FINAL neuro

The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure? 1. Inability to swallow 2. Elevated temperature 3. Altered hearing ability 4. Orthostatic hypotension

2. Elevated temperature

The nurse should place a child who had a medulloblastoma brain tumor (infratentorial) removed in which position postoperatively? 1. Trendelenburg's 2. Flat, on either side 3. With the head of the bed elevated above heart level 4. With the head of the bed elevated in low Fowler's position

2. Flat, on either side

A nurse is collecting data on a 7-year-old child who is suspected of having episodes of absence seizures. Which question should the nurse ask the parents to identify the symptoms associated with these types of seizures? 1. "Does the muscle twitching occur on one side of the body?" 2. "Does the muscle twitching occur on both sides of the body?" 3. "Does the sensation of twitching occur in the face and neck?" 4. "Does the child have a blank expression during these episodes?"

4. "Does the child have a blank expression during these episodes?"

A nurse caring for an infant with a diagnosis of hydrocephalus should monitor the infant for which sign of increased intracranial pressure (ICP)? 1. Proteinuria 2. Bradycardia 3. A drop in blood pressure 4. A bulging anterior fontanel

4. A bulging anterior fontanel

Cerebral palsy (CP) is a term applied to a disorder that impairs movement and posture. The effects on perception, language, and intellect are determined by the type that is diagnosed. What are the potential warning signs of CP? Select all that apply. 1. The infant's arms or legs are stiff or rigid. 2. A high risk factor for CP is very low birth weight. 3. By 8 months of age, the infant can sit without support. 4. The infant has strong head control but a limp body posture. 5. The infant has feeding difficulties, such as poor sucking and swallowing. 6. If the infant is able to crawl, only one side is used to propel himself or herself.

1. The infant's arms or legs are stiff or rigid. 2. A high risk factor for CP is very low birth weight. 5. The infant has feeding difficulties, such as poor sucking and swallowing. 6. If the infant is able to crawl, only one side is used to propel himself or herself.

The nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

1. Time the seizure. 3. Stay with the child. 5. Move furniture away from the child.

Which nursing actions apply to the care of a child who is having a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Insert an oral airway. 5. Place the child in a lateral side-lying position. 6. Loosen clothing around the child's neck.

1. Time the seizure. 3. Stay with the child. 5. Place the child in a lateral side-lying position. 6. Loosen clothing around the child's neck.

A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication.

1. Withhold the medication.

A nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse should immediately test the discharge for the presence of which substance? 1. Protein 2. Glucose 3. Neutrophils 4. White blood cells

2. Glucose

A nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. Which assessment finding should the nurse expect if this type of posturing were present? 1. Flexion of the upper extremities and extension of the lower extremities 2. Unilateral or bilateral postural change in which the extremities are rigid 3. Abnormal extension of the upper and lower extremities with some internal rotation 4. Arms are adducted with fists clenched and the legs are flaccid with external rotation

3. Abnormal extension of the upper and lower extremities with some internal rotation

The nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. The nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition? 1. "The herniation can be unilateral or bilateral." 2. "It involves only anterior portions of the brain." 3. "It can cause death if large amounts of tissue are involved." 4. "The brain herniates downward and around the tentorium cerebelli."

2. "It involves only anterior portions of the brain."

The nurse is caring for a child diagnosed with Down's syndrome. In describing the disorder to the parents, what characteristics are mostclosely associated with the syndrome and serve as the basis for the nurse's explanation? 1. Subaverage intellectual functioning with a congenial nature 2. Above-average intellectual functioning with deficits in adaptive behavior 3. Moderate to severe retardation and linkage to an extra chromosome 21, group G 4. Average intellectual functioning and the absence of deficits in adaptive behavior

3. Moderate to severe retardation and linkage to an extra chromosome 21, group G

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? 1. Increase oral fluids. 2. Document the finding. 3. Notify the health care provider. 4. Place the infant supine in a side-lying position.

3. Notify the health care provider.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3. Rigid extension and pronation of the arms and legs

The nurse enters a child's room and discovers that the child is having a seizure. Which actions should the nurse take? Select all that apply. 1. Call a code. 2. Run to get the crash cart. 3. Turn the child on her side. 4. Loosen any restrictive clothing. 5. Check the child's respiratory status. 6. Place an airway into the child's mouth.

3. Turn the child on her side. 4. Loosen any restrictive clothing. 5. Check the child's respiratory status.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings? 1.Nausea, delirium, and fever 2.Severe headache and back pain 3.Photophobia, fever, and confusion 4.Severe headache, fever, and a change in the level of consciousness

4.Severe headache, fever, and a change in the level of consciousness

A nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to caring for their child, who has a chronic illness. Which statement, if made by the parents, would indicate a need for further teaching? 1. "Our child sleeps in our bedroom at night." 2. "We worry about injuries when our child has a seizure." 3. "Our child is involved in a swim program with neighbors and friends." 4. "Our babysitter just completed cardiopulmonary resuscitation [CPR] training."

1. "Our child sleeps in our bedroom at night."

A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the health care provider's prescriptions, which would the nurse question as appropriate for a child with this diagnosis? 1. Administer an oral antibiotic. 2. Maintain strict intake and output. 3. Draw blood for a culture and sensitivity. 4. Place the child on droplet precautions in a private room.

