Chapter 23: The Child with a Sensory or Neurological Condition Nursing School Test Banks

Chapter 23: The Child with a Sensory or Neurological Condition

MULTIPLE CHOICE

1. A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?
a. Infants are in a supine or prone position most of the time.
b. Sucking on a nipple creates middle ear pressure.
c. They have increased susceptibility to upper respiratory tract infections.
d. The eustachian tube is short, straight, and wide.
ANS: D
An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.

DIF: Cognitive Level: Knowledge REF: Page 525 OBJ: 2
TOP: Otitis Media KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. What statement by a patients mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?
a. I will continue using the medication until symptoms are relieved.
b. I will share the medicine with siblings if their symptoms are the same.
c. I will give the medication with a glass of milk.
d. I will administer prescribed doses until all the medication is used.
ANS: D
Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.

DIF: Cognitive Level: Application REF: Page 527, Nursing Tip
OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. Which situation would cause the nurse to suspect a hearing impairment?
a. 3-month-old infant with a positive Moro reflex
b. 15-month-old toddler who is babbling
c. 18-month-old toddler who is speaking one-syllable words
d. 24-month-old toddler who communicates by pointing
ANS: D
The child who is not making verbal attempts by 18 months should undergo a complete physical examination.

DIF: Cognitive Level: Analysis REF: Page 527-528
OBJ: 3 TOP: Hearing Impairment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
a. Use gestures and signs as much as possible.
b. Let the childs parents communicate for her.
c. Face the child and speak clearly in short sentences.
d. Recognize that the childs ability to communicate will be on a 6-year-old childs level.
ANS: C
The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.

DIF: Cognitive Level: Application REF: Page 528, Nursing Tip
OBJ: 3 TOP: Hearing Impairment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

5. What would the nurse include when planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes?
a. Keeping the infant flat after feeding
b. Giving over-the-counter decongestants
c. Avoiding getting water in the ears
d. Cleaning the ear canal with cotton-tipped applicators
ANS: C
After a tympanostomy, care should be taken to avoid getting water in the ears.

DIF: Cognitive Level: Comprehension REF: Page 527 OBJ: 2
TOP: Postoperative Care of Tympanostomy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk

6. What assessment made by the school nurse would lead to the suspicion of strabismus?
a. Reddened sclera in one eye
b. Child covers one eye to read the chalkboard
c. Child complains of a headache
d. Copious tears while watching TV
ANS: B
Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder.

DIF: Cognitive Level: Analysis REF: Page 530-531
OBJ: 4 TOP: Strabismus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. What might the nurse explain as a common treatment for amblyopia?
a. Patching the good eye to force the brain to use the affected eye
b. Patching the affected eye to allow the refractory muscles to rest
c. Using glasses that will slightly blur the image for the good eye
d. Using corticosteroids to treat inflammation of the optic nerve
ANS: A
Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.

DIF: Cognitive Level: Knowledge REF: Page 530 OBJ: 4
TOP: Amblyopia KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. What assessment does the school nurse recognize as the cardinal sign of a hyphema?
a. Opacity of the lens
b. A yellow-white reflex on the pupil
c. A dark-red spot in front of the iris
d. Inflamed mucous membranes of the eyelids
ANS: C
A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.

DIF: Cognitive Level: Knowledge REF: Page 532 OBJ: N/A
TOP: Hyphema KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching?
a. Use aspirin instead of acetaminophen for children with viral illness.
b. Advise parents to have their children immunized against Reyes syndrome.
c. Avoid giving salicylate-containing medications to a child who has viral symptoms.
d. Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy.
ANS: C
Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms.

DIF: Cognitive Level: Application REF: Page 533 OBJ: 8
TOP: Reyes Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. What symptom leads the nurse caring for a 5-month-old with viral influenza to suspect the development of Reyes syndrome?
a. Respirations drop from 18 to 14 breaths/min
b. Falling asleep after feeding
c. Sudden vomiting without effort
d. Development of a macular rash
ANS: C
A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal.

DIF: Cognitive Level: Application REF: Page 533 OBJ: 8
TOP: Reyes Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. What does the nurse explains to parents of a child with febrile seizures?
a. They occur when the body temperature exceeds 38.3 C (101 F).
b. They can be prevented by anticonvulsant medication.
c. They usually lead to the development of epilepsy.
d. They occur when the temperature rises quickly.
ANS: D
Febrile seizures occur in response to a rapid rise in temperature, often above 38.8 C (102 F).

