Deck 32: Neurological Alterations

Question 1

The nurse assessing an infant finds the following signs and symptoms: sun setting eyes with sclera seen above the iris, a high-pitched cry, a bulging fontanel, dilated scalp veins, slight alteration in consciousness, and vomiting. The nurse is aware that these signs and symptoms are most consistent with:

A) increased intracranial pressure
B) spinal cord trauma
C) encephalitis caused by a virus
D) severe hypoxia

Answer 1

increased intracranial pressure

Question 2

An infant's brain is what portion of the weight of an adult's brain?

A) one-fourth
B) one-third
C) one-half
D) two-thirds

Answer 2

two-thirds

Question 3

The nurse reporting on duty learns that the nursing unit is using the AVPU scale on one of the nurse's assigned clients. The nurse recalls that the AVPU scale is used for:

A) determining the level of pain of an intubated child
B) measuring the weight of a child who cannot stand
C) obtaining a measure of the level of consciousness
D) obtaining a gross measure of intracranial pressure

Answer 3

obtaining a measure of the level of consciousness

Question 4

You are the nurse reporting on duty. You learn during report that one of the children assigned to your care has been in status epilepticus. You will recall that status epilepticus refers to:

A) a chronic seizure condition that is not well controlled and usually lasts for years or a lifetime
B) a prolonged seizure or a series of convulsions there loss of consciousness occurs for at least 30 minutes
C) an unconscious state induced by medication to keep seizures under control and give the brain a chance to rest
D) being diagnosed with epilepsy in the past, but not having seizures for 5 or more years

Question 5

Refractory seizures last more than how many minutes?

A) 30
B) 40
C) 50
D) 60

Question 6

The nurse assigned to work with a child who has simple partial seizures (also called focal seizures) will most expect to find that this child has which of the following signs and symptoms before, during, or immediately after a simple partial seizure?

A) an aura
B) loss of consciousness for several minutes
C) alterations in sensory perception
D) movements involving both sides of the body

Question 7

You are caring for a child who has a seizure that begins with tonic contractions of the fingers of the left hand. You notice the spasms progressing into tonic/clonic movements that proceed up the muscles of the left side of the body. Which of the following types of seizures will you report that this child experienced?

A) Jacksonian
B) Rolandic
C) sylvian
D) complex partial

Question 8

Which of the following will the nurse teach the family of a child who has tonic/clonic seizures to do then their child begins to have a seizure?

A) Put a padded tongue blade between the child's teeth.
B) Perform a jaw thrust and, if available, administer oxygen.
C) Hold the child down in the bed or restrain the child.
D) Administer a benzodiazepine by intramuscular (IM) method.

Question 9

If you are walking with a child who begins to have a seizure, you will ease the child to the floor to prevent injury. Which of the following additional actions will you most need to take?

A) Get the child onto a stretcher.
B) Place the child on his or her side.
C) Obtain a set of baseline vital signs.
D) Put a pillow under the child's head.

Question 10

You are to administer phenytoin (Dilantin) IV to a child who is having a series of seizures. Which of the following things is most important for you to do?

A) Hold the medication if the apical pulse is below 60.
B) Administer the medication as quickly as possible.
C) Push the medication between seizures or wait for a mild seizure.
D) Administer at a rate no greater than 0.5-1 milligram per kilogram (mg/kg) per minute.

Question 11

Older children and adolescents who develop hydrocephalus usually have hydrocephalus due to which of the following causes?

A) aqueductal stenosis
B) meningomyelocele
C) various congenital malformations
D) intracranial tumors, infection (meningitis), or head injury

Question 12

Which of the following signs and symptoms will the nurse most likely find then assessing an infant with Arnold-Chiari malformation?

A) difficulty sleeping, hypervigilant, and an arching of the back
B) weakness of the leg muscles, loss of sensation in the legs, and restlessness
C) difficulty swallowing, diminished or absent gag reflex, and respiratory distress
D) paradoxical irritability, diarrhea, and vomiting

Question 13

You are the nurse assigned to work with a child who has just returned from the recovery room postoperatively for placement of a shunt as a treatment for hydrocephalus. Which of the following positions will you place this child in?

A) elevated 45 degrees in a supine position
B) flat and lying on the unoperated side
C) flat and lying on the operated side
D) elevated 30 degrees and prone

Question 14

The nurse assessing a newborn baby finds that the baby has spina bifida with the lesion located high on the spinal column. The nurse realizes that this location often means which of the following?

A) The higher locations are often associated with additional neurological defects, especially hydrocephalus.
B) It is easier to correct spina bifida that is higher on the spinal column.
C) Higher lesions are less likely to involve respiratory difficulties.
D) Higher lesions seldom involve bladder or bowel problems.

Question 15

The nurse is answering questions for the parents of a newborn who has spina bifida. The parents ask then surgery can be done. Which of the following responses by the nurse is most accurate?

A) "Surgery is usually performed within the first few hours or days of life."
B) "It is possible that the spina bifida can be reduced and closed without surgery."
C) "Often the surgeons like to wait until the child is at least 2 years old to do surgery."
D) "Surgery needs to be done before the child stands and begins to walk."

