Question 1

What should be the nurse's first action when a child with a head injury complains of double vision and a headache,and then vomits?

Accepted Answer

These symptoms could indicate a serious head injury, such as a concussion or intracranial bleeding. Reporting this information to the physician is the first priority in order to determine the appropriate course of action, which could include further evaluation, imaging, or referral to a specialist. Immobilizing the neck or restricting oral fluid intake may not be necessary or appropriate at this stage, and darkening the room and using a cool cloth may provide some comfort but do not address the underlying issue.

Question 2

The nurse is preparing a school-age child for computed tomography (CT scan)to assess cerebral function.Which statement should the nurse include when preparing the child?

Accepted Answer

It is important to reassure the child that a CT scan is painless and non-invasive, as this can help alleviate anxiety about the procedure. The other options are not necessarily true or helpful in preparing the child for the scan.

Question 3

A nurse is explaining to parents how the central nervous system of a child differs from that of an adult.Which statement accurately describes these differences?

Accepted Answer

Peripheral nerves are not completely myelinated at birth.As myelinization progresses,so does the child's coordination and fine muscle movements.An infant has about 50 mL of CSF compared with 150 mL in an adult.Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP.The brain of the term infant is two thirds the weight of an adult's brain.

Question 4

What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)?

Accepted Answer

The priority nursing intervention for the child with ascending paralysis due to GBS is respiratory assessment. This is because respiratory muscle weakness is a common complication of GBS, which can lead to respiratory failure and the need for mechanical ventilation. Therefore, close monitoring of the child's respiratory status is critical to prevent respiratory compromise and ensure timely intervention if necessary. While immunosuppressive medications may be used to treat GBS, they are not the priority nursing intervention. Passive range-of-motion exercises may be beneficial for preventing contractures, but they are not the priority intervention in the acute phase of GBS. Anticoagulant therapy is not indicated in the management of GBS.

Question 5

Which type of seizures involves both hemispheres of the brain?

Accepted Answer

Generalized seizures involve both hemispheres of the brain, while focal (partial) seizures only affect one specific area or side of the brain. Acquired seizures are seizures that are not caused by an existing medical condition or injury, but rather occur as a result of some other factor such as drug use or withdrawal.

Question 6

A 5-year-old girl sustained a concussion when she fell out of a tree.In preparation for discharge,the nurse is discussing home care with her mother.Which statement made by the mother indicates a correct understanding of the teaching?

Accepted Answer

It is common for children to experience behavioral changes after sustaining a concussion, including irritability, restlessness, and changes in sleep patterns. However, vomiting, sleep disturbances, and diplopia (double vision) are not normal symptoms of a concussion and should be reported to the healthcare provider immediately.

Question 7

What nursing actions are indicated when the nurse is administering phenytoin (Dilantin)by the intravenous route to control seizures? Select all that apply.

Accepted Answer

The answer of What nursing actions are indicated when the...

Question 8

What is the most appropriate nursing response to the father of a newborn infant with myelomeningocele who asks about the cause of this condition?

Accepted Answer

Myelomeningocele is a multifactorial condition, meaning that it likely results from a combination of genetic and environmental factors. While some risk factors, such as a family history of neural tube defects or insufficient maternal folic acid intake, have been identified, there is no definitive cause for myelomeningocele. It is important to provide accurate information to the father, but also to be honest about the limitations of our understanding of this complex condition. Option A incorrectly suggests that myelomeningocele is solely caused by a single gene, and option B erroneously implicates the father's folic acid status as a primary cause. Option C correctly identifies that there may be a genetic component to the development of myelomeningocele, but is not a complete or accurate explanation of the condition.

Question 9

What should the nurse teach parents when the child is taking phenytoin (Dilantin)to control seizures?

Accepted Answer

Phenytoin (Dilantin) can cause gingival hyperplasia, which can be prevented by good oral hygiene. Using a soft toothbrush and flossing after every meal can help prevent this side effect. 
Option B is incorrect because Dilantin does not normally affect renal function, so monitoring for renal function is not required. Option C is incorrect because Dilantin should be taken on an empty stomach to ensure adequate absorption. Option D is incorrect because sudden cessation of Dilantin can lead to rebound seizures, and the decision to discontinue the medication should only be made by a healthcare provider.