DIF: Cognitive Level: Comprehension REF: Page 539 OBJ: 10
TOP: Febrile Seizures KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic?
a. Absence
b. Akinetic
c. Myoclonic
d. Complex partial
ANS: A
Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.

DIF: Cognitive Level: Comprehension REF: Page 540, Table 23-2
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. An adolescent has just had a generalized seizure and collapsed in the school nurses office. When should the nurse should call 911?
a. The seizure lasts more than 5 minutes.
b. The child is sleepy and lethargic after the seizure.
c. The child fell at the onset of the seizure.
d. The child is confused and has slurred speech after the seizure.
ANS: A
If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.

DIF: Cognitive Level: Application REF: Page 540, Table 23-2
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
a. Guide the child to the floor if the child is standing, and then go for help.
b. Move objects out of the childs immediate area.
c. Stick a padded tongue blade between the childs teeth.
d. Manually restrain the child.
ANS: B
During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

DIF: Cognitive Level: Application REF: Page 540, Table 23-2
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiety
ANS: B
Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.

DIF: Cognitive Level: Comprehension REF: Page 540, Table 23-2
OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
a. The medication should be given on an empty stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularly to prevent hyperplasia.
d. Blood pressure should be closely monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day.

DIF: Cognitive Level: Comprehension REF: Page 543, Figure 23-10
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed
ANS: C
Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

DIF: Cognitive Level: Comprehension REF: Page 544, Table 23-4
OBJ: 12 TOP: Cerebral Palsy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. Which assessment finding in a child with meningitis should be reported immediately?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
ANS: A
Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure.

DIF: Cognitive Level: Application REF: Page 536 OBJ: 9
TOP: Meningitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity

19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?
a. Correct anatomical position
b. Decorticate
c. Decerebrate
d. Opisthotonos
ANS: C
In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.

DIF: Cognitive Level: Application REF: Page 550, Figure 23-13
OBJ: 15 TOP: Posturing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. What will the nurse teach parents when giving instructions for acute conjunctivitis?
a. Apply cool compresses to the affected eye several times a day.
b. Instill topical steroid eye drops for 1 week.
c. Clear drainage from the inner to the outer aspect of the eye.
d. Keep the eye patched until the inflammation resolves.
ANS: C
Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).

DIF: Cognitive Level: Application REF: Page 532 OBJ: N/A
TOP: Conjunctivitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

21. A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
a. Sleepy but easily arousable
b. Complaining of a stiff neck
c. Cannot remember what happened to him
d. Pupils react sluggishly to light
ANS: C
A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

DIF: Cognitive Level: Analysis REF: Page 548-552
OBJ: 16 | 17 TOP: Head Injury KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?
a. Meningitis
b. Reyes syndrome
c. Brain tumor
d. Encephalitis
ANS: C
The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

DIF: Cognitive Level: Analysis REF: Page 538 OBJ: 10
TOP: Brain Tumor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against?
a. Encephalitis
b. Influenza
c. Bacterial meningitis
d. Otitis media
ANS: C
H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.

DIF: Cognitive Level: Knowledge REF: Page 536-537
OBJ: N/A TOP: Prevention of Meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

24. The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?
a. Temperature increase from 37.2 C (99 F) to 37.7 C (100 F)
b. Increase in blood pressure with an attendant decrease in pulse
c. Increase in respirations
d. Equilateral pupils
ANS: B
Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.

DIF: Cognitive Level: Comprehension REF: Page 552 OBJ: 14 | 17
TOP: ICP KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

25. A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected?
a. Patching the unaffected eye
b. Corrective lenses
c. Laser treatment
d. Surgery
ANS: B
In nonparalytic strabismus the refractory error is usually corrected with eyeglasses.

DIF: Cognitive Level: Comprehension REF: Page 531-532
OBJ: 5 TOP: Strabismus KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

26. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which of the following a statements by the parents alerts the nurse that they need further instruction?
a. We dress our son every morning for school.
b. Our son participates in the Special Olympics every year.
c. Our son attends play therapy at a center close to home.
d. We attend a support group once a week.
ANS: A
The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not take over projects because of their own need to assist or speed up the process.

