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

Question 1

The pediatric nurse caring for a patient with encephalitis explains to the parents that the most common origin of encephalitis is which of the following?

A) Bacterial
B) Fungal
C) Parasitic
D) Viral

Answer 1

Viral

Question 2

The pediatric nurse carefully monitors a patient's status by assessing the child's level of consciousness.The nurse understands that the Glasgow Coma Scale provides clues to which of the following?

A) Encephalitis
B) Irreversible coma
C) Neurological impairment
D) Neurological status

Answer 2

Neurological status

Question 3

A neonate receives a diagnosis of hydrocephalus.The pediatric nurse assesses for congenital anomalies related to this condition.Which condition is inconsistent with the nurse's knowledge of hydrocephalus?

A) Aqueductal stenosis
B) Chiari I and II malformations
C) Dandy-Walker malformation
D) Folic acid deficiency

Answer 3

Folic acid deficiency

Question 4

What would the nurse assess for in a child with a disturbance in the basal ganglia?

A) Ataxia
B) Hyperthermia
C) Hypotension
D) Incontinence

Question 5

The pediatric nurse explains to the parents of a comatose child that which structure controls the child's level of consciousness?

A) Basal ganglia
B) Brainstem
C) Central nervous system
D) Reticular activating system

Question 6

The pediatric nurse caring for patients in a trauma center examines a patient who has increased intracranial pressure as a result of a motor vehicle crash.The nurse is aware that secondary brain injuries can result from which factor?

A) Acidosis
B) Ischemia
C) Infections
D) Reduced oxygen

Question 7

A nurse admits a 5-year-old child with bacterial meningitis to the pediatric intensive care unit.Which information obtained by the nurse during the intake history is most helpful for the nurse to document?

A) Fell off swing hitting head 2 months ago
B) History of recent sinus infection
C) Mother with history of herpes simplex
D) Sibling with upper respiratory infection

Question 8

The student nurse studying the neurological system learns that areas of gray matter are found deep in the brain.To determine damage to the basal ganglia,what will the nurse assess?

A) Blood pressure
B) Homeostasis
C) Movement
D) Sensory impulses

Question 9

The pediatric nurse caring for hearing-impaired children teaches parents the recommended guidelines for communicating with their children.Which instruction is inconsistent with current guidelines?

A) Ignoring any related stigmas
B) Obtaining the child's attention before speaking
C) Positioning yourself at the child's eye level
D) Talking slowly and loudly to the child

Question 10

The student nurse studying anatomy and physiology understands which of the following to be the function of axons?

A) Bringing information to the brain
B) Maintaining myelin sheaths on nerves
C) Protecting sensory and motor pathways
D) Taking information away from the brain

Question 11

A nurse is caring for a child with suspected epilepsy.Which diagnostic test does the nurse facilitate as the priority for this child?

A) Cerebral angiogram
B) Electrocardiogram (ECG)
C) Electroencephalogram (EEG)
D) Lumbar puncture (LP)

Question 12

A hospitalized child is having a seizure.Which action by the nurse takes priority?

A) Apply oxygen and oximeter.
B) Give anti-seizure medications.
C) Pad the side rails of the bed.
D) Turn the child on his or her side.

Question 13

A child is prescribed baclofen (Lioresal)via intrathecal pump to treat severe muscle spasms related to cerebral palsy.What teaching does the nurse provide the child and parents?

A) Do not let this prescription run out.
B) The medication may cause gingival hyperplasia.
C) Periodic serum drug levels are needed.
D) Watch for excessive facial hair growth.

Question 14

An ophthalmologist examining the eyes of a patient explains to the nurse that the patient has an irregular curvature or uneven contour of the eye,resulting in impaired light refraction that causes blurred vision at all distances.Which condition does the nurse inform the parents about?

A) Astigmatism
B) Hyperopia
C) Myopia
D) Strabismus

Question 15

A nurse admits a child experiencing drowsiness and vomiting who has had a seizure at home.The parents state the child was healthy until 2 weeks ago when she had a viral illness.Which diagnostic testing does the nurse facilitate as a priority?