Question 16

The nurse working with the mother of a newborn who has spina bifida will place the priority on helping the mother with which of the following needs?

A) emotional support for the mother
B) understanding spina bifida completely
C) not changing her mind about breastfeeding
D) explaining this problem to family and friends

Question 17

The pediatric nurse is assigned to work with a child who has craniosynostosis. The nurse will most expect to find which of the following during the initial contact and assessment?

A) hydrocephalus
B) skull deformity
C) signs of infection
D) cyanosis

Question 18

When assessing neonates, the nurse will keep in mind that children with arteriovenous malformation will have which of the following initial signs?

A) altered state of consciousness
B) pallor to pale jaundice, abdominal pain, and loss of appetite
C) congestive heart failure, cardiomegaly, and a cerebral bruit
D) significant difference in blood pressure in the left and right arms

Question 19

If a child has a headache described as migraine-like and also has a seizure, the nurse should have a high suspicion of:

A) ruptured cerebral aneurysm
B) arteriovenous malformation
C) astrocytoma
D) hydrocephalus

Question 20

A parent asks the school nurse why she should not give her children aspirin for a fever. When the nurse replies that it has to do with the possible risk of a child getting Reye's syndrome while taking aspirin, the parents asks: "What is Reye's syndrome?" Which of the following responses by the nurse would most accurately describe Reye's syndrome?

A) fatal or near-fatal condition involving the circulatory system and the nervous system
B) an unusual allergy-like reaction to aspirin while in a mild immunosuppressed condition following an illness
C) a neurological reaction to aspirin that can cause paralysis to the alveoli and bring respiratory distress
D) a life-threatening condition following a mild viral illness, in which there is liver enlargement and cerebral edema

Question 21

A parent asks the nurse to explain what causes encephalitis, because a child in the neighborhood has come down with it. Which of the following answers by the nurse would be most accurate?

A) "It is caused by a specific type of fly often found in and near horse barns."
B) "Mosquito bites are the usual cause and call for the neighborhood to request spraying and draining of stagnant water sources."
C) "After the neonatal period it is usually caused by a virus, most commonly herpes type I, herpes simplex, but can be caused by other organisms."
D) "Cat scratch fever has become one of the major causes of encephalitis, so be sure your child does not play with any of the neighborhood cats."

Question 22

Head injuries are categorized as primary or secondary in nature. Which of the following injuries is an example of both primary and secondary head injury?

A) hitting the windshield of a car that was hit from behind
B) being hit with a baseball bat
C) falling out of a tree onto a hard surface
D) a severe blow in a boxing match

Question 23

Which of the following terms refers to primary and secondary head injuries?

A) stage one and stage two
B) coup and contra coup
C) alpha and beta
D) traumatic and nontraumatic

Question 24

Which of the following findings constitutes a grave preterminal sign in the head-injured child?

A) bradycardia followed by tachycardia
B) increasingly frequent episodes of hypertension
C) nausea and vomiting
D) severe migraine-type headache

Question 25

Which of the following is the classic sign of intensely high intracranial pressure and risk for brain herniation?

A) projectile vomiting and severe headache
B) veins that stand out noticeably on the face and the neck
C) severe earache as well as neck and facial pain
D) one dilated pupil and contralateral spasticity or flaccidity

Question 26

A child has a total Glasgow score of 6 and a motor score of 2. The nurse realizes that this child has which of the following types of head injury in terms of severity?

A) mild
B) moderate
C) normal
D) severe

Question 27

Which of the following medications is most likely to be given during the initial phase of increased intracranial pressure to shrink brain volume?

A) mannitol (Osmitrol)
B) magnesium sulfate
C) nimodipine (Nimotop)
D) pyridostigmine bromide (Mestinon)

Question 28

The nurse administering mannitol (Osmitrol) must observe closely for a rebound effect of the intracranial pressure. If there is a rebound effect with mannitol, which of the following courses of action does the nurse need to take?

A) Call neurosurgery at once.
B) Leave a message for the physician at his or her office.
C) Write a nursing order for vital signs every 4 hours.
D) Start an intravenous infusion of Ringer's lactate.

Question 29

The nurse is assessing for pain in the chemically paralyzed child who is intubated. Which of the following methods will the nurse use for assessing pain?

A) a picture chart
B) pen and paper
C) the parent's intuition about their child's pain
D) increase in pulse and blood pressure

Question 30

The nurse is working with an adolescent boy who has some neurological sequelae from a head injury. The nurse can best help the adolescent accept the disability by initiating which of the following interventions?

A) Tell the adolescent how lucky he is to be alive and all the things he has to live for.
B) Have the adolescent make a list of all the things he is thankful for and talk about it.
C) Encourage ventilation for frustrations, provide positive feedback, and help set up needed support.
D) Ask the chaplain to make an appointment to talk with this adolescent about his future.

Question 31

The majority of spinal cord injuries are a result of which of the following types of trauma?

A) motor vehicle crashes
B) falls
C) gymnastics
D) bicycle accidents