DIF: Cognitive Level: Application REF: Page 548 OBJ: 13
TOP: Cognitive Impairment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment

27. What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants?
a. Using ear plugs during takeoff
b. Omitting the meal just before takeoff
c. Letting the infant nurse during descent
d. Applying ear drops before takeoff
ANS: C
Encouraging an infant to swallow reduces the pressure in the ears during descent.

DIF: Cognitive Level: Comprehension REF: Page 529 OBJ: 1
TOP: Barotrauma KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

MULTIPLE RESPONSE

28. Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.)
a. Hypersensitivity to noise
b. Irritability
c. Reddened ear canal
d. Rolls head from side to side
e. Temperature of 39.4 C (103 F)
ANS: B, D, E
Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.

DIF: Cognitive Level: Comprehension REF: Page 526, Nursing Tip
OBJ: 2 TOP: Indications of Ear Infection
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

29. Which aspect(s) of a childs development does the nurse caution parents that hearing impairment can affect? (Select all that apply.)
a. Speech clarity
b. Language development
c. Immunity to disease
d. Personality development
e. Academic achievement
ANS: A, B, D, E
All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.

DIF: Cognitive Level: Comprehension REF: Page 527 OBJ: 3
TOP: Hearing Impairment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

30. What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.)
a. Isolation precautions
b. Provision of brightly lit room
c. Observation for increasing intracranial pressure
d. Preparation for spinal tap
e. Seizure precautions
ANS: A, C, D, E
All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive care of a child with meningitis.

DIF: Cognitive Level: Application REF: Page 537 OBJ: 9
TOP: Nursing Care of Child with Meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

31. What will the nurse include then documenting a grand mal seizure? (Select all that apply.)
a. Presence of incontinence
b. Current dose of antispasmodic medication
c. Activity level prior to and following seizure
d. Level of consciousness following seizure
e. Length of seizure
ANS: A, C, D, E
Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.

DIF: Cognitive Level: Application REF: Page 539 OBJ: 10
TOP: Documentation of Seizure KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

32. The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.)
a. Encourage books with large type.
b. Words in books should be closely spaced.
c. Provide adequate lighting without glare.
d. Be sure desks and chairs are adequate height.
e. Instruct child to squint when reading.
ANS: A, C, D
Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height.

DIF: Cognitive Level: Comprehension REF: Page 532 OBJ: 6
TOP: Decorticate Posturing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention

33. The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow Coma Scale. What score will the nurse give if the child is babbling?
a. 1
b. 2
c. 3
d. 4
ANS: D
If babbling, the 10-month-old infant receives a score of 4 for responses.

DIF: Cognitive Level: Application REF: Page 553, Table 23-6
OBJ: 18 TOP: Neurological Monitoring/Infants
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention

34. An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.)
a. Parental education regarding prevention
b. Respiratory support
c. Cardiovascular support
d. Controlled rewarming
e. Adequate cerebral oxygenation
ANS: B, C, D, E
Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up.

DIF: Cognitive Level: Comprehension REF: Page 553-554
OBJ: 19 TOP: Near-drowning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

35. The sign that suggests possible damage to the cortex of the brain is ____________ posturing.

ANS:
decorticate

Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet. This posture suggests injury to the brain cortex.

DIF: Cognitive Level: Comprehension REF: Page 550 OBJ: 15
TOP: Decorticate Posturing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

36. The nurse records the finding of ______________ _____________ when the child with meningitis cries out in pain when his head is flexed toward his chest.

ANS:
nuchal rigidity

Stiffness of the neck resulting from inflamed meninges is a sign of meningitis called nuchal rigidity.

DIF: Cognitive Level: Comprehension REF: Page 536 OBJ: 9
TOP: Nuchal Rigidity KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

37. The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle is the __________________ nerve.

ANS:
hypoglossal

The hypoglossal (XII) nerve allows the infant to be able to suck and swallow. It is also responsible for tongue movement.

DIF: Cognitive Level: Knowledge REF: Page 535, Figure 23-7 | Page 536, Table 23-1
OBJ: 7 TOP: Cranial Nerves
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

38. __________________ occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.

ANS:
Barotrauma

Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.

DIF: Cognitive Level: Knowledge REF: Page 529 OBJ: 1
TOP: Barotrauma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

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