Deck 54: The Child With Alterations in Neurologic Function

Question 1

Which preventative strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures? Select all that apply.
1) Increasing oral intake of fluids
2) Administering dose-appropriate aspirin
3) Providing a sponge bath with cold water
4) Decreasing oral fluid intake
5) Patting the child dry after a tepid bath

Answer 1

1, 5

Question 2

The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?
1) Passive range-of-motion exercises to promote hip flexion
2) Oxygen at 2 L nasal cannula to keep saturation above 95%
3) Hourly vital signs and neurologic checks
4) Elevate head of bed 30 degrees

Answer 2

1

Question 3

A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?
1) Hypotonia and muscle instability
2) Hypertonia and persistence primitive reflexes
3) Tremors and exaggerated posturing
4) Hemiplegia and hypertonia

Answer 3

1

Question 4

Which nursing diagnoses should the nurse include in the plan of care for a pediatric client who experiences a traumatic brain injury (TBI)? Select all that apply.
1) Risk for Ineffective Tissue Perfusion: Cerebral
2) Risk for Aspiration
3) Risk for Imbalanced Fluid Volume
4) Compromised Family Coping
5) Chronic Pain

Question 5

A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data?
1) Decreased protein count
2) Clear, straw-colored fluid
3) Positive for red blood cells (RBCs)
4) Decreased glucose level

Question 6

A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. Which does the nurse suspect based on these data?
1) Spinal cord injury
2) Increased intracranial pressure.
3) Typical for sleep
4) Improvement

Question 7

Which side effect should the nurse include in the parent teaching for a child who is prescribed a baclofen pump for cerebral palsy?
1) Diarrhea
2) Hypertonia
3) Hypotonia
4) Restlessness

Question 8

Which should the nurse include in the plan of care for a hospitalized school-age child with myelodysplasia? Select all that apply.
1) Implementing interventions for a client of normal intelligence
2) Using latex precautions when providing client care
3) Allowing the client to self-catheterize
4) Ensuring that the client has a low-fiber diet
5) Encouraging the client to shift positions hourly when in the wheelchair

Question 9

A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?
1) Take vital signs.
2) Establish an intravenous line.
3) Perform rapid neurologic assessment.
4) Maintain patent airway.

Question 10

When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother?
1) The mother leaves the filled mop bucket on the floor while in another room.
2) The mother turns all pan handles to the back of the stove.
3) The mother fills the bath tub before bringing the baby into the bathroom.
4) When riding in a car, the child is in a car seat in the middle of the back seat.

Question 11

The nurse is caring for a 9-month-old infant who just returned from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question?
1) Vital signs and neurologic checks hourly
2) Small, frequent formula feedings
3) Elevate head of bed
4) Daily head circumference

Question 12

A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect?
1) Appendicitis
2) Bowel obstruction
3) Urinary tract infection
4) Kidney stones

Question 13

A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate?
1) Applying a diaper to prevent contamination of sac
2) Positioning the newborn in a side-lying position
3) Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery
4) Positioning the newborn in a prone position

Question 14

Which assessment finding for a 4-month-old infant would require further action by the nurse?
1) The posterior fontanel is open.
2) The infant has good head control when held upright.
3) The infant is able to roll only from abdomen to back.
4) The anterior fontanel is open and soft.

Question 15

Which nursing diagnoses should the nurse include in the plan of care for a pediatric client diagnosed with cerebral palsy? Select all that apply.
1) Risk for Constipation
2) Impaired Tissue Integrity
3) Impaired Verbal Communication
4) Acute Pain
5) Risk for Delayed Development

Question 16

The nurse is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the nurse concern?
1) Nausea, vomiting, and confusion
2) Headache, vomiting, and seizures
3) Sore throat, moist respirations, and cough
4) Fever, rash, and photophobia

Question 17

Which is the priority nursing diagnosis when planning care for a pediatric client who is diagnosed with bacterial meningitis?
1) Impaired Gas Exchange
2) Risk for Infection
3) Anxiety (parental)
4) Acute Pain

Question 18

Which clinical manifestation should the nurse monitor for when assessing a pediatric client who is diagnosed with a basilar skull fracture?
1) Periorbital ecchymosis
2) Subdural hematoma
3) Protruding bone
4) Epidural hematoma

Question 19

The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education?
1) "I will not use carbonated beverages to dilute his medication."
2) "I will give his medicine on an empty stomach so he will absorb it better."
3) "I will not let him chew his tablet."
4) "I will bring him to the physician's office for regular blood work to check bleeding times."

Question 20

A teacher states to the school nurse, "I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?" Which should the nurse include in the response to the teacher?
1) The child has a crush on the teacher.
2) The child has increased intracranial pressure.
3) The child may have had a head injury.
4) The child is experiencing absence seizures.

Question 21

Which clinical manifestations support the diagnosis of viral meningitis? Select all that apply.
1) Abrupt onset of fever
2) Headache
3) Myalgia
4) Hemorrhagic rash
5) Purpura

Question 22

The nurse is planning a teaching session for the parents of a child who is diagnosed with simple partial seizures. Which causes should the nurse include when teaching the parents? Select all that apply.
1) Lesions
2) Cysts
3) Tumor
4) Brain abscesses
5) Brain trauma

Question 23

Which nursing diagnoses should the nurse include in the plan of care for a pediatric client diagnosed with hydrocephalus? Select all that apply.
1) Risk for Infection
2) Impaired Physical Mobility
3) Risk for Caregiver Role Strain
4) Risk for Injury
5) Risk for Constipation