Question 1

During assessment of a 6-year-old child with meningitis,the nurse places the child supine and attempts to put the child's chin on her chest.The child cries out in pain and flexes her knees.How does the nurse document this assessment finding in the medical record?

Accepted Answer

Two assessment tests are used in evaluating a patient with meningitis: the Kernig sign and the Brudzinski sign.The nurse has demonstrated a positive Brudzinski sign.The Kernig sign is elicited by placing the patient supine with hips flexed and raising and straightening the leg.Pain behind the knee and resistance are abnormal findings possibly indicative of meningitis.The Moro reflex is done on infants.The Grey-Turner sign is bruising of the flanks,often accompanying pancreatitis.

Question 2

A nurse is caring for a child who had a sudden onset of muscle weakness beginning in the legs and progressing in an ascending fashion,but who otherwise appears healthy.Which laboratory result would confirm the nurse's suspicion about the origin of this problem?

Accepted Answer

This child has manifestations of Guillain-Barré syndrome.Elevated CSF protein in the absence of infection supports this diagnosis.

Question 3

The high school nurse is teaching a healthy living class to high school seniors.One student asks why she should take folic acid now when she is not planning to become pregnant.Which response by the nurse is the most appropriate?

Accepted Answer

Neural tube defects (NTDs)generally occur between the 18th and 28th days of pregnancy,often before the woman knows she is pregnant.All women of childbearing age should get 400 µg/day of folic acid to help prevent NTDs.It is a good habit to get into prior to contemplating pregnancy,but this answer does not give specific information.Most people do not have a serious deficiency of folic acid;however,pregnant women (and those who could be pregnant)need to have a minimal amount of folic acid.Several foods are good sources of folic acid,including green leafy vegetables,liver,legumes,orange juice,and fortified breakfast cereals;it is also contained in multivitamins.

Question 4

A nurse is caring for an 8-year-old with Guillain-Barré Syndrome (GBS).On hourly rounds,the nurse assesses that the child's lung sounds are diminished,respiratory rate is 8 breaths/min and shallow,and pulse oximeter is 88%.What action by the nurse takes priority?

Accepted Answer

In GBS,respiratory muscles can be affected,leading to respiratory failure.The nurse needs to prepare for intubation.The child's muscles are too weak for oxygen or the spirometer to help her,and she may be too weak to use the spirometer or to take deep breaths.

Question 5

A nurse is preparing to discharge a 10-year-old child who was diagnosed with bacterial meningitis.Which action by the nurse takes priority?

Accepted Answer

Children with bacterial meningitis are often discharged with a PICC line in place for home IV antibiotic infusions.Depending on the needs of the child,the other options may or may not be appropriate.

Question 6

A nurse in a well-child clinic notes that a 5-month-old is not able to hold her head up.Which action by the nurse is the most appropriate?

Accepted Answer

Difficulty holding the head up by an appropriate age is a manifestation of hydrocephalus.Another sign of this disorder is an enlarging head,so the nurse measures the child's head and compares it to age-related norms.The other actions are appropriate,but not as specifically associated with hydrocephalus as measuring head circumference.

Question 7

A nurse is teaching a parent group about caring for their infants and toddlers.What does the nurse teach to prevent a serious neurological problem in infants?

Accepted Answer

Infant botulism can be caused by feeding honey to a child less than 12 months of age,so the nurse teaches parents to avoid this.The other statements are inaccurate.

Question 8

A child who is intubated and mechanically ventilated has an intracranial pressure monitoring device in place.The child is agitated.Which medication order would the nurse question based on the assessment data?

Accepted Answer

Pain and agitation are treated aggressively because they both can increase intracranial pressure.Appropriate drug choices include fentanyl,lorazepam,and morphine.Corticosteroids do not treat either pain or agitation and their use in cerebral edema is controversial.

Question 9

A child has had an episode of lip smacking while staring into space,but did not seem to lose consciousness.She was confused afterward but said her hands felt tingly before the other symptoms started.How should the nurse document this event?

Accepted Answer

A focal seizure involves only one part of the brain and manifests with involuntary movements,sensory symptoms,possible staring into space,no loss of consciousness,and confusion afterward."Alteration in consciousness" is too vague in this case to be a useful description."Convulsion" is an outdated term.A generalized seizure involves both hemispheres of the brain and manifestations usually include loss of consciousness and tonic-clonic movements.

Question 10

A nurse is caring for a 10-year-old child with a brain injury.On assessing the child,the nurse finds the following data: opens eyes only to pain,mutters inappropriate words,has abnormal extension to stimulation.Which action by the nurse takes priority?

Accepted Answer

A child with a Glasgow Coma Score of less than 8 needs to be intubated and mechanically ventilated.This child's score is 7 (eye opening = 2,verbal response = 3,motor response = 2).The child may need an invasive procedure due to the increased intracranial pressure,but this would not take priority over managing the airway and providing adequate oxygenation.The findings need to be documented,but further action is needed.Raising the head of the bed may or may not be beneficial,but does not take priority over intubation.

