Chapter 45: Cerebral Dysfunction Nursing School Test Banks

Chapter 45: Cerebral Dysfunction

MULTIPLE CHOICE

1. Which term is used to describe a childs level of consciousness when the child can be aroused with stimulation?

a.

Stupor

c.

Obtundation

b.

Confusion

d.

Disorientation

ANS: C

Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.

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

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

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

a.

Coma

c.

Obtundation

b.

Stupor

d.

Persistent vegetative state

ANS: B

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

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

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

3. 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.

Intracranial pressure (ICP) and level of consciousness.

ANS: B

The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not part of the Glasgow Coma Scale.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1418-1419

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

4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as:

a.

Eye trauma.

c.

Severe brainstem damage.

b.

Neurosurgical emergency.

d.

Indication of brain death.

ANS: B

The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1420

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

5. Which test is never performed on a child who is awake?

a.

Oculovestibular response

b.

Dolls head maneuver

c.

Funduscopic examination for papilledema

d.

Assessment of pyramidal tract lesions

ANS: A

The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Dolls head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1421

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

6. The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which statement should the nurse include?

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

For CT scans, the child will not be allowed to move and must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure.

PTS: 1 DIF: Cognitive Level: Application REF: 1422-1424

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

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

a.

Nuclear brain scan

c.

Computed tomography (CT) scan

b.

Echoencephalography

d.

Magnetic resonance imaging (MRI)

ANS: C

A CT scan provides visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and tissue discrimination that is unavailable with any other techniques.

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

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

8. The priority nursing intervention when a child is unconscious after a fall is to:

a.

Establish an adequate airway.

b.

Perform neurologic assessment.

c.

Monitor intercranial pressure.

d.

Determine whether a neck injury is present.

ANS: A

Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1425

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

9. Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema?

a.

Mannitol

c.

Atropine sulfate

b.

Epinephrine hydrochloride

d.

Sodium bicarbonate

ANS: A

For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1426

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

10. Which statement is most descriptive of a concussion?

a.

Petechial hemorrhages cause amnesia.

b.

Visible bruising and tearing of cerebral tissue occur.

c.

It is a transient, reversible neuronal dysfunction.

d.

A slight lesion develops remote from the site of trauma.

ANS: C

A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.

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

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

11. Which type of fracture describes traumatic separation of cranial sutures?

a.

Basilar

c.

Diastatic

b.

Compound

d.

Depressed

ANS: C

Diastatic skull fractures are traumatic separations of the cranial sutures. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture has the bone exposed through the skin. A depressed fracture has the bone pushed inward, causing pressure on the brain.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1456

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

12. 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

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. 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: 1431

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

13. The nurse should recommend medical attention if a child with a slight head injury experiences:

a.

Sleepiness.

c.

Headache, even if slight.

b.

Vomiting, even once.

d.

Confusion or abnormal behavior.

ANS: D

Medical attention should be sought if the child exhibits confusion or abnormal behavior; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.

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

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

14. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect?

a.

Brainstem

c.

Subdural hemorrhage

b.

Skull fracture

d.

Epidural hemorrhage

ANS: A

Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1431

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

15. A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she seems fine. The nurse should explain that the toddler:

a.

May have a brain injury.

c.

May start having seizures.

b.

Needs this because of her age.

d.

Probably has a skull fracture.

ANS: A

The childs history of the fall, brief loss of consciousness, and vomiting four times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the childs age, and is necessary to determine whether a brain injury has occurred.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1432

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

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

a.

Posturing.

c.

Focal neurologic signs.

b.

Vital signs.

d.

Level of consciousness.

ANS: 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. Neurologic posturing indicates neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1417

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

17. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The childs level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. The most appropriate nursing action is to:

a.

Discuss with parents the childs previous experiences with pain.

b.

Discuss with practitioner what analgesia can be safely administered.

c.