A) Complete blood count
B) Liver biopsy
C) Lumbar puncture
D) Serum glucose

Question 16

A student nurse is tutoring another student on anatomy and physiology.What does the tutor explain is the function of myelin sheaths on certain nerves?

A) Allow rapid transmission of nerve impulses
B) Assist in long-term storage of memories
C) Prevent "cross-communication" between nerves
D) Protect the nerves from temperature changes

Question 17

A pediatric nurse performs a physical examination on a neonate and notes a spinal lesion with the meninges protruding through the defect that contains spinal cord elements.The nurse documents which condition as being present?

A) Hydrocephalus
B) Meningitis
C) Meningocele
D) Myelomeningocele
E) Spina bifida occulta

Question 18

A school-aged child wishes to learn embroidery from her grandmother,but the grandmother reports that the child can only concentrate on the projects for a short time and seems frustrated.What action by the nurse is the most appropriate?

A) Advise that the child needs more physical activity.
B) Explain that the child is too young for this project.
C) Suggest that the child have a routine vision exam.
D) Teach behavior modification to the grandmother.

Question 19

A nurse is caring for a child who only awakens to painful stimuli and produces no verbal responses.Which term is the most appropriate when documenting this child's status?

A) Lethargy
B) Obtundation
C) Persistent vegetative state
D) Stupor

Question 20

A nurse is caring for a child who has intracranial pressure (ICP)monitoring.The nurse assesses the child and notes that the ICP is 9 mm Hg.Which action by the nurse is most appropriate?

A) Activate the rapid response team.
B) Document the finding in the chart.
C) Hyperventilate the patient.
D) Prepare to administer mannitol (Osmotrol).

Question 21

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

A) Administering broad-spectrum antibiotics
B) Assessing and treating pain aggressively
C) Facilitating blood cultures and lumbar puncture
D) Maintaining a quiet, nonstimulating environment

Question 22

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?

A) "It is a good habit to get into while you are young and can develop good habits."
B) "Most people in this country have a serious deficiency of vitamins and folic acid."
C) "Neural tube defects occur so early that you might not know you are even pregnant."
D) "There are no foods that contain folic acid so you have to take a supplement."

Question 23

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?

A) Administer high-flow oxygen by mask.
B) Call the rapid response team; prepare for intubation.
C) Encourage the patient to take slow, deep breaths.
D) Have the patient use the incentive spirometer.

Question 24

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?

A) Always treat any temperature elevation to prevent seizures.
B) Avoid vaccinations with live, attenuated viruses.
C) Do not use artificial sweeteners in your baby's food.
D) Never give honey to a child less than 1 year of age.

Question 25

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?

A) Assess the baby's fontanels for bulging.
B) Attach a cardiac and respiratory monitor.
C) Obtain and document the baby's vital signs.
D) Try feeding the baby with sucrose water.

Question 26

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?

A) Daily weight equals admission weight.
B) Joints move freely during range of motion.
C) No signs of infection are present at the insertion site.
D) Skin is intact without redness or breakdown.

Question 27

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?

A) Blood pressure change from 110/58 to 134/40 mm Hg in a child with brain injury
B) Child with brain injury who has vomited twice in 12 hours, now sleeping
C) Child with meningitis who is irritable, complaining of a "bad" headache
D) Oral temperature of 100.4°F (38°C) in a child with meningitis

Question 28

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?

A) Assesses child's pain including report of headache
B) Confirms the dose of 66 g in a 20% solution
C) Double-checks child's urine output for the shift
D) Explains to the child that nausea may occur

Question 29

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?

A) Muscle weakness will progress in an ascending fashion.
B) Pain control will be an important aspect of the child's care.
C) This disease is a result of a previous viral infection.
D) Weakness and fatigue will probably be worse during the day.

Question 30

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

A) Compensation for an increase in one of the skull's components
B) Hypothesis about the length of a coma determining the outcome
C) Immunomodulatory theory of an inborn resistance to rabies
D) Theory that seizures change the neurons and provoke more seizures

Question 31

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?

A) Administers IV antibiotics
B) Asks for medication to treat nausea
C) Palpates the shunt tract with assessments
D) Raises the head of the bed to 30°

Question 32

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?

A) Alpha-fetoprotein testing can be done in pregnancy.
B) Genetic testing is available for this condition.
C) It is rare for two children in one family to be affected.
D) Usually spina bifida affects only female children.

