surgery is usually performed within the first few hours or days of life.

b.

It is possible that the spina bifida can be reduced and closed without surgery.

c.

Often the surgeons like to wait until the child is at least 2 years old to do surgery.

d.

Surgery needs to be done before the child stands and begins to walk.

ANS: A

Feedback

A

Correct. Most authorities believe that erly closure within the first few hours or days of life offers the most favorable outcome.

B

Incorrect. Spina bifida must be corrected by surgery. Immediate surgical closure reduces the risk of infection, morbidity, and mortality

C

Incorrect. Most authorities believe that early closure within the first few hours or days of life offers the most favorable outcome.

D

Incorrect. Most authorities believe that early closure within the first few hours or days of life offers the most favorable outcome.

PTS:1REF:p. 1216 Structural Abnormalities

OBJ: Cognitive Level: Application

16.The nurse working with the mother of a newborn who has spina bifida will place the priority on helping the mother with which of the following needs?

a.

emotional support for the mother

b.

understanding spina bifida completely

c.

not changing her mind about breastfeeding

d.

explaining this problem to family and friends

ANS: A

Feedback

A

Correct. Priority should be placed on providing the mother emotional support. Not only is she dealing with grief associated with not having a normal baby and the medical, social, and intellectual implications associated with spina bifida, but she is going through the postpartum period. She may be extremely emotional and vulnerable.

B

Incorrect. Initially, priority would not be placed on helping the mother understand spina bifida completely. At the time of diagnosis the initial facts are usually overwhelming. The nurse needs to help the mother sort out her feelings first.

C

Incorrect. Priority would not be placed on the mothers decision to breastfeed or bottle feed.

D

Incorrect. Explaining this problem to family and friends does not address the mothers needs.

PTS:1REF:p. 1217 Infections

OBJ: Cognitive Level: Application

17.The pediatric nurse is assigned to work with a child who has craniosynostosis. The nurse will most expect to find which of the following during the initial contact and assessment?

a.

hydrocephalus

c.

signs of infection

b.

skull deformity

d.

cyanosis

ANS: B

Feedback

A

Incorrect. Increased intracranial pressure (ICP) is seen in children with more than one prematurely fused suture, but this does not necessarily result in hydrocephalus.

B

Correct. The nurse will expect to find skull deformity in the child who has craniosynostosis. Craniosynostosis is the premature closure of the cranial sutures. When this occurs, bone growth will continue but in a direction parallel to the suture line, leading to compensatory overgrowth at the normal suture lines and skull deformity.

C

Incorrect. Signs of infection would not be an expected finding prior to surgical correction.

D

Incorrect. Cyanosis would not be an expected finding because there is not an excess of deoxygenated hemoglobin in the blood.

PTS:1REF:p. 1218 Neurological Injuries

OBJ: Cognitive Level: Comprehension

18.When assessing neonates, the nurse will keep in mind that children with arteriovenous malformation will have which of the following initial signs?

a.

altered state of consciousness

b.

pallor to pale jaundice, abdominal pain, and loss of appetite

c.

congestive heart failure, cardiomegaly, and a cerebral bruit

d.

significant difference in blood pressure in the left and right arms

ANS: C

Feedback

A

Incorrect. An altered state of consciousness is not an initial sign in children with arteriovenous malformation.

B

Incorrect. The initial signs in children with arteriovenous malformation do not include pallor to pale jaundice, abdominal pain, and loss of appetite.

C

Correct. The initial signs in children with arteriovenous malformation include congestive heart failure, cardiomegaly, and a cerebral bruit.

D

Incorrect. The initial sign in children with arteriovenous malformation does not include significant difference in blood pressure in the left and right arms.

PTS:1REF:p. 1220 Neurological Injuries

OBJ: Cognitive Level: Application

19.If a child has a headache described as migraine-like and also has a seizure, the nurse should have a high suspicion of:

a.

ruptured cerebral aneurysm

c.

astrocytoma

b.

arteriovenous malformation

d.

hydrocephalus

ANS: B

Feedback

A

Incorrect. Signs of a ruptured cerebral aneurysm would result in symptoms similar to a stroke.

B

Correct. If a child has a headache described as migraine-like and also has a seizure, the nurse should have a high suspicion of arteriovenous malformation. In children, a seizure is often the first sign of a neurological problem.

