Deck 27: Alterations in Neurologic Function

Question 1

A lumbar puncture is performed on an infant suspected of having meningitis. Which finding does the nurse expect in the cerebral spinal fluid if the infant has meningitis?
1) Elevated WBC count
2) Elevated RBC count
3) Normal glucose
4) Decreased WBC count

Answer 1

1

Question 2

The nurse is performing an admission assessment on an infant diagnosed with hydrocephalus and a malfunctioning shunt. Which assessment findings should the nurse expect? Select all that apply.
1) Vomiting
2) Fever
3) Irritability
4) Poor appetite
5) Decreased level of consciousness

Answer 2

1, 2, 3, 4

Question 3

With a group of new parents, the nurse is reviewing treatment for viral illnesses such as influenza. Which statement by the parents indicates appropriate understanding of the teaching session?
1) "Some over-the-counter medications contain aspirin."
2) "Acetaminophen is good for treatment of fevers in young children."
3) "I can use ibuprofen as needed when my child has aches and pains."
4) "Aspirin is acceptable if my child does not have a virus."

Answer 3

1

Question 4

A child diagnosed with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized. Which nursing interventions are appropriate for this child? Select all that apply.
1) Place a continuous-pulse oximetry monitor on the child.
2) Place the child in a room near the nurse's station.
3) Allow for several visitors to remain at the child's bedside.
4) Use soft restraints if the child becomes confused.
5) Use sedation around the clock to decrease agitation.

Question 5

Which statement made by a parent during a well-child visit would cause the nurse to suspect the child has cerebral palsy?
1) "My 6-month-old baby is rolling from back to prone now."
2) "My 3-month-old seems to have floppy muscle tone."
3) "My 8-month-old can sit without support."
4) "My 10-month-old is not walking."

Question 6

A child is ready for discharge after surgery for a myelomeningocele repair. Before discharge, the nurse works with the parents to establish a catheterization schedule to prevent urinary tract infection. With what frequency should the nurse instruct the parents to catheterize the child?
1) Every 1 to 2 hours
2) Every 3 to 4 hours
3) Every 6 to 8 hours
4) Every 10 to 12 hours

Question 7

A 5-year-old child is admitted to the hospital with increased intracranial pressure after a motor vehicle struck the child. The child weighs 15 kg.
The neurosurgeon orders: Mannitol 0.5 g/kg/10 minutes IV first, followed by Mannitol 0.25 g/kg IV every 4 hours.
Medication on hand: Mannitol 100 g/500mL D5W.
Calculate how many mL/hr to set the IV pump to infuse the Mannitol ordered every 4 hours.

Question 8

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?
1) Incisional pain
2) Movement of all extremities
3) Negative Brudzinski sign
4) Bulging fontanel

Question 9

A school-age client is transported to the emergency department by ambulance from the scene of a car accident. The client is alert and oriented × 3; pulse, respirations, and blood pressure are stable; and the neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The client states, "I can't feel or move my legs." Which injury does the nurse suspect?
1) Traumatic brain injury
2) Ruptured spleen
3) Traumatic shock
4) Spinal cord injury

Question 10

The nurse educator is describing the pediatric differences associated with the anatomy and physiology of the neurologic system to a group of nursing students. Which statements made by the class indicate appropriate understanding of this topic after the teaching session? Select all that apply.
1) The bones of the cranium are connected by connective tissue to allow for brain growth.
2) The spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies.
3) Maturation of the nerves continues until age 10.
4) Myelination is complete at birth,
5) Myelination proceeds in a cephalocaudal direction.

Question 11

A toddler-age client has a tonic-clonic seizure while in a crib in the hospital. The client's jaw is clamped. Which nursing action is the priority?
1) Place a padded tongue blade between the child's jaws.
2) Stay with the child and observe the respiratory status.
3) Prepare the suction equipment.
4) Restrain the child to prevent injury.

Question 12

A child sustains a traumatic brain injury and is monitored in the pediatric intensive-care unit (PICU). The nurse is using the Glasgow Coma Scale to assess the child. Which items will the nurse assess when using this tool? Select all that apply.
1) Eye opening
2) Verbal response
3) Motor response
4) Head circumference
5) Pulse oximetry

Question 13

A school-age client sustains a basilar skull fracture. Which symptom is a priority for this nurse to assess for when providing care to this client?
1) Cerebral spinal fluid leakage from the nose or ears
2) Headache
3) Transient confusion
4) Periorbital ecchymosis

Question 14

The nurse is planning care for a school-age child diagnosed with bacterial meningitis. Which intervention is most appropriate?
1) Keeping environmental stimuli at a minimum
2) Avoiding giving pain medications that could dull sensorium
3) Measuring head circumference to assess developing complications
4) Having the child move the head from side to side at least every two hours

Question 15

A child is diagnosed with epilepsy and is prescribed daily phenytoin (Dilantin). Which topic is most appropriate for the nurse to include in the discharge teaching?
1) Increasing fluid intake
2) Performing good dental hygiene
3) Decreasing intake of vitamin D
4) Taking the medication with milk

Question 16

A school-age client experiences a near-drowning episode and is admitted to the pediatric intensive-care unit (PICU). The parents express guilt over the near drowning of their child. Which response by the nurse is most appropriate?
1) "You will need to watch the child more closely."
2) "Tell me more about your feelings related to the accident."
3) "The child will be fine, so don't worry."
4) "Why did you let the child almost drown?"

Question 17

A child with myelomeningocele, corrected at birth, is now 5 years old. Which is the priority nursing diagnosis for a child with corrected spina bifida at this age?
1) Risk for Altered Nutrition
2) Risk for Impaired Tissue Perfusion-Cranial
3) Risk for Altered Urinary Elimination
4) Risk for Altered Comfort

Question 18

Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage?
1) Placing infant supine to decrease pressure on the sac
2) Appling a heat lamp to facilitate drying and toughening of the sac
3) Measuring head circumference every shift to identify developing hydrocephalus
4) Appling a diaper to prevent contamination of the sac

Question 19

A nurse is caring for a child who is diagnosed with cerebral palsy. Which goal of therapy is most appropriate for the nurse to include in the plan of care?
1) Reversing the degenerative processes that have occurred
2) Curing the underlying defect causing the disorder
3) Preventing the spread to individuals in close contact with the child
4) Promoting optimum development