Deck 23: The Child with a Sensory or Neurological Condition

Question 1

The assessment finding that should be reported immediately if observed in a child with meningitis is:

A) irregular respirations.
B) tachycardia.
C) slight drop in blood pressure.
D) elevated temperature.

Answer 1

irregular respirations.

Question 2

When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing action would be to:

A) guide the child to the floor if the child is standing, and then go for help.
B) move objects out of the child's immediate area.
C) stick a padded tongue blade between the child's teeth.
D) manually restrain the child.

Answer 2

move objects out of the child's immediate area.

Question 3

A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure?

A) Absence
B) Akinetic
C) Myoclonic
D) Complex partial

Answer 3

Absence

Question 4

The nurse is planning to teach parents about prevention of Reye's syndrome. What information would the nurse include in this teaching?

A) Use aspirin instead of acetaminophen for children with viral illness.
B) Advise parents to have their children immunized against Reye's syndrome.
C) Avoid giving salicylate-containing medications to a child who has viral symptoms.
D) Get the child tested for Reye's syndrome if the child exhibits fever, vomiting, and lethargy.

Question 5

The nurse caring for a 5-month-old with viral influenza suspects the development of Reye's syndrome when the child:

A) has respirations drop from 18 to 14 breaths/min.
B) goes to sleep after feeding.
C) suddenly vomits without effort.
D) develops a macular rash.

Question 6

The school nurse would suspect strabismus when the child:

A) has a reddened sclera in one eye.
B) covers one eye to read the chalkboard.
C) complains of a headache.
D) has copious tears while watching TV.

Question 7

The nurse determines a mother understands instructions about administering an oral antibiotic for otitis media when the mother verbalizes that she will:

A) continue using the medication until symptoms are relieved.
B) share the medicine with siblings if their symptoms are the same.
C) give the medication with a glass of milk.
D) administer prescribed doses until all the medication is used.

Question 8

The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated. The nurse recognizes this posture as:

A) correct anatomical position.
B) decorticate.
C) decerebrate.
D) opisthotonos.

Question 9

The best way for the nurse to communicate with a 10-year-old child who has a hearing impairment would be to:

A) use gestures and signs as much as possible.
B) let the child's parents communicate for her.
C) face the child and speak clearly in short sentences.
D) recognize that the child's ability to communicate will be on a 6-year-old child's level.

Question 10

The school nurse recognizes the cardinal sign of a hyphema when she assesses:

A) opacity of the lens.
B) a yellow-white reflex on the pupil.
C) a dark-red spot in front of the iris.
D) inflamed mucous membranes of the eyelids.

Question 11

The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?

A) Athetoid
B) Ataxic
C) Spastic
D) Mixed

Question 12

A parent comments that her infant has had several ear infections in the past few months. The nurse understands that infants are more susceptible to otitis media because:

A) infants are in a supine or prone position most of the time.
B) sucking on a nipple creates middle ear pressure.
C) they have increased susceptibility to upper respiratory tract infections.
D) the eustachian tube is short, straight, and wide.

Question 13

An adolescent has just had a generalized seizure and collapsed in the school nurse's office. The nurse should call 911 if the student:

A) has a seizure lasting more than 5 minutes.
B) is sleepy and lethargic after the seizure.
C) fell at the onset of the seizure.
D) is confused and has slurred speech after the seizure.

Question 14

The nurse explains that febrile seizures:

A) occur when the body temperature exceeds 38.3? C (101° F).
B) can be prevented by anticonvulsant medication.
C) usually lead to the development of epilepsy.
D) occur when the temperature rises quickly.

Question 15

The nurse planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes would include:

A) keeping the infant flat after feeding.
B) giving over-the-counter decongestants.
C) avoiding getting water in the ears.
D) cleaning the ear canal with cotton-tipped applicators.

Question 16

The nurse giving instructions for acute conjunctivitis would teach parents to:

A) apply cool compresses to the affected eye several times a day.
B) instill topical steroid eye drops for 1 week.
C) clear drainage from the inner to the outer aspect of the eye.
D) keep the eye patched until the inflammation resolves.

Question 17

The situation in which the nurse would suspect a hearing impairment is a(n):

A) 3-month-old infant with a positive Moro reflex.
B) 15-month-old toddler who is babbling.
C) 18-month-old toddler who is speaking one-syllable words.
D) 24-month-old toddler who communicates by pointing.

Question 18

The nurse explains that a common treatment for amblyopia is:

A) patching the good eye to force the brain to use the affected eye.
B) patching the affected eye to allow the refractory muscles to rest.
C) using glasses that will slightly blur the image for the good eye.
D) using corticosteroids to treat inflammation of the optic nerve.

Question 19

A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. After a generalized tonic-clonic seizure, the nurse would expect that the child might be:

A) restless.
B) sleepy.
C) nauseated.
D) anxious.

Question 20

The nurse creating a teaching plan that includes the long-term administration of phenytoin (Dilantin) would state that:

A) the medication should be given on an empty stomach.
B) insomnia can be a significant side effect.
C) gums should be massaged regularly to prevent hyperplasia.
D) blood pressure should be closely monitored.

Question 21

The sign that suggests possible damage to the cortex of the brain is ____________ posturing.

Question 22

A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. The nurse would suspect:

A) meningitis.
B) Reye's syndrome.
C) brain tumor.
D) encephalitis.

Question 23

The nurse records the finding of ______________ _____________ when the child with meningitis cries out in pain when his head is flexed toward his chest.

Question 24

The nurse cautions parents that hearing impairment can affect which aspect(s) of the child's development? Select all that apply.

A) Speech clarity
B) Language development
C) Emotional stability
D) Personality development
E) Academic achievement
F) None of the above

Question 25

A child is brought to the emergency department after he fell and hit his head on the ground. The nursing assessment that suggests the child has a concussion is:

A) sleepy but easily arousable.
B) complaining of a stiff neck.
C) cannot remember what happened to him.
D) pupils react sluggishly to light.

Question 26

What intervention(s) would the nurse caring for a child with infectious meningitis include? Select all that apply.

A) Isolation precautions
B) Provision of dimly lit room
C) Observation for increasing intracranial pressure
D) Preparation for spinal tap
E) Seizure precautions
F) None of the above

Question 27

The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B to protect against:

A) encephalitis.
B) influenza.
C) bacterial meningitis.
D) otitis media.

Question 28

What would the nurse, who is preparing air travel instructions to prevent barotrauma in infants, include in teaching? Select all that apply.

A) Using ear plugs during takeoff
B) Holding infant upright during flight
C) Omitting the meal just before takeoff
D) Letting the infant nurse during descent
E) Applying ear drops before takeoff

Question 29

In caring for a 3-year-old with a head injury, the nurse would report the probability of increasing intracranial pressure (ICP) based on the assessment of:

A) temperature increase from 37.2? C (99° F) to 37.7° C (100° F).
B) increase in blood pressure with an attendant decrease in pulse.
C) increase in respirations.
D) equilateral pupils.

Question 30

Why would the pediatric nurse suspect the probability of an ear infection in a 6-month-old child? Select all that apply.

A) Hypersensitivity to noise
B) Irritability
C) Reddened ear canal
D) Rolls head from side to side
E) Temperature of 39.4° C (103° F)

Question 31

When documenting a grand mal seizure, what would the nurse include? Select all that apply.

A) Presence of incontinence
B) Current dose of antispasmodic medication
C) Activity level prior to and following seizure
D) Level of consciousness following seizure
E) Length of seizure