Question 33

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?

A) Ask about other developmental milestones .
B) Document the finding in the child's chart.
C) Measure the child's head circumference.
D) Obtain the child's length and weight.

Question 34

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?

A) Elevated CSF protein
B) Increased liver enzymes
C) Leukocytosis
D) Low hemoglobin

Question 35

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?

A) Alteration in consciousness
B) Convulsion
C) Focal seizure
D) Generalized seizure

Question 36

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?

A) Assess the child for signs of hydrocephalus.
B) Document the measurement in the child's chart.
C) Educate the parents on possible shunt placement.
D) Inquire about signs of increased intracranial pressure.

Question 37

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

A) Arrange home health-care visits for antibiotic infusions.
B) Consult with physical therapy about a home exercise plan.
C) Ensure the parents can plan high-protein meals.
D) Make a social work referral for long-term care placement.

Question 38

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?

A) Absent Moro reflex
B) Exaggerated Grey-Turner sign
C) Negative Kernig sign
D) Positive Brudzinski sign

Question 39

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?

A) Alert the operating room for emergent surgery.
B) Document the findings; reassess in 15 minutes.
C) Notify the provider; prepare for intubation.
D) Raise the head of the child's bed to 45°.

Question 40

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?

A) Fentanyl (Sublimaze)
B) Lorazepam (Ativan)
C) Methylprednisolone (Solu-Medrol)
D) Morphine (Astramorph)

Question 41

A child has been examined by a pediatric ophthalmologist,and findings indicate a dulled red reflex and cloudy lens.Which treatment plan does the nurse educate the parents on based on these findings?

A) Occlusion therapy to the affected eye for 6 months
B) Periodic administration of IV mannitol (Osmotrol)
C) Surgery to remove the cataract and placement of a lens
D) Use of eyedrops for the rest of the child's life

Question 42

A nurse assesses a 1-month old's Glasgow Coma Scale (GCS)and finds the following: opens eyes to pain,irritable cry,localizes pain.Your calculation indicates that this child's GCS is ____________________.

Question 43

A child is brought to the pediatric clinic by her mother,who reports redness,swelling,and pain around the child's right eye.Which information does the nurse give the mother?

A) A steroid injection may be needed to reduce swelling.
B) Intravenous antibiotic treatment for 7 days is usually curative.
C) See an ophthalmologist to assess for any corneal damage.
D) Use warm wet compresses to remove any crusting.

Question 44

The pediatric nurse is caring for a child with increased intracranial pressure (ICP).The nurse places priority on completing which interventions?

A) Administering mannitol (Osmitrol)
B) Lowering the head of the bed
C) Maintaining a patent airway
D) Performing vigorous suctioning
E) Preventing hyperthermia

Question 45

A camp nurse reads on a medical history form that a camper has "drop attacks." What does the nurse understand about this condition?

A) Atonic seizure activity
B) Fainting spells
C) Loss of consciousness
D) Sudden muscle weakness

Question 46

A child's chart indicates he has leukocoria and a hyphema in the right eye.Which teaching does the nurse implement for the child and parents?

A) Application of antibiotic ointment and eye patch
B) Possibility of other children having this genetic disorder
C) Surgery, possible enucleation, possible chemotherapy
D) Wearing appropriate eye protection during sports

Question 47

A nurse is preparing discharge teaching for an adolescent with a new diagnosis of epilepsy.What information should the nurse provide?

A) "Driving is not allowed while taking anti-seizure drugs."
B) "Participating in sports again in the future is possible."
C) "Several drugs will be tried at once, then reduced over time."
D) "Wearing a Medic-Alert bracelet is not needed for seizures."
E) "You should check the school's seizure action plan."

Question 48

A nurse is caring for a child and notes Battle's sign during the assessment.Which action by the nurse is the most appropriate?

A) Assist with obtaining laboratory studies.
B) Document the findings in the child's chart.
C) Measure the child's abdominal girth.
D) Notify the provider and facilitate a CT or an MRI.

Question 49

A nurse assesses an infant for signs of increased intracranial pressure.Which signs would lead the nurse to notify the rapid response team?

