Question 1

The nurse is planning care for a preschool-age child with spastic cerebral palsy. Which nursing diagnosis should the nurse identify to guide care for this patient's musculoskeletal status?&#10;A) Risk for self-care deficit related to impaired mobility&#10;B) Risk for disuse syndrome related to spasticity of muscle groups&#10;C) Impaired verbal communication related to neurologic impairment&#10;D) Risk for delayed growth and development related to activity restriction

Accepted Answer

Children with cerebral palsy need promotion of any function that is not already impaired to prevent further loss of function and allow them to master the highest level of
self-care. Learning to be ambulatory is an important part of self-care because it pays a large role in determining how independent the child can become. Walking can be difficult for the child to master because of lack of muscle coordination. Preventing contractures is also important to maintain motor function. Risk for self-care deficit focuses on self-care measures such as dressing, toothbrushing, bathing, and toileting, so the child can not only gain self-esteem by accomplishing these tasks but also achieve optimal independence. Impaired verbal communication addresses focuses on speech and not necessary the entire musculoskeletal status. The risk for delayed growth and development focuses on the child's potential inability to pursue stimulating activities and surroundings because of not being fully mobile.

Question 2

An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this patient?&#10;A) Numbness of fingers and decreased temperature&#10;B) Increased pulse rate and decreased blood pressure&#10;C) Increased temperature and decreased respiratory rate&#10;D) Decreased level of consciousness and increased respiratory rate

Accepted Answer

Manifestations of increased intracranial pressure include increased body temperature and decreased respiratory rate. Pulse rate slows, and the blood pressure increases.

Question 3

The nurse is planning a program for a community that focuses on the 2020 National Health Goals for neurologic health. Which topics should the nurse include in this presentation? (Select all that apply.)

A) Ensuring a diet adequate in vitamins and protein
B) Use of helmets for bicycle and motorcycle safety
C) Learning the signs and symptoms of inflammatory disorders
D) Practicing good hand washing technique and infection control
E) Importance of proper emergency care to protect the head and neck

Use of helmets for bicycle and motorcycle safety
Practicing good hand washing technique and infection control
Importance of proper emergency care to protect the head and neck

Accepted Answer

Nurses can help the nation achieve the 2020 National Health Goals through helping prevent neurologic injury by educating children and parents about the use of helmets for bicycle and motorcycle safety, by administering and teaching paramedical personnel to administer safe care at accident scenes so children's heads and necks are protected, and by decreasing the possible spread of bacterial meningitis through good hand washing and infection control precautions in hospitals. Interventions about diet and manifestations of inflammatory disorders will not help achieve the 2020 National Health Goals.

Question 4

A postpartum patient is upset that the baby was born with a congenital port-wine birthmark on the skin of the upper part of the right side of the face. What should the nurse explain to the mother about this birthmark?

A) "The birthmark is a part of a syndrome that can be cured with medication."
B) "The birthmark can be removed surgically so the child will develop normally."
C) "The birthmark is a concentration of melanin in the skin and causes cosmetic problems."
D) "The baby may have some numbness on the left side of the body because of the birthmark."

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Accepted Answer

Sturge-Weber syndrome is characterized by a congenital port-wine birthmark on the skin of the upper part of the face that follows the distribution of the first division of the fifth cranial nerve. Because of involvement of the meningeal blood vessels, blood flow can be sluggish, and anoxia may develop in some portions of the cerebral cortex. The child will develop symptoms of numbness on the side opposite the lesion from destruction of motor neurons. This syndrome cannot be cured with medication.
Removing the birthmark with surgery will not correct the long-term effects of the problem. The birthmark is not caused by a concentration of melanin in the skin. This problem has the potential to cause more than cosmetic health problems.

Question 5

The parents of a child with a thoracic-level spinal injury are anxious to learn the
Long-term prognosis for their child and ask if the child will walk again. How should the nurse respond to the parents?

A) "Damage usually progresses after the first week."
B) "It is most unlikely that your son will ever walk again."
C) "What has the physician said about your son's recovery?"
D) "It will be several weeks before an answer to your question is possible."

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Accepted Answer

Spinal injuries result when the spinal cord becomes compressed or severed by the vertebrae; further cord damage can result from hemorrhage, edema, or inflammation at the injury site as the blood supply becomes impeded. Predictions of useful body function cannot be made accurately at the time of the injury. Three phases of recovery must first take place. The nurse cannot accurately say that damage will progress after the first week. The nurse has no way of knowing if the child will walk again. The nurse can answer the parent's question without finding out what the physician has said about the child's recovery.

Question 6

The nurse is caring for a preschool-age child recovering from a lumbar puncture. What should the nurse do to ensure the patient does not develop a spinal headache?&#10;A) Measure temperature every hour.&#10;B) Restrict fluids for 2 hours after the procedure.&#10;C) Elevate the head of the bed to a 30-degree angle.&#10;D) Take the pillow away and have the patient lie flat in bed.

Accepted Answer

A child may develop a headache after a lumbar puncture as a result of the reduction in CSF volume or invasion of a small air pocket during the puncture. The nurse should encourage the child to lie flat for at least 30 minutes. The child's blood pressure, pulse, and respirations should be assessed for changes that indicate an increase in intracranial pressure. The child should drink a glass of fluid after the procedure to help prevent cerebral irritation caused by air rising in the subarachnoid space and to help increase the amount of CSF. The head of the bed should be flat and not elevated to a 30-degree angle.

Question 7

The nurse instructs the parents of a child with Guillain-Barré syndrome on care that will be needed once the child is discharged home. Which statement made by the parents indicates that teaching has been effective?

