Deck 56: The Child With Alterations in Neurologic Function

Question 1

A child has experienced a near-drowning episode,and is admitted to the Pediatric Intensive Care Unit.The parents express guilt over the near-drowning of their child.Which is the nurse's best response?

A)"You will need to watch the child more closely."
B)"Tell me more about your feelings."
C)"The child will be fine,so don't worry."
D)"Why did you let the child almost drown?"

Answer 1

"Tell me more about your feelings."

Question 2

The nurse is planning care for a school-age child with bacterial meningitis.Which of the following should be included?

A)Keep environmental stimuli at a minimum.
B)Avoid giving pain medications that could dull sensorium.
C)Measure head circumference to assess developing complications.
D)Have the child move her head from side to side at least once every 2 hours.

Answer 2

Have the child move her head from side to side at least once every 2 hours.

Question 3

A nurse is caring for a child who has recently been diagnosed with cerebral palsy.What are the major goals of therapy for this child?

A)Reversal of degenerative processes that have occurred
B)Curing the underlying defect causing the disorder
C)Preventing the spread to individuals in close contact with the child
D)Promoting optimum development

Answer 3

Promoting optimum development

Question 4

A 2-year-old has a tonic-clonic seizure while in the hospital crib.The child's jaws are clamped.Which is the most important nursing action at this time?

A)Place a padded tongue blade between the child's jaws.
B)Stay with the child and observe his respiratory status.
C)Prepare the suction equipment.
D)Restrain the child to prevent injury.

Question 5

A nurse is caring for a 15-year-old boy who is recovering from a grade 3 concussion.Which educational statement would be important for the nurse to present to the teen's family?

A)The client should not play sports for 1 year after the concussion.
B)If the client has another concussion in the near future,recovery time should remain the same.
C)The client can experience dizziness for more than 6 weeks after the concussion.
D)Concussions usually are associated with skull fractures.

Question 6

The nurse should suspect a child has cerebral palsy if the parent makes which statement?

A)"My 6-month-old baby is rolling from back to front now."
B)"My 3-month-old hasn't smiled at me."
C)"My 8-month-old can sit without support."
D)"My 10-month-old is not walking."

Question 7

A child with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized.Which action should the nurse do first?

A)Place a continuous pulse oximetry monitor on the child.
B)Place the child in a room away from the nurse's station.
C)Allow for several visitors to remain at the child's bedside.
D)Use soft restraints if the child becomes confused.

Question 8

A lumbar puncture is done on an infant suspected to have meningitis.If the infant has bacterial meningitis,the nurse would expect the cerebral spinal fluid to show what result?

A)An elevated white blood cell count
B)An elevated red blood cell count
C)Normal glucose
D)A decreased white blood cell count

Question 9

A child has sustained a traumatic brain injury,and is being monitored in the pediatric intensive care unit.The nurse is using the Glasgow Coma Scale to assess the child.Which assessments will be included? Select all that apply.

A)Eye opening
B)Verbal response
C)Motor response
D)Head circumference
E)Pulse oximetry

Question 10

A child has been diagnosed with epilepsy,and is on daily phenytoin (Dilantin).Which client education should the nurse include?

A)Fluid intake
B)Good dental hygiene
C)A decrease in vitamin D intake
D)Taking the medication with milk

Question 11

A child has sustained a basilar skull fracture.For which complication should the nurse assess?

A)Cerebral spinal fluid leakage from the nose or ears
B)Headache
C)Transient confusion
D)Periorbital ecchymosis

Question 12

An infant has just been born with a myelomeningocele.The infant has been admitted to the neonatal intensive care unit.Upon noticing the nursing tech preparing an open crib for this infant,the nurse should:

A)Not say anything;the tech is doing an appropriate action.
B)Stop the tech and ask her to prepare a warmer for this infant.
C)Remind the tech to include adequate warm blankets in the crib.
D)Ask the tech to place a hat and warm gown for the infant in the crib.

Question 13

Which is an important nursing intervention when caring for an infant with a myelomeningocele in the preop stage?

A)Place infant supine to decrease pressure on the sac.
B)Apply a heat lamp to facilitate drying and toughening of the sac.
C)Measure head circumference daily to identify developing hydrocephalus.
D)Apply a diaper to prevent contamination of the sac.

Question 14

A child with a myelomeningocele corrected at birth is now 5 years old.What is a priority nursing diagnosis for a child with corrected spina bifida at this age?

A)Risk for infection
B)Risk for impaired tissue perfusion-cranial
C)Risk for altered urinary elimination
D)Risk for altered comfort