Chapter 52: The Child with a Neurologic Alteration My Nursing Test Banks

Chapter 52: The Child with a Neurologic Alteration

Test Bank

MULTIPLE CHOICE

1. What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?

a.

Headache

b.

Bulging fontanel

c.

Tachypnea

d.

Increase in head circumference

ANS: A

Feedback

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.

B

This is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel.

C

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.

D

By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1418 | Box 52-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Your head will be restrained during the procedure.

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

Feedback

A

To reduce fear and enhance cooperation during the MRI, the child should be made aware that the head will be restricted to obtain accurate information.

B

Drinking fluids is usually done for gastrointestinal procedures.

C

A child should lie flat after a lumbar puncture, not during an MRI.

D

Electrodes are attached to the head for an electroencephalogram.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1415

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

3. Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?

a.

Coma

b.

Stupor

c.

Obtundation

d.

Persistent vegetative state

ANS: B

Feedback

A

Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli.

B

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation.

C

Obtundation describes a level of consciousness in which the child is arousable with stimulation.

D

Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1419

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. The Glasgow Coma Scale consists of an assessment of

a.

Pupil reactivity and motor response

b.

Eye opening and verbal and motor responses

c.

Level of consciousness and verbal response

d.

ICP and level of consciousness

ANS: B

Feedback

A

Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale.

B

The Glasgow Coma Scale assesses eye opening, and verbal and motor responses.

C

Level of consciousness is not a part of the Glasgow Coma Scale.

D

Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1419 | Table 52-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Securely fastening the diaper

b.

Measurement of pupil size

c.

Measurement of head circumference

d.

Administration of seizure medications

ANS: C

Feedback

A

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.

B

Pupil size measurement is usually not necessary.

C

Head circumference measurement is essential because hydrocephalus can develop in these infants.

D

Seizure medications are not routinely given to infants who do not have seizures.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1422

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

6. The most common problem of children born with a myelomeningocele is

a.

Neurogenic bladder

b.

Intellectual impairment

c.

Respiratory compromise

d.

Cranioschisis

ANS: A

Feedback

A

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children.

B

Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus.

C

Respiratory compromise is not a common problem in myelomeningocele.

D

Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1423

OBJ: Nursing Process: Problem Identification

MSC: Client Needs: Physiologic Integrity

7. A recommendation to prevent neural tube defects is the supplementation of

a.

Vitamin A throughout pregnancy

b.

Multivitamin preparations as soon as pregnancy is suspected

c.

Folic acid for all women of childbearing age

d.

Folic acid during the first and second trimesters of pregnancy

ANS: C

Feedback

A

Vitamin A does not have a relation to the prevention of spina bifida.

B

Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy.

C

The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly.

D

Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1422

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

8. How much folic acid is recommended for women of childbearing age?

a.

1.0 mg

b.

0.4 mg

c.

1.5 mg

d.

2.0 mg

ANS: B

Feedback

A

1.0 mg is too low a dose.

B

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age has contributed to a reduction in the number of children with neural tube defects.

C

1.5 mg is not the recommended dosage of folic acid.

D

2.0 mg is not the recommended dosage of folic acid.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1421

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

9. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include

a.

Avoiding using any latex product

b.

Using only nonallergenic latex products

c.

Administering medication for long-term desensitization

d.

Teaching family about long-term management of asthma

ANS: A

Feedback

A

Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75% of this patient population.

B

There are no nonallergic latex products.

C

At this time, desensitization is not an option.

D

The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1422

OBJ: Nursing Process: Intervention MSC: Client Needs: Physiologic Integrity

10. When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of

a.

Hydrocephalus

b.

Syndrome of inappropriate antidiuretic hormone (SIADH)

c.

Cerebral palsy

d.

Reyes syndrome

ANS: A

Feedback

A

The combination of signs is strongly suggestive of hydrocephalus.

B

SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity.

C

The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones.

D

Reyes syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1423 | Table 52-2

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

11. What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy?

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

Feedback

A

Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy.

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.

C

Slow, writhing, uncontrolled, involuntary movements occur with athetoid or dyskinetic cerebral palsy.

D

Clumsy movements, loss of coordination, equilibrium, and kinesthetic sense occur in ataxic cerebral palsy.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1426

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. 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

Feedback

A

In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color.

B

The CSF pressure is usually increased in acute bacterial meningitis.

C

Many polymorphonuclear cells are present in CSF with acute bacterial meningitis.

D

The CSF glucose level is usually decreased compared with the serum glucose level.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1439

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

13. 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

Feedback

A

The knee-chest position is not appropriate for a lumbar puncture.

B

An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurses body.

C

A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture.

D

The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1415

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

14. A mother reports that her child has episodes where 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

Feedback

A

Absence seizures are very brief episodes of altered awareness. The child has a blank expression.