A) "We need to be sure to change our child's body position at least twice a day."
B) "Our child might experience weakness even after recovering from the illness."
C) "It will take about 10 days for our child to be back normal and return to school."
D) "This disease affects the heart and lungs, so our child will have limited ability going forward."

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Accepted Answer

Most children recover completely, without any residual effects of the syndrome; although, some may continue to have minor problems such as residual weakness. To prevent muscle contractures and effects of immobility, turning and repositioning every 2 hours is important in addition to passive range-of-motion exercises about every 4 hours. It will take longer than 10 days for the child to recover and return to school. This disease does not directly affect the heart and lungs. There should be minimal residual disability going forward.

Question 8

An adolescent recovering from a spinal cord injury calls out for help. The patient's face is bright red, and the patient is experiencing a severe headache. What is the first thing that the nurse should do for this patient?

A) Administer mouth-to-mouth resuscitation.
B) Assess if the urinary retention catheter is blocked.
C) Massage the lower extremities to cause vasodilation.
D) Lower the head of the bed to increase cerebral circulation.

Accepted Answer

The patient is demonstrating signs of autonomic dysreflexia, which include extreme hypertension, tachycardia, flushed face, and severe occipital headache. This can occur if the patient's bladder is allowed to fill. The resultant sensory stimulation relayed to the damaged cord can initiate a powerful sympathetic reflex reaction. The nurse should assess that the patient's urinary catheter is not obstructed, so urine can flow freely and reduce the sensory stimulation. The patient is talking, so mouth-to-mouth resuscitation is not necessary. Massaging the lower extremities and lowering the head of the bed will not relieve the sensory stimulation caused by the blocked urinary catheter.

Question 9

The nurse is caring for an 8-month-old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis?&#10;A) The child has a strong Moro reflex when startled.&#10;B) The child bears weight on both feet when held upright.&#10;C) The child cries when held in a ventral suspension position.&#10;D) The child holds the back very straight when in a sitting position.

Accepted Answer

Spasticity is excessive tone in the voluntary muscles that results in loss of upper motor neurons. A child with spastic cerebral palsy has hypertonic muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski reflex, and continuation of neonatal reflexes, such as the tonic neck reflex, well past the age at which these usually disappear. If infants with this disorder are held in a ventral suspension position, they arch their backs and extend their arms and legs abnormally.
They tend to assume a "scissors gait" because tight adductor thigh muscles cause their legs to cross when held upright. This involvement may be so severe it leads to a subluxated hip. Posture when in a sitting position is not remarkable for this health problem.

Question 10

A preadolescent child with ataxia-telangiectasia is demonstrating an exacerbation of choreoathetosis. What should the nurse do to help this patient?&#10;A) Provide comfort measures.&#10;B) Assist the patient to walk several times a day.&#10;C) Encourage the patient to increase independence.&#10;D) Recommend transferring the patient to a rehabilitation facility.

Accepted Answer

Ataxia-telangiectasia is a primary immunodeficiency disorder that results in progressive cerebellar degeneration. Telangiectasia or red vascular markings appear on the conjunctiva and skin at the flexor creases. Neurologic symptoms caused by the degeneration process can usually be detected in early infancy when developmental milestones are not met. Children develop an awkward gait when they begin to walk.
Choreoathetosis or rapid, purposeless movements may develop. Unfortunately, there is no effective treatment, and children with this disorder often die in late adolescence of infection, respiratory failure, or a malignant brain tumor. The nurse should provide comfort measures when caring for this child. The patient may not be able to walk. It is an unrealistic expectation for this child to increase independence. A rehabilitation facility is not going to help with the long-term prognosis of this disorder.

Question 11

An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder?&#10;A) The child should maintain an active lifestyle.&#10;B) Immediately provide medication if a seizure begins.&#10;C) Have the child carry a padded tongue blade with her at all times.&#10;D) Ensure quiet time late in the day, when seizure activity is most likely to occur.

Accepted Answer

The answer of An 8-year-old child is being treated for...

Question 12

A preadolescent weighing 99 lb is prescribed carbamazepine (Tegretol) 10 mg/kg per 24 hours in two divided doses. How much medication will the nurse provide the patient for one dose? (Enter numeric response only.)

Accepted Answer

The answer of A preadolescent weighing 99 lb is prescribed...

Question 13

The nurse is caring for a child with a closed head injury. The child's blood pressure is 120/58 mmHg, and intracranial pressure is 16 mmHg. What is this child's cerebral perfusion pressure? (Enter numeric value only. Calculate to the nearing hundredth decimal point.)

Accepted Answer

The answer of The nurse is caring for a child...

Question 14

The nurse is assessing pupil size and reaction to light in a child with a cervical neck injury. Which cranial nerve is the nurse assessing in this patient?&#10;A) II (optic)&#10;B) III (oculomotor)&#10;C) IV (trochlear)&#10;D) VI (abducens)

Accepted Answer

The answer of The nurse is assessing pupil size and...

Question 15

The nurse is planning care for a preschool-age child diagnosed with meningitis. What should the nurse identify as a priority goal for this patient's care?&#10;A) Inspect the teeth for obvious caries.&#10;B) Reduce the pain related to nuchal rigidity.&#10;C) Provide an opportunity for therapeutic play.&#10;D) Increase stimulation opportunities to prevent coma.

Accepted Answer

The answer of The nurse is planning care for a...

Deck 49: Nursing Care of a Family When a Child Has a Neurologic Disorder