C

Incorrect. An astrocytoma is a type of brain tumor with manifestations of seizures, increased ICP, visual changes, and hemiparesis.

D

Incorrect. The nurse would not have a high suspicion of hydrocephalus.

PTS:1REF:p. 1221 Neurological Injuries

OBJ: Cognitive Level: Application

20.A parent asks the school nurse why she should not give her children aspirin for a fever. When the nurse replies that it has to do with the possible risk of a child getting Reyes syndrome while taking aspirin, the parents asks: What is Reyes syndrome? Which of the following responses by the nurse would most accurately describe Reyes syndrome?

a.

fatal or near-fatal condition involving the circulatory system and the nervous system

b.

an unusual allergy-like reaction to aspirin while in a mild immunosuppressed condition following an illness

c.

a neurological reaction to aspirin that can cause paralysis to the alveoli and bring respiratory distress

d.

a life-threatening condition following a mild viral illness, in which there is liver enlargement and cerebral edema

ANS: D

Feedback

A

Incorrect. Reyes syndrome is not a fatal or near-fatal condition involving the circulatory system and the nervous system.

B

Incorrect. Reyes syndrome is not an unusual allergy-like reaction to aspirin while in a mild immunosuppressed condition following an illness.

C

Incorrect. Reyes syndrome is not a neurological reaction to aspirin that can cause paralysis to the alveoli and bring respiratory distress.

D

Correct. Reyes syndrome is a life-threatening encephalopathy following a mild viral illness, in which there is liver enlargement and cerebral edema. The liver becomes enlarged and assumes a yellow hue caused by fatty deposits in its microvasculature. At the same time cerebral edema with accompanying increased intracranial pressure becomes evident.

PTS:1REF:p. 1221 Neurological Injuries

OBJ: Cognitive Level: Application

21.A parent asks the nurse to explain what causes encephalitis, because a child in the neighborhood has come down with it. Which of the following answers by the nurse would be most accurate?

a.

It is caused by a specific type of fly often found in and near horse barns.

b.

Mosquito bites are the usual cause and call for the neighborhood to request spraying and draining of stagnant water sources.

c.

After the neonatal period it is usually caused by a virus, most commonly herpes type I, herpes simplex, but can be caused by other organisms.

d.

Cat scratch fever has become one of the major causes of encephalitis, so be sure your child does not play with any of the neighborhood cats.

ANS: C

Feedback

A

Incorrect. Encephalitis is not caused by a specific type of fly often found in and near horse barns. Most infections are caused by viruses.

B

Incorrect. Encephalitis can be caused by mosquitoes, but it is not the usual cause.

C

Correct. Encephalitis can be caused by direct invasion of the CNS by a virus or postinfectious involvement of the CNS after a viral disease. After the neonatal period it is usually caused by a virus, most commonly herpes type I, herpes simplex, but can be caused by other organisms, such as bacteria, spirochetes, fungi, and protozoa.

D

Incorrect. Cat scratch fever can cause encephalitis, but it is not the major cause. It usually follows the scratch or bite of a cat or kitten and is caused by bacteria.

PTS:1REF:p. 1229 Neurological Injuries

OBJ: Cognitive Level: Comprehension

22.Head injuries are categorized as primary or secondary in nature. Which of the following injuries is an example of both primary and secondary head injury?

a.

hitting the windshield of a car that was hit from behind

b.

being hit with a baseball bat

c.

falling out of a tree onto a hard surface

d.

a severe blow in a boxing match

ANS: A

Feedback

A

Correct. Primary head injuries are those in which damage is sustained at the time of the injury and include skull fractures, contusions, and intracranial hematomas. Secondary head injuries refer to the consequences of the primary injury and include increased intracranial pressure, infection, and cerebral edema. An example of both primary and secondary head injury is hitting the windshield of a car that was hit from behind. The acceleration injury from the initial impact is called coup. The counter or deceleration injury is called contrecoup.

B

Incorrect. Being hit with a baseball bat is an example of a primary head injury producing a coup injury.

C

Incorrect. Falling out of a tree onto a hard surface is an example of a primary head injury

D

Incorrect. A severe blow in a boxing match is a primary head injury. The mechanism of injury, or external force to the head or neck, is the result of a direct blow to the head.