Explain that analgesia is contraindicated with a head injury.

d.

Explain that analgesia is unnecessary when child is not fully awake and alert.

ANS: B

A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the childs neurologic status and to promote comfort and relieve anxiety. Gathering information about the childs previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and resultant increased intracranial pressure.

PTS: 1 DIF: Cognitive Level: Application REF: 1433

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

18. 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

The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1434

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

19. A 3-year-old child is hospitalized after a near-drowning accident. The childs mother complains to the nurse, This seems unnecessary when he is perfectly fine. The nurses best reply is:

a.

He still needs a little extra oxygen.

b.

Im sure he is fine, but the doctor wants to make sure.

c.

The reason for this is that complications could still occur.

d.

It is important to observe for possible central nervous system problems.

ANS: C

All children who have a near-drowning experience should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur up to 24 hours after the incident. Stating that, He still needs a little extra oxygen does not respond directly to the mothers concern. Why is her child still receiving oxygen? The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary.

PTS: 1 DIF: Cognitive Level: Application REF: 1434

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

20. The most common clinical manifestation of brain tumors in children is:

a.

Irritability.

c.

Headaches and vomiting.

b.

Seizures.

d.

Fever and poor fine motor control.

ANS: C

Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Irritability, seizures, and fever and poor fine motor control are clinical manifestations of brain tumors, but headaches and vomiting are the most common.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1436

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

21. Which statement best describes a neuroblastoma?

a.

Diagnosis is usually made after metastasis occurs.

b.

Early diagnosis is usually possible because of the obvious clinical manifestations.

c.

It is the most common brain tumor in young children.

d.

It is the most common benign tumor in young children.

ANS: A

Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1438

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

22. The mother of a 1-month-old infant tells the nurse that she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on knowing that:

a.

Meningitis rarely occurs during infancy.

b.

Often a genetic predisposition to meningitis is found.

c.

Vaccination to prevent all types of meningitis is now available.

d.

Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.

ANS: D

H. influenzae type B meningitis has virtually been eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.

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

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

23. The vector reservoir for agents causing viral encephalitis in the United States is:

a.

Tarantula spiders.

c.

Carnivorous wild animals.

b.

Mosquitoes and ticks.

d.

Domestic and wild animals.

ANS: B

Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes and ticks. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1443

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

24. What action may be beneficial in reducing the risk of Reyes syndrome?

a.

Immunization against the disease

b.

Medical attention for all head injuries

c.

Prompt treatment of bacterial meningitis

d.

Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza

ANS: D

Although the etiology of Reyes syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reyes syndrome; thus use of aspirin is avoided. No immunization currently exists for Reyes syndrome. Reyes syndrome is not correlated with head injuries or bacterial meningitis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1445

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

25. When taking the history of a child hospitalized with Reyes syndrome, the nurse should not be surprised that a week ago the child had recovered from:

a.

Measles.

c.

Meningitis.

b.

Varicella.

d.

Hepatitis.

ANS: B

Most cases of Reyes syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reyes syndrome.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1445

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

26. When caring for the child with Reyes syndrome, the priority nursing intervention is to:

a.

Monitor intake and output.

c.

Observe for petechiae.

b.

Prevent skin breakdown.

d.

Do range-of-motion (ROM) exercises.

ANS: A

Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing ROM exercises are important interventions in the care of a critically ill or comatose child. Careful monitoring of intake and output is a priority.

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

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

27. A young childs parents call the nurse after their child was bitten by a raccoon in the woods. The nurses recommendation should be based on knowing that:

a.

The child should be hospitalized for close observation.

b.

No treatment is necessary if thorough wound cleaning is done.

c.

Antirabies prophylaxis must be initiated.

d.

Antirabies prophylaxis must be initiated if clinical manifestations appear.

ANS: C

Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible. Hospitalization is not necessary. The wound cleansing, passive immunization, and immune globulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1444

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

28. A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurses best response is:

a.