B

Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep.

C

Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups.

D

There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1434 | Box 52-5

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. 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 overtired and needs more rest.

ANS: C

Feedback

A

This response does not address the childs symptoms or the fathers concern.

B

This behavior 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.

C

The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained.

D

This response ignores both the childs symptoms and the fathers concern about the daydreaming behavior.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1434 | Box 52-5

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. The nurse teaches parents to alert their health care 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

Feedback

A

Weight gain, not loss, is a side effect of valproic acid.

B

Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding.

C

Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications.

D

Anorexia is not a side effect of valproic acid.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1435 | Table 52-3

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

17. A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this childs level of consciousness?

a.

Disoriented

b.

Obtunded

c.

Lethargic

d.

Stuporous

ANS: B

Feedback

A

Disoriented refers to lack of ability to recognize place or person.

B

Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment.

C

An individual is lethargic when he or she awakens easily but exhibits limited responsiveness.

D

Stupor refers to requiring considerable stimulation to arouse the individual.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1419

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. Which type of fractures describes traumatic separation of cranial sutures?

a.

Basilar

b.

Linear

c.

Commuted

d.

Depressed

ANS: C

Feedback

A

A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone.

B

A linear fracture includes a straight-line fracture without dura involvement.

C

Commuted skull fractures include fragmentation of the bone or a multiple fracture line.

D

A depressed fracture has the bone pushed inward, causing pressure on the brain.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1428

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

19. Which statement best describes a subdural hematoma?

a.

Bleeding occurs between the dura and the skull.

b.

Bleeding occurs between the dura and the cerebrum.

c.

Bleeding is generally arterial, and brain compression occurs rapidly.

d.

The hematoma commonly occurs in the parietotemporal region.

ANS: B

Feedback

A

An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

B

A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space.

C

An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

D

An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1428

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

20. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of nursing assessment to detect early signs of a worsening condition is

a.

Posturing

b.

Vital signs

c.

Focal neurologic signs

d.

Level of consciousness

ANS: D

Feedback

A

Neurologic posturing is indicative of neurologic damage.

B

Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

C

Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

D

The most important nursing observation is assessment of the childs level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1416

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

21. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching?

a.

I should expect my child to have a few episodes of vomiting.

b.

If I notice sleep disturbances, I should contact the physician immediately.

c.

I should expect my child to have some behavioral changes after the accident.

d.

If I notice diplopia, I will have my child rest for 1 hour.

ANS: C

Feedback

A

If the child has these clinical signs, they should be immediately reported for evaluation.

B

If the child has these clinical signs, they should be immediately reported for evaluation.

C

The parents are advised of probable posttraumatic symptoms. These include behavioral changes and sleep disturbances.

D

If the child has these clinical signs, they should be immediately reported for evaluation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1429

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

22. Which type of seizures involves both hemispheres of the brain?

a.

Focal

b.

Partial

c.

Generalized

d.

Acquired

ANS: C

Feedback

A

Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected.

B

Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex.

C

Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres.

D

A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1434 | Box 52-5

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

23. 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 standing and go for help.

b.

Turn the childs body on the side.

c.

Place a padded tongue blade between the teeth.

d.

Quickly slip soft restraints on the childs wrists.

ANS: B

Feedback

A

The child should be placed on a soft surface if he is not in bed; however, it is inappropriate to leave the child during the seizure.

B

Positioning the child on his side will prevent aspiration.

C

Nothing should be inserted into the childs mouth during a seizure to prevent injury to the mouth, gums, or teeth.

D

Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1436

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

24. After a tonic-clonic seizure, it would not be unusual for a child to display

a.

Irritability and hunger

b.

Lethargy and confusion

c.

Nausea and vomiting

d.

Nervousness and excitability

ANS: B

Feedback

A

Neither irritability nor hunger is typical of the period after a tonic-clonic seizure.

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.

C

Nausea and vomiting are not expected reactions in the postictal period.

D

The child will more likely be confused and lethargic after a tonic-clonic seizure.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1434 | Box 52-5

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

25. 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 the teeth after every meal.

b.

The child will require monitoring of renal 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

Feedback

A

A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect.

B

The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction.

C

Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food.

D

Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1435 | Table 52-3

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

26. 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

Feedback

A

The exact cause of most cases of neural tube defects is unknown. There may be a genetic predisposition, but no pattern has been identified.

B

Folic acid deficiency in the mother has been linked to neural tube defect.

C

There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1421

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

27. Which change in status 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

Feedback

A

Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length.

B

Temperature elevation may occur in children with ICP.

C

Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

D

The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1428

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

28. The nurse should expect a child who has frequent tension type of headaches to describe headache pain as

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

Feedback

A

The child who has tension type of headaches may describe the pain as a bandlike tightness or pressure, tight neck muscles, or soreness in the scalp.

