Deck 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder

Question 1

When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of which of the following?

A) Neonatal conjunctivitis
B) Facial deformities
C) Intracranial hemorrhage
D) Incomplete myelinization

Answer 1

Intracranial hemorrhage

Question 2

The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which of the following problems?

A) Febrile seizures
B) Head trauma
C) Caput succedaneum
D) Posterior plagiocephaly

Answer 2

Head trauma

Question 3

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for which of the following?

A) Indications of increased intracranial pressure
B) An increase in the blood glucose level
C) A decrease in the liver enzymes
D) A presence of protein in the urine

Answer 3

Indications of increased intracranial pressure

Question 4

The physician has ordered rectal diazepam (Valium) for a 2-year-old boy with status epilepticus. Which of the following instructions is essential for the nurse to teach the parents?

A) Monitor their child's level of sedation.
B) Watch for fever indicating infection.
C) Gradually reduce the dosage as seizures stop.
D) Monitor for an allergic reaction to the medication.

Question 5

As a result of seizure activity, a computed tomography (CT) scan was performed and showed that an 18-month-old child has intracranial arteriovenous malformation. When developing the child's plan of care, the nurse would expect to implement actions to prevent which of the following?

A) Drug interactions
B) Developmental disabilities
C) Hemorrhagic stroke
D) Respiratory paralysis

Question 6

A 16-year-old boy complains to the school nurse of headaches and a stiff neck. Which of the following signs and symptoms would alert the nurse that the child may have bacterial meningitis?

A) Fixed and dilated pupils
B) Frequent urination
C) Sunset eyes
D) Sunlight is "too bright"

Question 7

A 4-year-old boy has a febrile seizure during a well-child visit. Which of the following would be a priority?

A) Hyperextending the child's head while placing him on his side
B) Using a tongue blade to pry open the child's jaw
C) Loosening the child's clothing to ensure a patent airway
D) Protecting the child from harm during the seizure

Question 8

The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his breath when he gets frustrated. Which of the following will be most important to include in this plan?

A) Provide cuddle time whenever the child begins to act out.
B) Explain the child's behavior to the parents.
C) Encourage the parents to interact more with the child.
D) Stay close to prevent injury when he gets frustrated.

Question 9

The nurse is caring for an 8-year-old boy who has chronic epilepsy. Which of the following would be most important to address when teaching the child and parents about living with this condition?

A) Multiple corrective surgeries to slowly remove diseased parts of his brain
B) Physical, occupational, and speech therapy to maximize his potential
C) Support for maintaining self-esteem because of his altered lifestyle
D) Hyperventilation therapy to counteract the periods of decreased oxygenation

Question 10

A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which of the following food selections would be most appropriate for his lunch?

A) Fried eggs, bacon, and iced tea
B) A hamburger on a bun, French fries, and milk
C) Spaghetti with meatballs, garlic bread, and a cola drink
D) A grilled cheese sandwich, potato chips, and a milkshake

Question 11

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands the need for this treatment is based on which of the following?

A) PaCO₂ levels decrease, causing vasoconstriction.
B) Drainage of cerebrospinal fluid occurs.
C) Activity is controlled via a stimulator.
D) Hyperexcitability of the nerves is reduced.

Question 12

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. The nurse documents this finding as:

A) Confusion
B) Obtunded
C) Stupor
D) Coma

Question 13

During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve?

A) Olfactory
B) Trigeminal
C) Facial
D) Accessory

Question 14

The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as:

A) Decorticate posturing
B) Nystagmus
C) Doll's eye
D) Sunsetting

Question 15

Which of the following would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?

A) Bradycardia
B) Cheyne-Stokes respirations
C) Fixed, dilated pupils
D) Projectile vomiting

Question 16

A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of which of the following into the discussion?

A) The child's risk for cognitive problems is greatly increased.
B) Structural damage occurs with febrile seizure.
C) The child's risk for epilepsy is now increased.
D) Febrile seizures are benign in nature.

Question 17

A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates?

A) Tonic
B) Focal clonic
C) Multifocal clonic
D) Myoclonic

Question 18

Hydrocephalus is suspected in a 4-month-old infant. Which of the following would the nurse expect to assess?

A) Sunken fontanels
B) Diminished reflexes
C) Lower extremity spasticity
D) Skull symmetry

Question 19

A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they state which of the following?

A) "Having the shunt put in decreases his risk for developmental problems."
B) "If he doesn't get an infection in the first week, the risk is greatly reduced."
C) "He will need more surgeries to replace the shunt as he grows."
D) "The shunt will help to prevent any further complications from his disease."

Question 20

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which of the following? Select all answers that apply.

A) Complaints of stiff neck
B) Photophobia
C) Absent headache
D) Negative Brudzinski sign
E) Vomiting

Question 21

A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. Which of the following would the nurse include in the child's discharge instructions?

A) "Expect his headache to get worse initially and then disappear."
B) "Wake him every 2 hours to check his movement and responses."
C) "Call your medical provider if he vomits more than five times."
D) "Any watery fluid draining from his ears is normal."

Question 22

During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, which of the following would be most important for the instructor to integrate into the response?

A) Strokes in children often have an identifiable cause.
B) The signs and symptoms in children are different from an adult.
C) Research has identified specific treatments for children.
D) Ischemic strokes are more common than hemorrhagic strokes.

Question 23

A 10-month-old is brought to the emergency department by her parents after they found her face down in the bathtub. The mother said, "I just left the bathroom to answer the phone. When I came back, I found her." Which of the following assessments would be the priority?

A) Airway, breathing, and circulation
B) Level of consciousness
C) Vital signs
D) Pupillary response