Chapter 49: Neuromuscular or Muscular Dysfunction Nursing School Test Banks

Chapter 49: Neuromuscular or Muscular Dysfunction

MULTIPLE CHOICE

1. Spastic cerebral palsy is characterized by:

a.

Hypertonicity and poor control of posture, balance, and coordinated motion.

b.

Athetosis and dystonic movements.

c.

Wide-based gait and poor performance of rapid, repetitive movements.

d.

Tremors and lack of active movement.

ANS: A

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic/athetoid cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1572

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

2. The parents of a child with cerebral palsy ask the nurse if any drugs can decrease their childs spasticity. The nurses response should be based on knowing that:

a.

Anticonvulsant medications are sometimes useful for controlling spasticity.

b.

Medications that would be useful in reducing spasticity are too toxic for use with children.

c.

Many different medications can be highly effective in controlling spasticity.

d.

Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.

ANS: D

Baclofen given intrathecally is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are presently available for the control of spasticity.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1574

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

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

a.

Neurogenic bladder.

c.

Respiratory compromise.

b.

Intellectual impairment.

d.

Cranioschisis.

ANS: A

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1582

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

4. Which problem is most often associated with myelomeningocele?

a.

Hydrocephalus

c.

Biliary atresia

b.

Craniosynostosis

d.

Esophageal atresia

ANS: A

Hydrocephalus is an associated anomaly in 80% to 90% of children. Craniosynostosis is the premature closing of the cranial sutures and is not associated with myelomeningocele. Biliary and esophageal atresias are not associated with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1580

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

5. A current 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

The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. Vitamin A and multivitamin preparations do not have a relation to the prevention of spina bifida. Folic acid supplementation is recommended for the preconceptual period and during the pregnancy. Only 42% of women actually follow these guidelines.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1582

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

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

a.

0.1 mg

c.

1.5 mg

b.

0.4 mg

d.

2 mg

ANS: B

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age will prevent 50% to 70% of cases of neural tube defects. A dose of 0.1 mg is too low, and 1.5 mg and 2 mg are not recommended dosages of folic acid.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1582

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

7. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. The most appropriate way to position and feed this neonate is to place him:

a.

Prone and tube feed.

b.

Prone, turn head to side, and nipple feed.

c.

Supine in infant carrier and nipple feed.

d.

Supine, with defect supported with rolled blankets, and nipple feed.

ANS: B

In the prone position, feeding is a problem. The infants head is turned to one side for feeding. If the child is able to nipple feed, no indication is present for tube feeding. Before surgery, the infant is kept in the prone position to minimize tension on the sac and risk of trauma.

PTS: 1 DIF: Cognitive Level: Application REF: 1583

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

8. The nurse is talking to a parent with a child who has a latex allergy. Which statement by the parent would indicate a correct understanding of the teaching?

a.

My child will have an allergic reaction if he comes in contact with yeast products.

b.

My child may have an upset stomach if he eats a food made with wheat or barley.

c.

My child will probably develop an allergy to peanuts.

d.

My child should not eat bananas or kiwis.

ANS: D

There are cross-reactions between latex allergies and a number of foods such as bananas, avocados, kiwi, and chestnuts. Although yeast products, wheat and barley, and peanuts are potential allergens, they are currently not known to cross-react with latex.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1585

OBJ: Nursing Process: Planning 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 the family about long-term management of asthma.

ANS: 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. There are no nonallergenic latex products. At this time desensitization is not an option. 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: 1584

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

10. Which 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

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

PTS: 1 DIF: Cognitive Level: Application REF: 1572

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

11. A young boy has just been diagnosed with pseudohypertrophic (Duchennes) muscular dystrophy. The management plan should include:

a.

Recommending genetic counseling.

b.

Explaining that the disease is easily treated.

c.

Suggesting ways to limit the use of muscles.

d.

Assisting the family in finding a nursing facility to provide his care.

ANS: A

Pseudohypertrophic (Duchennes) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.

PTS: 1 DIF: Cognitive Level: Application REF: 1588

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

12. Therapeutic management of a child with tetanus includes the administration of:

a.

Nonsteroidal antiinflammatory drugs (NSAIDs) to reduce inflammation.

b.

Muscle stimulants to counteract muscle weakness.

c.

Bronchodilators to prevent respiratory complications.

d.

Antibiotics to control bacterial proliferation at the site of injury.

ANS: D

Antibiotics are administered to control the proliferation of the vegetative forms of the organism at the site of infection. Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression. Bronchodilators would not be used unless specifically indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 1592

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

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

a.

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

b.

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

c.

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

d.

There may be no definitive cause identified.

ANS: D

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

PTS: 1 DIF: Cognitive Level: Application REF: 1581

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

14. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborns defect?

a.

Fissure in the spinal column that leaves the meninges and the spinal cord exposed

b.

Herniation of the brain and meninges through a defect in the skull

c.

Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements

d.

Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves

ANS: D

A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1580

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

15. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type 1). Which signs and symptoms are associated with this disease?

a.

Spinal muscular atrophy

b.

Neural atrophy of muscles

c.

Progressive weakness and wasting of skeletal muscle

d.