PTS:1REF:p. 1231 Neurological Injuries

OBJ: Cognitive Level: Application

23.Which of the following terms refers to primary and secondary head injuries?

a.

stage one and stage two

c.

alpha and beta

b.

coup and contra coup

d.

traumatic and nontraumatic

ANS: B

Feedback

A

Incorrect. Stage one and stage two do not refer to primary and secondary head injuries.

B

Correct. The terms coup and contra coup refer to primary and secondary head injuries.

C

Incorrect. The terms alpha and beta do not refer to primary and secondary head injuries.

D

Incorrect. The terms traumatic and nontraumatic do not refer to primary and secondary head injuries.

PTS:1

REF: p. 1232 Clinical Manifestations and Assessment of Altered Neurological Status

OBJ: Cognitive Level: Comprehension

24.Which of the following findings constitutes a grave preterminal sign in the head-injured child?

a.

bradycardia followed by tachycardia

b.

increasingly frequent episodes of hypertension

c.

nausea and vomiting

d.

severe migraine-type headache

ANS: A

Feedback

A

Correct. A grave preterminal sign in the head-injured child is bradycardia followed by tachycardia. Heart rate is an index of brain stem functions. Bradycardia is frequently associated with ICP. However, tachycardia (sign of blood or fluid loss, hypovolemic shock, hypoxia, anxiety or pain) following bradycardia is a grave preterminal sign.

B

Incorrect. Increasingly frequent episodes of hypertension are not a grave preterminal sign in the head-injured child. Hypertension alone may indicate pain, anxiety, or a preexisting condition.

C

Incorrect. The child with a moderate head injury may complain of nausea and vomit, but these symptoms are not a grave preterminal sign.

D

Incorrect. A severe migraine-type headache is not a grave preterminal sign but may indicate a moderate head injury.

PTS:1REF:p. 1237 Neurological Injuries

OBJ: Cognitive Level: Application

25.Which of the following is the classic sign of intensely high intracranial pressure and risk for brain herniation?

a.

projectile vomiting and severe headache

b.

veins that stand out noticeably on the face and the neck

c.

severe earache as well as neck and facial pain

d.

one dilated pupil and contralateral spasticity or flaccidity

ANS: D

Feedback

A

Incorrect. Projectile vomiting and severe headache are not classic signs of intensely high intracranial pressure, and the child is not at risk for brain herniation.

B

Incorrect. Veins that stand out noticeably on the face and the neck are not classic signs of intensely high intracranial pressure, and the child is not at risk for brain herniation.

C

Incorrect. Severe earache as well as neck and facial pain are not classic signs of intensely high intracranial pressure, and the child is not at risk for brain herniation.

D

Correct. The child with one dilated pupil and contralateral spasticity or flaccidity displays the classic sign of intensely high intracranial pressure and risk for brain herniation.

PTS:1REF:p. 1237 Neurological Injuries

OBJ: Cognitive Level: Application

26.A child has a total Glasgow score of 6 and a motor score of 2. The nurse realizes that this child has which of the following types of head injury in terms of severity?

a.

mild

c.

normal

b.

moderate

d.

severe

ANS: D

Feedback

A

Incorrect. A child with a total Glasgow score from 13 to 15 or a motor score of 6 has a mild head injury.

B

Incorrect. A child with a total Glasgow score from 9 to 12 or a motor score from 4 to 5 has a moderate head injury.

C

Incorrect. A normal Glasgow score is a total of 15 with a motor score of 6.

D

Correct. A child with a total Glasgow score of 6 or a motor score of 2 has a severe head injury.

PTS:1REF:p. 1237 Neurological Injuries

OBJ: Cognitive Level: Application

27.Which of the following medications is most likely to be given during the initial phase of increased intracranial pressure to shrink brain volume?

a.

mannitol (Osmitrol)

c.

nimodipine (Nimotop)

b.

magnesium sulfate

d.

pyridostigmine bromide (Mestinon)

ANS: A

Feedback

A

Correct. Mannitol (Osmitrol), a potent diuretic, is most likely to be given during the initial phase of increased intracranial pressure to shrink brain volume.

B

Incorrect. Magnesium sulfate will not be given during the initial phase of increased intracranial pressure to shrink brain volume. Magnesium sulfate is used to prevent and treat hypomagnesemia, to manage seizures and hypertension, and as a bronchodilator.