Epilepsy is easily treated.

b.

Very few children have actual epilepsy.

c.

The seizure may or may not mean that your child has epilepsy.

d.

Your child has had only one convulsion; it probably wont happen again.

ANS: C

Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The treatment of epilepsy involves a thorough assessment to determine the type of seizure the child is having and the cause of events, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not make generalized comments like Very few children have actual epilepsy and Your child has had only one convulsion; it probably wont happen again until further assessment is made.

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

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

29. Which type of seizure involves both hemispheres of the brain?

a.

Focal

c.

Generalized

b.

Partial

d.

Acquired

ANS: C

Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electrical discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. 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: 1446

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

30. The initial clinical manifestation of generalized seizures is:

a.

Being confused.

c.

Losing consciousness.

b.

Feeling frightened.

d.

Seeing flashing lights.

ANS: C

Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1447

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

31. Which type of seizure may be difficult to detect?

a.

Absence

c.

Simple partial

b.

Generalized

d.

Complex partial

ANS: A

Absence seizures may go unrecognized because little change occurs in the childs behavior during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1447

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

32. An important nursing intervention when caring for a child who is experiencing a seizure is to:

a.

Describe and record the seizure activity observed.

b.

Restrain the child when seizure occurs to prevent bodily harm.

c.

Place a tongue blade between the teeth if they become clenched.

d.

Suction the child during a seizure to prevent aspiration.

ANS: A

When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in his or her mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on his or her side, facilitating drainage.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1433

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

33. Which clinical manifestations would suggest hydrocephalus in a neonate?

a.

Bulging fontanel and dilated scalp veins

b.

Closed fontanel and high-pitched cry

c.

Constant low-pitched cry and restlessness

d.

Depressed fontanel and decreased blood pressure

ANS: A

Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1457

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

34. 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

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. Drinking fluids is usually done for neurologic procedures. A child should lie flat after a lumbar puncture, not after an MRI. Electrodes are attached to the head for an electroencephalogram.

PTS: 1 DIF: Cognitive Level: Application REF: 1458

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

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

a.

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

b.

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

c.

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

d.

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

ANS: D

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

PTS: 1 DIF: Cognitive Level: Application REF: 1440

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

36. The nurse has received report on four children. Which child should the nurse assess first?

a.

A school-age child in a coma with stable vital signs

b.

A preschool child with a head injury and decreasing level of consciousness

c.

An adolescent admitted after a motor vehicle accident who is oriented to person and place

d.

A toddler in a persistent vegetative state with a low-grade fever

ANS: B

The nurse should assess the child with a head injury and decreasing level of consciousness (LOC) first. Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his or her surroundings would be of least worry to the nurse.

PTS: 1 DIF: Cognitive Level: Application REF: 1418

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

37. The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record?

a.

8

c.

13

b.

11

d.

15

ANS: D

The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patients level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15.

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

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

38. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death?

a.

Papilledema

c.

Dolls head maneuver

b.

Delirium

d.

Periodic and irregular breathing

ANS: D

Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Delirium is a state of mental confusion and excitement marked by disorientation to time and place. The dolls head maneuver is a test for brainstem or oculomotor nerve dysfunction.

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

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

39. An appropriate nursing intervention when caring for an unconscious child should be to:

a.

Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP).

b.

Avoid using narcotics or sedatives to provide comfort and pain relief.

c.

Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.

d.

Give tepid sponge baths to reduce fever because antipyretics are contraindicated.

ANS: C

Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The childs position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.

PTS: 1 DIF: Cognitive Level: Application REF: 1424

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

40. A 10-year-old boy has been hit by a car while riding his bicycle in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be to:

a.

Place on side.

c.

Stabilize neck and spine.

b.

Take blood pressure.

d.

Check scalp and back for bleeding.

ANS: C

After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The childs position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding.

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

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

41. A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests:

a.

Diabetic coma.

c.