A) Bulging fontanels
B) Change in LOC
C) Irregular respirations
D) Posturing
E) Seizures

Question 50

The pediatric nurse prepares a care plan for a patient admitted to the intensive care unit for meningitis.Which nursing interventions does the nurse include in the care plan for this patient? (Select all answers that apply.)

A) Assess and treat pain as needed.
B) Implement transmission-based precautions.
C) Initiate and maintain IV access.
D) Monitor vital signs every 4 hours.
E) Monitor neurological status and symptoms.

Question 51

A pediatric nurse caring for patients in an emergency room performs an assessment of a child who survived a drowning incident.Which does the nurse assess when using the Orlowski scale on this child?

A) Arterial pH < 7.10
B) Comatose on admission to the emergency room
C) No resuscitation efforts for more than 10 minutes after rescue
D) Submersion time > 20 minutes
E) Used for children who are 10 years of age or older

Question 52

An adolescent has frequent headaches accompanied by nausea and vomiting.What item is most appropriate for the nurse to include in the teaching plan for this adolescent patient?

A) How to give him- or herself an injection of medication
B) The maximum daily dose of acetaminophen (Tylenol)
C) Ways to manage temporary ptosis or rhinorrhea
D) What to do in case of a seizure during the headache

Question 53

A pediatric nurse reads the diagnosis "SCIWORA" on a child's chart.Which assessment finding does the nurse anticipate to correlate with this condition?

A) Altered level of consciousness
B) Diplopia and visual disturbances
C) Inability to hold his head up
D) Weakness/paralysis of muscles

Question 54

The nurse is admitting an adolescent with known myasthenia gravis to the intensive care unit with respiratory failure.Which questions would be most important for the nurse to ask to attempt to find the cause of the problem?

A) "Could your child have skipped doses of his medication?"
B) "Do you know if your child uses drugs or drinks alcohol?"
C) "Has your child been sick or overly fatigued recently?"
D) "How long has your child been diagnosed with myasthenia gravis?"
E) "Is it possible that your child took too much medication?"

Question 55

A nurse is working with a teen who has epilepsy treated with carbamazepine (Tegretol).Laboratory results indicate a serum drug level of 2 µg/mL.Which action by the nurse is the most appropriate?

A) Assess the teen for noncompliance.
B) Document the results in the chart.
C) Have the teen continue the regimen.
D) Tell the teen to cut the dose in half.

Question 56

The nurse is preparing discharge teaching for the parents of a 7-year-old boy with hydrocephalus and a ventriculoperitoneal shunt.Which information does the nurse include in the discharge teaching?

A) After the shunt site has healed, contact sports are permitted
B) How to accurately take the child's temperature when needed
C) Monitoring for shunt infection is always a priority action.
D) Report any nausea, vomiting, or change in behavior.
E) Shunt removal can occur after hydrocephalus has been controlled.

Question 57

The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP)prepares a home care teaching plan for the caregivers on discharge.Which items will the nurse include in the teaching plan?

A) Apply splints and braces to facilitate muscle control.
B) Buy toys that are appropriate for the child's abilities.
C) Encourage the child to perform self-care tasks.
D) Ensure the clothing has buttons to stimulate dexterity.
E) Use skeletal muscle relaxants for short-term control.

Question 58

The nurse is providing care for a child in the intensive care unit who requires intracranial monitoring.The child's blood pressure is 100/42 mm Hg and his ICP is 10 mm Hg.Your calculation indicates that the child's cerebral perfusion pressure (CPP)is ____________________.

Question 59

A nurse is caring for a 1-year-old child who was admitted for seizures.The parents ask what could have caused the child's seizure.The nurse explains that seizures can be caused by which problems?

A) Brain injury
B) Central nervous system infection
C) Hypertension
D) Renal failure
E) Unknown cause

Question 60

The clinic nurse is providing community education to a parent group.The topic is over-the-counter medications containing aspirin or aspirin compounds.Which products does the nurse advise the parents to avoid?

A) Kaopectate (bismuth subsalicylate)
B) Lamictal (limotragine)
C) Pedia-profen (ibuprofen)
D) Pepto-Bismol (bismuth subsalicylate)
E) Ventolin (albuterol)