C

Incorrect. Nimodipine (Nimotop) will not be given during the initial phase of increased intracranial pressure to shrink brain volume. Nimodipine is a calcium channel blocker used to improve neurological deficits due to spasm following subarachnoid hemorrhage.

D

Incorrect. Pyridostigmine bromide (Mestinon) will not be given during the initial phase of increased intracranial pressure to shrink brain volume. Pyridostigmine bromide is used to treat myasthenia gravis.

PTS:1REF:p. 1238 Neurological Injuries

OBJ: Cognitive Level: Comprehension

28.The nurse administering mannitol (Osmitrol) must observe closely for a rebound effect of the intracranial pressure. If there is a rebound effect with mannitol, which of the following courses of action does the nurse need to take?

a.

Call neurosurgery at once.

b.

Leave a message for the physician at his or her office.

c.

Write a nursing order for vital signs every 4 hours.

d.

Start an intravenous infusion of Ringers lactate.

ANS: A

Feedback

A

Correct. In some children there may be a rebound effect with mannitol as it may increase cerebral blood flow. If this occurs, the signs of ICP will reappear with more intensity than originally noted. The nurse should call neurosurgery at once so other modalities to control the pressure can be initiated.

B

Incorrect. The nurse should not leave a message for the physician at his or her office because increased ICP must be treated immediately.

C

Incorrect. The nurse should not write a nursing order for vital signs every 4 hours.

D

Incorrect. The nurse should not start an intravenous infusion of Ringers lactate.

PTS:1REF:p. 1238 Diagnostics

OBJ: Cognitive Level: Application

29.The nurse is assessing for pain in the chemically paralyzed child who is intubated. Which of the following methods will the nurse use for assessing pain?

a.

a picture chart

b.

pen and paper

c.

the parents intuition about their childs pain

d.

increase in pulse and blood pressure

ANS: D

Feedback

A

Incorrect. To assess pain in the chemically paralyzed child who is intubated the nurse would not use a picture chart.

B

Incorrect. To assess pain in the chemically paralyzed child who is intubated the nurse would not use a pen and paper.

C

Incorrect. To assess pain in the chemically paralyzed child who is intubated the nurse would not ask the parents intuition about their childs pain.

D

Correct. To assess pain in the chemically paralyzed child who is intubated the nurse would watch for tachycardia, increased blood pressure, and tears.

PTS:1REF:p. 1238 Seizures

OBJ: Cognitive Level: Application

30.The nurse is working with an adolescent boy who has some neurological sequelae from a head injury. The nurse can best help the adolescent accept the disability by initiating which of the following interventions?

a.

Tell the adolescent how lucky he is to be alive and all the things he has to live for.

b.

Have the adolescent make a list of all the things he is thankful for and talk about it.

c.

Encourage ventilation for frustrations, provide positive feedback, and help set up needed support.

d.

Ask the chaplain to make an appointment to talk with this adolescent about his future.

ANS: C

Feedback

A

Incorrect. Adolescents who have some neurological sequelae from a head injury may feel they have lost control of their lives and bodies and are different from their peers. This response is inappropriate and will not help the adolescent accept the disability.

B

Incorrect. This response is inappropriate and will not help the adolescent accept the disability.

C

Correct. The nurse can best help the adolescent accept the disability by encouraging ventilation for frustrations, providing positive feedback, and helping set up needed support.

D

Incorrect. This response is inappropriate and will not help the adolescent accept the disability.

PTS:1REF:p. 1239 Seizures

OBJ: Cognitive Level: Application

31.The majority of spinal cord injuries are a result of which of the following types of trauma?

a.

motor vehicle crashes

c.

gymnastics

b.

falls

d.

bicycle accidents

ANS: A

Feedback

A

Correct. The majority of spinal cord injuries are a result of motor vehicle crashes.

B

Incorrect. The majority of spinal cord injuries are not the result of falls. Falling from heights occurs less often in children than adults.

C

Incorrect. Although sports injuries such as in gymnastics can cause spinal cord injuries, it is not the major cause.

D

Incorrect. Bicycle accidents involving automobiles hitting bicycles can cause spinal cord injuries, but it is not the major cause.

PTS:1REF:p. 1240 Seizures

OBJ: Cognitive Level: Comprehension

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