B

A common symptom of migraines is throbbing headache pain, typically on one side of the eye.

C

A headache that is worse in the morning and improves throughout the course of the day is typical of ICP.

D

Abdominal pain may accompany headache pain in migraines.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1443

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

29. What is an appropriate nursing intervention for the child with a tension headache?

a.

Assess for an aura.

b.

Maintain complete bed rest.

c.

Administer pharmacologic headache relief measures.

d.

Assess for nausea and vomiting.

ANS: C

Feedback

A

An aura is associated with migraines but not with tension headaches.

B

Complete bed rest is not required.

C

Administration of pharmacologic techniques is appropriate to assist in the management of a tension headache.

D

Nausea and vomiting are associated with a migraine but not with tension headaches.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1445

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

30. Which statement 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

Feedback

A

Visual stimuli, not auditory stimuli, are known to be a common trigger for migraines.

B

Exercise is not a trigger for migraines. The adolescent needs regular physical exercise.

C

Altered sleep patterns and fatigue is a common migraine trigger for migraine headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue.

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1445

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

31. 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

Feedback

A

Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority.

B

Airway is always the number one priority. 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.

C

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.

D

Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This is not the priority nursing intervention.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1441

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

32. 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

Feedback

A

Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally.

B

Fosphenytoin can be given intravenously as a second round of medication if seizures continue.

C

Phenobarbital can be given intravenously as a second round of medication if seizures continue.

D

Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1438

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

33. 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

Feedback

A

Stabilizing the childs neck does not address the childs symptoms.

B

Any indication of ICP should be promptly reported to the physician.

C

This intervention may facilitate the childs comfort. It would not be the nurses first action.

D

The childs episode of vomiting does not necessitate a fluid restriction.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1418 | Box 52-1

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

34. 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 mL of CSF compared with 50 mL in the adult.

b.

Papilledema is a common manifestation of ICP 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

Feedback

A

An infant has about 50 mL of CSF compared with 150 mL in an adult.

B

Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP.

C

The brain of the term infant is two thirds the weight of an adults brain.

D

Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the childs coordination and fine muscle movements.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1411

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

35. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when preparing the child?

a.

Pain medication will be given.

b.

The scan will not hurt.

c.

You will be able to move once the equipment is in place.

d.

Unfortunately no one can remain in the room with you during the test.

ANS: B

Feedback

A

Pain medication is not required; however, sedation is sometimes necessary.

B

For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful.

C

The child will not be allowed to move and will be immobilized.

D

Someone is able to remain with the child during the procedure.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1415

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

36. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?

a.

Nuclear brain scan

b.

Echoencephalography

c.

CT scan

d.

MRI

ANS: C

Feedback

A

A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective.

B

Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions.

C

A CT scan provides a visualization of the horizontal and vertical cross sections of the brain at any axis.

D

MRI permits visualization of morphologic features of target structures and permits tissue discrimination that is unavailable with any other techniques.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1415

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

1. What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply.

a.

It must be given with D51/2NS.

b.

The child will require monitoring of therapeutic serum levels while taking this medication.

c.

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

d.

It must be given in normal saline.

e.

It must be filtered.

ANS: B, D, E

Feedback

Correct

The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D51/2NS. The IV dose must be filtered.

Incorrect

The IV dose must be given in normal saline, not D51/2NS. Dilantin has not been found to cause gastrointestinal upset, and since it is being given by the IV route, this is not a concern. The medication can be taken without food.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1435 | Table 52-3

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

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

Feedback

Correct

The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose.

Incorrect

The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1414

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes (select all that apply)

a.

Monitoring and maintaining systemic blood pressure

b.

Administering corticosteroids

c.

Minimizing environmental stimuli

d.

Discussing long-term care issues with the family

e.

Monitoring for respiratory complications

ANS: A, B, E

Feedback

Correct

Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury.

Incorrect

Spinal cord injury is a catastrophic event. Discussion regarding long-term care should be delayed until the child is stable.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1431

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

1. Prolonged seizure activity, in the form of either a single seizure lasting 30 minutes or recurrent seizures lasting more than 30 minutes, with no return to a normal level of consciousness is known as _________________.

ANS:

status epilepticus

The nurse caring for this patient should be aware that the causes of status epilepticus are many. Acute CNS injury from head trauma, meningitis, or electrolyte imbalance frequently precipitate status epilepticus.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1437

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

TRUE/FALSE

1. If a child has a concussion, a second concussion will have no further ill effects. Is this statement true or false?

ANS: F

A second concussion may cause more harm to the brain and even lead to possible death. The parents of a child who has experienced a concussion should be encouraged to speak to their health care provider about whether the child can return to activities or sports. This condition is known as second impact syndrome.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1429

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

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