Upper respiratory tract infection.

b.

Brainstem injury.

d.

Leaking of cerebrospinal fluid (CSF).

ANS: D

Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved.

PTS: 1 DIF: Cognitive Level: Application REF: 1432

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

42. A child has been seizure-free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which intervention in the response?

a.

Medications can be discontinued at this time.

b.

The child will need to take the drugs for 5 years after the last seizure.

c.

A stepwise approach will be used to reduce the dosage gradually.

d.

Seizure disorders are a lifelong problem. Medications cannot be discontinued.

ANS: C

A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure-free for 2 years and has a normal electroencephalogram. Medications must be gradually reduced to minimize the recurrence of seizures. Seizure medications can be safely discontinued. The risk of recurrence is greatest within the first year.

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

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

MULTIPLE RESPONSE

43. The treatment of brain tumors in children consists of which therapies (Select all that apply)?

a.

Surgery

b.

Bone marrow transplantation

c.

Chemotherapy

d.

Stem cell transplantation

e.

Radiation

f.

Myelography

ANS: A, C, E

Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow, stem cell, and myelographuy are transplantation therapies are not used to treat brain tumors in children.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1436

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

44. Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply):

a.

Low-pitched cry.

b.

Sunken fontanel.

c.

Diplopia and blurred vision.

d.

Irritability.

e.

Distended scalp veins.

f.

Increased blood pressure.

ANS: C, D, E

Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1417

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

45. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the childs postoperative care (Select all that apply)?

a.

Observe closely for signs of infection.

b.

Pump the shunt reservoir to maintain patency.

c.

Administer sedation to decrease irritability.

d.

Maintain Trendelenburg position to decrease pressure on the shunt.

e.

Maintain an accurate record of intake and output.

f.

Monitor for abdominal distention.

ANS: A, E, F

Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping the shunt reservoir, administering sedation, and maintaining Trendelenburg position are not interventions associated with this condition.

PTS: 1 DIF: Cognitive Level: Application REF: 1456

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

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

a.

Elevated white blood cell (WBC) count

b.

Decreased protein

c.

Decreased glucose

d.

Cloudy in color

e.

Increase in red blood cells (RBCs)

ANS: A, C, D

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

PTS: 1 DIF: Cognitive Level: Analysis REF: 1440

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

47. The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed (Select all that apply)?

a.

Headache

b.

Photophobia

c.

Bulging anterior fontanel

d.

Weak cry

e.

Poor muscle tone

ANS: C, D, E

Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1440

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

48. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)?

a.

Tachycardia

b.

Alteration in pupil size and reactivity

c.

Increased motor response

d.

Extension or flexion posturing

e.

Cheyne-Stokes respirations

ANS: B, D, E

Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1418

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

MATCHING

A 6-year-old child is having a generalized seizure in the classroom at school. Place in order the interventions the school nurse should implement, starting with the highest-priority intervention and sequencing to the lowest-priority intervention.

a.

Take vital signs.

b.

Ease child to the floor.

c.

Allow child to rest.

d.

Turn child to the side.

e.

Integrate child back into the school environment.

49. First priority

50. Second priority

51. Third priority

52. Fourth priority

53. Fifth priority

49. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 1452 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs should be taken next and the child should be allowed to rest. When feasible, the child is integrated into the environment as soon as possible.

50. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 1452 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs should be taken next and the child should be allowed to rest. When feasible, the child is integrated into the environment as soon as possible.

51. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 1452 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs should be taken next and the child should be allowed to rest. When feasible, the child is integrated into the environment as soon as possible.

52. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 1452 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs should be taken next and the child should be allowed to rest. When feasible, the child is integrated into the environment as soon as possible.

53. ANS: E PTS: 1 DIF: Cognitive Level: Application

REF: 1452 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs should be taken next and the child should be allowed to rest. When feasible, the child is integrated into the environment as soon as possible.

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