Question 11

A student nurse is preparing to give a 48.5-lb(22-kg)child IV mannitol (Osmitrol).What action by the student causes the nursing instructor to intervene?

Accepted Answer

Mannitol is an osmotic diuretic often used to decrease intraocular pressure.The correct dose is 1-2 g/kg,so the safe dose range is 22-44 g.The nurse would intervene if the student prepared to administer 66 g.The other actions are appropriate.

Question 12

A nurse is caring for four patients in the pediatric intensive care unit with head injuries or brain infections.Which child should the nurse see first?

Accepted Answer

Hypertension (with widening pulse pressure),bradycardia,and changes in respiratory pattern are components of Cushing's triad,a late sign of increased intracranial pressure,indicative of impending herniation.The change in the child's blood pressure,including the widened pulse pressure (difference between systolic and diastolic pressures),is worrisome.A child with a head injury and minimal vomiting is not alarming.A child with a brain infection who is irritable with a headache needs attention,but not over the child with possible herniation.An oral temperature of 100°F would be expected in a child with a brain infection.

Question 13

A child has been admitted with bacterial meningitis.Which action by the nurse takes priority?

Accepted Answer

All actions are appropriate for the child with acute bacterial meningitis.However,the priority is obtaining cultures so that appropriate therapy can be identified.After cultures are obtained,the nurse will administer broad-spectrum antibiotics until the culture and sensitivity results are known.

Question 14

A health-care provider administers edrophonium (Tensilon)to a school-age child with new onset of muscle weakness.The child is able to hold her eyes open for the duration of the drug's half-life.Which information does the nurse plan to teach the child and parents?

Accepted Answer

A positive result to a Tensilon test is diagnostic for myasthenia gravis,an autoimmune disease uncommon in children.Muscle weakness is the main symptom,and the weakness is particularly pronounced in muscles used for eye movement,chewing,swallowing,and breathing.Weakness is usually worse during the day or during times of stress.It is not painful,muscle weakness does not progress in ascending fashion as in Guillain-Barré syndrome,and the cause is unknown.

Question 15

A 6-week-old baby is brought to the clinic for a follow-up visit after having surgical repair of a myelomeningocele.His head circumference was 33 cm (12 inches)at birth.Now the nurse assesses his head circumference at 36 cm (14.1 inches).What action by the nurse is most appropriate?

Accepted Answer

Increasing head circumference is a sign of possible hydrocephalus.The average head circumference of an infant at birth is 33-38 cm (12-14 inches)and increases by 2 cm/month (0.75 inches/month).This child's head circumference is normal and the nurse should document the information;no other actions are needed.

Question 16

A woman is considering a second pregnancy,but tells the nurse she is not sure she wants to get pregnant again because her first child was born with spina bifida.She is taking folic acid on the advice of her health-care provider.Which information can the nurse provide this woman?

Accepted Answer

During pregnancy,testing of maternal blood for elevated alpha-fetoprotein is available for an early indication of spina bifida.The other options are incorrect.

Question 17

An infant born with spina bifida with a repaired myelomeningocele is brought the emergency department,where the parents report that the infant is very fussy and is feeding poorly.Which nursing action takes priority?

Accepted Answer

Poor feeding and irritability are signs of increased intracranial pressure (ICP)in infants.A child with spina bifida is at risk for hydrocephalus,which can lead to increased ICP.A corroborating sign would be bulging fontanels.The nurse should quickly palpate the infant's fontanels.Monitoring the child and obtaining vital signs are important actions too,but palpating the fontanels can be done quickly as the nurse handles the child and performs other procedures.The nurse should not attempt to feed this baby now.

Question 18

A student nurse is confused about the Monroe-Kelly doctrine.How does the registered nurse explain it to the student?

Accepted Answer

The brain consists of three components: brain matter,cerebral spinal fluid (CSF),and blood.Because the skull is a hard vault (after fontanels have closed),an increase in one of the components is not tolerated.The Monroe-Kelly doctrine states that in order to compensate for an increase in one of the components,there must be an equitable decrease in the other two components in order to prevent brain injury.

Question 19

A new nurse is caring for a child who had a ventriculoperitoneal shunt placed 2 days ago for hydrocephalus.Which action by the new nurse causes the experienced nurse to intervene?

Accepted Answer

Peritonitis is a complication of this procedure and manifestations of this include rebound tenderness,abdominal muscle rigidity,nausea,and vomiting.The new nurse should conduct a more thorough abdominal assessment instead of asking for anti-nausea medication.The other actions are appropriate and do not require the experienced nurse to intervene.

Question 20

A child has an invasive intracranial pressure monitoring device in place.Which assessment finding indicates that goals for a priority nursing diagnosis have been met?

Accepted Answer

All indications show that goals for various nursing diagnoses have been met;however,the priority here would be preventing infection at the intracranial pressure monitoring site,which would have a direct route to the brain.

Quiz 28: Caring for the Child With a Neurological or Sensory Condition