Pseudohypertrophy of certain muscle groups

ANS: C

Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells. Kugelberg-Welander syndrome is a juvenile spinal muscular atrophy with a later onset. Charcot-Marie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the peroneal nerves. Progressive weakness of the distal muscles of the arms and feet is found. Duchennes muscular dystrophy is characterized by muscles, especially in the calves, thighs, and upper arms, that become enlarged from fatty infiltration and feel unusually firm or woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1585

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

16. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the morning. Which interventions should the nurse plan for the care of the myelomeningocele sac?

a.

Open to air

b.

Covered with a sterile, moist, nonadherent dressing

c.

Reinforcement of the original dressing if drainage noted

d.

A diaper secured over the dressing

ANS: B

Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not placed over the dressing because stool contamination can occur.

PTS: 1 DIF: Cognitive Level: Application REF: 1583

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

17. The nurse is admitting a school-age child with suspected Guillain-Barr syndrome (GBS). Which nursing intervention is a priority in the care for this child?

a.

Monitoring intake and output

c.

Placing on a telemetry monitor

b.

Assessing respiratory efforts

d.

Obtaining laboratory studies

ANS: B

Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory compromise, administration of intravenous immunoglobulin (IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be used. Monitoring intake and output, telemetry monitoring, and obtaining laboratory studies may be part of the plan of care but are not the priority.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1591

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

18. The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit. Which health care provider prescriptions should the nurse clarify with the health care provider before implementing?

a.

Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time.

b.

Provide total parenteral nutrition (TPN) at 25 mL/hr intravenously.

c.

Titrate oxygen to keep pulse oximetry saturations greater than 92.

d.

Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every 12 hours.

ANS: D

The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic therapy is not part of the management of infant botulism because the botulinum toxin is an intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular should not be administered because they may potentiate the blocking effects of the neurotoxin. Treatment consists of immediate administration of botulism immune globulin intravenously (BIG-IV) without delaying for laboratory diagnosis. Early administration of BIG-IV neutralizes the toxin and stops the progression of the disease. The human-derived botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in infant botulism. Approximately 50% of affected infants require intubation and mechanical ventilation; therefore, respiratory support is crucial, as is nutritional support because these infants are unable to feed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1594

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

19. A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first?

a.

Place the adolescent in a flat right side-lying position.

b.

Place a cool washcloth on the adolescents forehead and continue to monitor the blood pressure.

c.

Implement a standing prescription to empty the bladder with a sterile in-and-out Foley catheter.

d.

Take a full set of vital signs and notify the health care provider.

ANS: C

The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is relieved. Positioning the adolescent, placing a cool washcloth on the adolescents forehead, continuing to monitor blood pressure and vital signs, and notifying the health care provider would not reverse the sympathetic reflex situation.

PTS: 1 DIF: Cognitive Level: Application REF: 1598

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

20. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Which nursing care interventions are needed for this child (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

Spinal cord injury patients are physiologically labile, and close monitoring of blood pressure and respirations 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. Minimizing environmental stimuli and discussing long-term care issues with the family do not apply to providing care for this patient.

PTS: 1 DIF: Cognitive Level: Application REF: 1596

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

21. Which assessment findings should the nurse note in a school-age child with Duchennes muscular dystrophy (DMD) (Select all that apply)?

a.

Lordosis

b.

Gowers sign

c.

Kyphosis

d.

Scoliosis

e.

Waddling gait

ANS: A, B, E

Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in DMD. Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gowers sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment findings with DMD.

PTS: 1 DIF: Cognitive Level: Application REF: 1588

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

22. The nurse is conducting discharge teaching with parents of a preschool child with myelomeningocele, repaired at birth, who is being discharged from the hospital after a urinary tract infection (UTI). Which should the nurse include in the discharge instructions related to management of the childs genitourinary function (Select all that apply)?

a.

Continue to perform the clean intermittent catheterizations (CIC) at home.

b.

Administer the oxybutynin chloride (Ditropan) as prescribed.

c.

Reduce fluid intake in the afternoon and evening hours.

d.

Monitor for signs of a recurrent UTI.

e.

Administer furosemide (Lasix) as prescribed.

ANS: A, B, D

Discharge teaching to prevent renal complications in a child with myelomeningocele include: (1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of regular emptying of the bladder, such as clean intermittent catheterization (CIC) taught to and performed by parents and self-catheterization taught to children; and (3) medications to improve bladder storage and continence, such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited, and Lasix is not used to improve renal function for children with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Application REF: 1582

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

23. The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant (Select all that apply)?

a.

Temperature instability

d.

Bradycardia

b.

Irritability

e.

Hypertension

c.

Lethargy

ANS: A, B, C

The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1583

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

COMPLETION

24. A toddler is admitted to the hospital with a possible diagnosis of tetanus. The health care provider has prescribed lorazepam (Ativan) intravenously 0.05 mg/kg/dose every 6 hours prn as a muscle relaxant. The child weighs 22 lbs. How many milligrams of Ativan should the nurse administer per dose? _____ Record your answer using one decimal place.

ANS:

0.5

Find the childs weight in kilograms by dividing 22 by 2.2 = 22/2.2 = 10 kg. Multiply the 0.05-mg dose by 10 = 0.05 mg 10 kg = 0.5 mg per dose.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1593

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

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