Deck 55: The Child With Alterations in Neurological Function

Question 1

A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes:

A)Applying a diaper to prevent contamination of sac.
B)Positioning the newborn in a side-lying position.
C)Encouraging the mother to hold the newborn, because she will not be able to pick him up after surgery.
D)Positioning the newborn in a prone position.

Answer 1

Positioning the newborn in a prone position.

Question 2

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?

A)The mother leaves the filled mop bucket on the floor while in another room.
B)The mother turns all pan handles to the back of the stove.
C)The mother fills the bath tub before bringing the baby into the bathroom.
D)When riding in a car, the child is in a car seat in the middle of the back seat.

Answer 2

The mother leaves the filled mop bucket on the floor while in another room.

Question 3

A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse's initial action?

A)Take vital signs.
B)Establish an intravenous line.
C)Perform rapid neurological assessment.
D)Maintain patent airway.

Answer 3

Maintain patent airway.

Question 4

A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are:

A)A sign that this child has a spinal cord injury.
B)A sign of increased intracranial pressure.
C)Typical for a sleeping child at this age.
D)A sign that the child's condition is improving.

Question 5

A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show:

A)Decreased protein count.
B)Clear, straw-colored fluid.
C)Positive for RBCs.
D)Decreased glucose level.

Question 6

A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include:

A)Appendicitis.
B)Bowel obstruction.
C)Urinary tract infection.
D)Kidney stones.

Question 7

The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question?

A)Vital signs and neuro checks hourly
B)Small, frequent formula feedings
C)Elevate head of bed
D)Daily head circumference

Question 8

The mother brings her five-month-old infant to the clinic for a well-child visit. The mother tells the nurse that the baby's father had febrile seizures when he was an infant. The mother says she is concerned her baby will have a febrile seizure and wants to know what she should do to prevent it. The nurse explains:

A)That the baby has no more risk of febrile seizures than any other baby.
B)When the infant has a fever, the mother should give the baby dose-appropriate aspirin.
C)That the baby should be sponged with cold water.
D)The mother should increase the child's fluid intake.
E)That after the tepid bath, the child should be patted dry.

Question 9

Following an outbreak of chicken pox in the school, the school nurse is concerned that children are at risk for Reye syndrome. The nurse sends home letters reminding the parents not to administer aspirin and describes the initial symptoms of Reye syndrome which are:

A)Nausea, vomiting, and confusion.
B)Headache, vomiting, and seizures.
C)Sore throat, moist respirations, and cough.
D)Fever, rash, and photophobia.

Question 10

The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal?

A)The posterior fontanel is open.
B)The infant has good head control when held upright.
C)The infant is able to roll only from abdomen to back.
D)The anterior fontanel is open and soft.

Question 11

The teacher is speaking to the school nurse about one of the girls in the fifth grade. The girl has always been a good student but lately seems to be daydreaming a lot. The teacher says, "Sometimes when I ask her a question, she will just stare at me for 15 seconds, then blink and ask me to repeat the question. What do you think is going on with her?" Based on this data, the nurse will suspect:

A)The girl has a crush on a boy in the class.
B)The girl has increased intracranial pressure.
C)The child may have had a head injury.
D)The girl is experiencing absence seizures.

Question 12

The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician's order would the nurse question?

A)Passive range-of-motion exercises
B)Oxygen at 2L nasal cannula to keep saturation above 95%
C)Hourly vital signs and neuro checks
D)Elevate head of bed 30 degrees

Question 13

A nine-month-old 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?

A)Hypotonia and muscle instability
B)Hypertonia and persistence primitive reflexes
C)Tremors and exaggerated posturing
D)Hemiplegia and hypertonia

Question 14

The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newborn indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction. The nurse will monitor the infant for signs of neonatal abstinence syndrome, including:

A)Poor feeding.
B)Difficult to arouse.
C)Constipation.
D)Seizures.
E)Yawning.

Question 15

The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child has been put on valproic acid (Depakote) for control of seizures. The nurse knows that the mother does not understand the effects of valproic acid when she states:

A)"I will not use carbonated beverages to dilute his medication."
B)"I will give his medicine on an empty stomach so he will absorb it better."
C)"I will not let him chew his tablet."
D)"I will bring him to the physician office for regular blood work to check bleeding times."

Question 16

The nurse is teaching the kindergarten teacher about a five-year-old with cerebral palsy who will be starting school. The child has a continuous baclofen pump. The nurse informs the teacher of possible side effects of this drug, including:

A)Diarrhea.
B)Hypertonia.
C)Hypotonia.
D)Restlessness.

Question 17

The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis?

A)Impaired gas exchange
B)Infection, risk for
C)Anxiety (parental)
D)Acute pain

Question 18

A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for:

A)Periorbital ecchymosis.
B)Subdural hematoma.
C)Protruding bone.
D)Epidural hematoma.

Question 19

In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to:

A)Expect the child to have normal intelligence.
B)Use latex precautions.
C)Allow the child to do her own self-catheterization.
D)Ensure that the child has a low-fiber diet.
E)Encourage the child to shift positions hourly when in her wheelchair.