Question 10

A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago.Nursing care for this child includes (select all that apply)

Accepted Answer

Monitoring and maintaining systemic blood pressure, administering corticosteroids, and monitoring for respiratory complications are all important nursing care for a 14-year-old girl in the intensive care unit after a spinal cord injury 2 days ago.

Question 11

Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?

Accepted Answer

A CT scan provides a visualization of the horizontal and vertical cross sections of the brain at any axis.A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective.Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions.MRI permits visualization of morphologic features of target structures and permits tissue discrimination that is unavailable with any other techniques.

Question 12

The nurse should expect a child who has frequent tension type of headaches to describe headache pain as

Accepted Answer

Tension type headaches are often described as a tight or band-like sensation around the head, which is consistent with the child's response of "There is a rubber-band squeezing my head."

Question 13

A nurse should expect which cerebral spinal fluid (CSF)laboratory results on a child diagnosed with bacterial meningitis? Select all that apply.

Accepted Answer

Bacterial meningitis typically causes an elevated white blood count (WBC) in the CSF due to the inflammatory response. It also causes decreased glucose levels in the CSF, as the bacteria consume the glucose for energy. The CSF may appear cloudy due to the presence of bacteria and an increase in protein. The presence of red blood cells (RBCs) is not a typical finding in bacterial meningitis.

Question 14

What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure?

Accepted Answer

Turning the child's body on the side helps to prevent aspiration and maintain an open airway during the seizure.

Question 15

Prolonged seizure activity,in the form of either a single seizure lasting 30 minutes or recurrent seizures lasting more than 30 minutes,with no return to a normal level of consciousness is known as _________________.

Accepted Answer

The answer of Prolonged seizure activity,in the form of either...

Question 16

After a tonic-clonic seizure,it would not be unusual for a child to display

Accepted Answer

After a tonic-clonic seizure, it is common for a child to feel tired (lethargy) and confused. This is because the seizure can cause confusion and disorientation, and the body has exerted a lot of energy during the seizure. Irritability, hunger, nausea, vomiting, nervousness, and excitability are less common after-effects of seizures in children.

Question 17

A child is brought to the emergency department in generalized tonic-clonic status epilepticus.Which medication should the nurse expect to be given initially in this situation?

Accepted Answer

Lorazepam (Ativan) is the initial medication of choice for generalized status epilepticus due to its fast onset of action and efficacy in terminating seizures. Clorazepate dipotassium and phenobarbital have a slower onset of action and are typically used as second-line agents. Fosphenytoin may also be used as a second-line agent, but it is not typically the initial medication of choice.

Question 18

What is an appropriate nursing intervention for the child with a tension headache?

Accepted Answer

Administering pharmacologic headache relief measures such as over-the-counter pain relievers or prescription medication can help alleviate tension headaches in children. Other interventions, such as relaxation techniques or stress management, may also be helpful. However, bed rest is typically not necessary for tension headaches and assessing for an aura or nausea/vomiting may not necessarily change the immediate nursing intervention for the headache.

Question 19

Which statement by an adolescent indicates an understanding about factors that can trigger migraine headaches?

Accepted Answer

Stress can trigger migraines.Relaxation therapy can help the adolescent control stress and headaches.Other precipitating factors in addition to stress include poor diet,food sensitivities,and flashing lights.Visual stimuli,not auditory stimuli,are known to be a common trigger for migraines.Exercise is not a trigger for migraines.The adolescent needs regular physical exercise.Altered sleep patterns and fatigue are common triggers for migraine headaches.Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue.

Question 20

Which change in status should alert the nurse to increased intracranial pressure (ICP)in a child with a head injury?

Accepted Answer

Confusion and altered mental status are classic signs of increased ICP in a child with a head injury. Rapid, shallow breathing and irregular, rapid heart rate may be seen but are not specific to increased ICP. Increased diastolic pressure with narrowing pulse pressure may occur later in the progression of increased ICP.

Quiz 52: The Child With a Neurologic Alteration