Deck 23: The Child With a Sensory or Neurological Condition

Question 1

Which assessment finding in a child with meningitis should be reported immediately?

A) Irregular respirations
B) Tachycardia
C) Slight drop in blood pressure
D) Elevated temperature

Answer 1

Irregular respirations

Question 2

A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds.What would the nurse expect to assess after a generalized tonic-clonic seizure?

A) Restlessness
B) Sleepiness
C) Nausea
D) Anxiety

Answer 2

Sleepiness

Question 3

An adolescent has just had a generalized seizure and collapsed in the school nurse's office.When should the nurse should call 911?

A) The seizure lasts more than 5 minutes.
B) The child is sleepy and lethargic after the seizure.
C) The child vomited at the onset of the seizure.
D) The child is confused and has slurred speech after the seizure.

Answer 3

The seizure lasts more than 5 minutes.

Question 4

A parent comments that her infant has had several ear infections in the past few months.Why are infants more susceptible to otitis media?

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 5

What will the nurse teach parents when giving instructions for acute conjunctivitis?

A) Apply cool compresses to the affected eye several times a day.
B) Instill topical steroid eyedrops 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 6

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 7

The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated.How does the nurse identify this posture?

A) Correct anatomical position
B) Decorticate
C) Decerebrate
D) Opisthotonos

Question 8

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

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

Question 9

What assessment does the school nurse recognize as the cardinal sign of a hyphema?

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 10

Which situation would cause the nurse to suspect a hearing impairment?

A) 3-month-old infant with a positive Moro (startle reaction)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 11

What symptom leads the nurse caring for a 5-month-old child with viral influenza to suspect the development of Reye's syndrome?

A) Respirations drop from 18 to 14 breaths/minute
B) Falling asleep after feeding
C) Sudden vomiting without effort
D) Development of a macular rash

Question 12

What does the nurse explain to parents of a child with febrile seizures?

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

Question 13

What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?

A) Assist the child to bed 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.

Question 14

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 15

What assessment made by the school nurse would lead to the suspicion of strabismus?

A) Reddened sclera in one eye
B) Child covers one eye to read the chalkboard
C) Child complains of a headache
D) Copious tears while watching TV

Question 16

What would the nurse include when planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes?

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 17

What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?

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 18

What statement by a patient's mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?

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

Question 19

What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?

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 20

What might the nurse explain as a common treatment for amblyopia?

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 21

The nurse is educating parents on prevention of eyestrain in their 5-year-old child.What information will the nurse include? (Select all that apply. )

A) Encourage books with large type.
B) Words in books should be closely spaced.
C) Provide adequate lighting without glare.
D) Be sure desks and chairs are adequate height.
E) Instruct child to squint when reading.

Question 22

An 8-year-old near-drowning victim is rushed into the ED.What priorities of care will be implemented? (Select all that apply. )

A) Parental education regarding prevention
B) Respiratory support
C) Cardiovascular support
D) Controlled rewarming
E) Adequate cerebral oxygenation

Question 23

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.What does the nurse suspect?

A) Meningitis
B) Reye's syndrome
C) Brain tumor
D) Encephalitis

Question 24

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

A) Isolation precautions
B) Provision of brightly lit room
C) Observation for increasing intracranial pressure
D) Preparation for spinal tap
E) Seizure precautions

Question 25

What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants?

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

Question 26

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

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 27

Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges.Which statement by the parents alerts the nurse they need further instruction?

A) "We dress our son every morning for school."
B) "Our son participates in the Special Olympics every year."
C) "Our son attends play therapy at a center close to home."
D) "We attend a support group once a week."

Question 28

What will the nurse include when documenting a grand mal seizure? (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

Question 29

Which aspect(s)of a child's development does the nurse caution parents that hearing impairment can affect? (Select all that apply. )

A) Speech clarity
B) Language development
C) Immunity to disease
D) Personality development
E) Academic achievement

Question 30

The nurse urges the mother of a 6-month-old child to get her child inoculated with Haemophilus influenzae type B.What does this immunization protect against?

A) Encephalitis
B) Influenza
C) Bacterial meningitis
D) Otitis media

Question 31

A child is diagnosed with nonparalytic strabismus.How will this disorder most likely be corrected?

A) Patching the unaffected eye
B) Corrective lenses
C) Laser treatment
D) Surgery

Question 32

The nurse is caring for a 3-year-old child with a head injury.Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?

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 33

Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply. )

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