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?

Accepted Answer

Elevated WBC count in the cerebral spinal fluid is a hallmark finding in meningitis. This is because the inflammation caused by the infection leads to an increase in white blood cells in the cerebrospinal fluid. Elevated RBC count is not typically seen in meningitis. Normal glucose levels in the CSF are expected in meningitis. Decreased WBC counts are not expected findings in meningitis.

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.

Accepted Answer

A,B,C,D

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?

Accepted Answer

A

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.

Accepted Answer

Placing a continuous-pulse oximetry monitor on the child is important to monitor respiratory function as sedatives can cause respiratory depression. Placing the child in a room near the nurse's station ensures close monitoring and rapid response for any adverse effects of the sedative. Allowing several visitors to remain at the bedside and using soft restraints if the child becomes confused are not appropriate interventions for a child who is sedated as sedation can impair cognitive function and increase the risk of falls. Using sedation around the clock to decrease agitation is not appropriate because the sedative may need to be titrated and adjusted as the child's pain and anxiety level changes.

Question 5

Which statement made by a parent during a well-child visit would cause the nurse to suspect the child has cerebral palsy?

Accepted Answer

Floppy muscle tone is a common sign of cerebral palsy in infants. Rolling from back to prone, sitting without support, and not walking are all developmental milestones that may vary and do not necessarily suggest cerebral palsy.

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?

Accepted Answer

The correct frequency for catheterization to prevent urinary tract infections in a child after myelomeningocele repair is every 3 to 4 hours. This schedule helps to ensure the bladder is regularly emptied, reducing the risk of infection and promoting urinary tract health.

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.

Accepted Answer

The answer of A 5-year-old child is admitted to the...

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?

Accepted Answer

A malfunctioning shunt can cause a build-up of cerebrospinal fluid (CSF), leading to increased pressure and a bulging fontanel. Incisional pain and movement of all extremities are not necessarily indicative of shunt malfunction. A negative Brudzinski sign (lack of neck stiffness) is a normal finding.

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?

Accepted Answer

The inability to move or feel the legs indicates a potential spinal cord injury, which requires immediate medical attention and immobilization. The other options do not fit the client's symptoms. A traumatic brain injury may cause confusion, disorientation, or loss of consciousness but not affect the legs. A ruptured spleen may cause abdominal pain and bleeding but not affect the legs. Traumatic shock may cause hypotension, tachycardia, and altered mental status but not affect the legs.

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.

Accepted Answer

A is correct because the bones of the cranium are not fused at birth but are connected by sutures, which allow for brain growth. B is correct because the spine of infants is relatively mobile due to immature neck muscles and incomplete ossification of the vertebrae. C is incorrect because maturation of the nerves continues until adolescence, not just until age 10. D is incorrect because myelination of nerve fibers is not complete at birth and continues throughout childhood and even into adolescence. E is correct because myelination proceeds in a cephalocaudal direction, meaning that the fibers of the brain and spinal cord closest to the head are myelinated first, followed by those further down the spinal cord.

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?

Accepted Answer

The priority nursing action is to observe the respiratory status of the client. It is important to ensure that the airway is clear and that the client is breathing properly. In this situation, the nurse should stay with the child and monitor the respiratory status. The other options are not appropriate. Placing a padded tongue blade between the jaws could cause harm to the child. Preparing the suction equipment is not a priority until the seizure has ended, and restraining the child could cause 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.

Accepted Answer

The Glasgow Coma Scale assesses eye opening, verbal response, and motor response to evaluate level of consciousness in a patient with a traumatic brain injury. Head circumference and pulse oximetry are not included in this tool.

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?

Accepted Answer

Cerebral spinal fluid leakage from the nose or ears is a potentially life-threatening complication of a basilar skull fracture, as it can put the client at risk for meningitis. It is important for the nurse to assess for this symptom and report it immediately to the healthcare provider. The other symptoms listed are also associated with basilar skull fractures, but do not have the same level of urgency as CSF leakage.

Question 14

The nurse is planning care for a school-age child diagnosed with bacterial meningitis. Which intervention is most appropriate?

Accepted Answer

Keeping environmental stimuli at a minimum is appropriate for a child with bacterial meningitis, as they may be sensitive to light, noise, and touch due to the inflammation of the meninges.

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?

Accepted Answer

Phenytoin can cause gingival hyperplasia and poor dental hygiene can exacerbate this condition. Therefore, it is important for the nurse to include information about performing good dental hygiene in the discharge teaching. While increasing fluid intake and taking the medication with milk may be important for some medications, it is not specifically relevant for phenytoin. Decreasing intake of vitamin D is not necessary unless the patient is experiencing toxicity, which is not a common side effect of phenytoin.

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?

Accepted Answer

The most appropriate response by the nurse is to provide emotional support to the parents by exploring their feelings related to the accident. This helps the parents deal with their guilt and process their emotions in a healthy manner. The other options can be seen as blaming the parents or downplaying the severity of the situation.

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?

Accepted Answer

Children with spina bifida may experience urinary incontinence or retention, which can lead to complications such as urinary tract infections and impaired renal function. Therefore, monitoring and managing urinary elimination is a priority nursing diagnosis for a child with corrected spina bifida.

Question 18

Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage?

Accepted Answer

Measuring head circumference every shift is important in identifying developing hydrocephalus, which is a common complication in infants with myelomeningocele. This allows for appropriate interventions to be initiated promptly to prevent further neurological damage.

Answer: A
 Placing the infant supine is essential in minimizing pressure on the sac, which can further damage the nerves and result in increased neurological deficits. This also facilitates visualization and monitoring of the sac and surrounding skin for any changes or signs of infection.

Answer: D
 Applying a diaper to prevent contamination of the sac is crucial in maintaining a sterile environment and preventing infections, which can be detrimental to the infant's health. A diaper should be used instead of cloth or gauze dressing to minimize the risk of trauma to the sac.

Answer: B
 Applying a heat lamp to facilitate drying and toughening of the sac is contraindicated because heat can cause increased swelling and further damage to the nerves. It is not recommended as part of the preoperative care for infants with myelomeningocele.

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?

Accepted Answer

Cerebral palsy is a non-progressive condition that affects motor function and can result in developmental delays. Therefore, the most appropriate goal of therapy is to promote optimum development by providing supportive care and therapies aimed at improving the child's motor skills and overall quality of life. Reversing degenerative processes or curing the underlying defect is not possible as cerebral palsy is a permanent condition. Additionally, cerebral palsy is not contagious, so preventing its spread to others is not a relevant goal.

Quiz 27: Alterations in Neurologic Function