1. Administer an oral antibiotic.

A school-age child with Down syndrome is brought to the ambulatory care center by the mother. The child has bruising all over the body. To work most effectively with this child, the nurse first addresses which complication associated with Down syndrome? 1. Children with Down syndrome are more likely to develop acute leukemia than the average child. 2. Children with Down syndrome fall down easily as a result of hyperflexibility and muscle weakness. 3. Children with Down syndrome are at risk for physical abuse because of their low intellectual functioning. 4. Children with Down syndrome scratch themselves a lot because of dry, cracked, and frequently fissuring skin.

1. Children with Down syndrome are more likely to develop acute leukemia than the average child.

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What should the nurse document that the child is experiencing? 1. Decorticate posturing 2. Decerebrate posturing 3. Flexion of the arms and legs 4. Normal expected positioning after head injury

1. Decorticate posturing

The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem? 1. Infection 2. Choking 3. Inability to tolerate stimulation 4. Delayed growth and development

1. Infection

A nurse reviews the plan of care for a child with Reye's syndrome. Which priority intervention should the nurse include in the plan of care? 1. Monitor for signs of increased intracranial pressure. 2. Immediately check the presence of protein in the urine. 3. Reassure the parents hyperglycemia is a common symptom. 4. Teach the parents signs and symptoms of a bacterial infection.

1. Monitor for signs of increased intracranial pressure.

A nurse notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse should determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement should the nurse plan to include in the discharge teaching with the parents to reflect this safety need? 1. "Feed your infant in a side-lying position." 2. "Place a helmet on your infant when in bed." 3. "Hyperextend your infant's head with a rolled blanket under the neck area." 4. "When picking up your infant, support the infant's neck and head with the open palm of your hand."

4. "When picking up your infant, support the infant's neck and head with the open palm of your hand."

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture

4. A chronic disability characterized by impaired muscle movement and posture

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

2. Reposition the infant frequently.

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? 1. Nausea 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size

1. Nausea

The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding should the nurse expect to note on assessment of the child? 1. Not easily arousable and limited interaction 2. Loss of the ability to think clearly and rapidly 3. Loss of the ability to recognize place or person 4. Awake, alert, interacting with the environment

1. Not easily arousable and limited interaction

The nurse is developing a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique should be performed that will best detect the presence of an increase in intracranial pressure? 1. Check urine for specific gravity. 2. Monitor for signs of dehydration. 3. Assess anterior fontanel for bulging. 4. Assess blood pressure for signs of hypotension.

3. Assess anterior fontanel for bulging.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1. Enteric 2. Contact 3. Droplet 4. Neutropenic

3. Droplet

A nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? 1. Increased systolic blood pressure 2. Abnormal posturing of extremities 3. Significant widening pulse pressure 4. Changes in level of consciousness (LOC)

4. Changes in level of consciousness (LOC)

The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse should modify the client's plan of care based on which interpretation of the client's change? 1. An insignificant finding 2. An improvement in condition 3. Decreasing intracranial pressure 4. Deteriorating neurological function

4. Deteriorating neurological function

The nursing student is assigned to care for a child with a brain injury who has a temporal lobe herniation. The nursing instructor determines that the student needs to further research this type of injury if the student states that which finding is a characteristic of this type of herniation? 1. It can cause ipsilateral pupil dilation. 2. It produces compression of the sixth cranial nerve. 3. A shifting of the temporal lobe laterally across the tentorial notch occurs. 4. Flaccid paralysis, pupil fixation, and death can occur if the intracranial pressure continues to rise.

2. It produces compression of the sixth cranial nerve

The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure? 1. "Does twitching occur in the face and neck?" 2. "Does the muscle twitching occur on one side of the body?" 3. "Does the muscle twitching occur on both sides of the body?" 4. "Does the child have a blank expression during these episodes?"

4. "Does the child have a blank expression during these episodes?"

The nurse is preparing a plan of care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care knowing that this type of posturing indicates which finding? 1. Damage to the pons 2. Damage to the midbrain 3. Damage to the diencephalon 4. A lesion in the cerebral hemisphere

4. A lesion in the cerebral hemisphere

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which instruction should the nurse provide to the mother? 1. Increase stimuli in the home environment. 2. Avoid daytime naps so that the child will sleep at night 3. Give the child frequent small meals, if vomiting occurs. 4. Check the skin and eyes every day for a yellow discoloration..

4. Check the skin and eyes every day for a yellow discoloration

The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which nursing action to maintain the infant's safety? 1. Covering the back dressing with a binder 2. Placing the infant in a head-down position 3. Strapping the infant in a baby seat sitting up 4. Elevating the head with the infant in the prone position

4. Elevating the head with the infant in the prone position

A child is diagnosed with Reye's syndrome. The nurse develops a nursing care plan for the child and should include which intervention in the plan? 1. Assessing hearing loss 2. Monitoring urine output 3. Changing body position every 2 hours 4. Providing a quiet atmosphere with dimmed lighting

4. Providing a quiet atmosphere with dimmed lighting

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCPs) prescriptions and should contact the HCP to question which prescription? 1. Suction as needed. 2. Obtain daily weight. 3. Provide clear liquid intake. 4. Maintain a patent intravenous line.

1. Suction as needed.

The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective? 1. "We're glad we only have to give our child the medication for 30 days." 2. "We will make appointments for follow-up blood work and care as directed." 3. "We're glad there are no side effects from taking the antiseizure medications." 4. "After our child has been seizure free for 1 month, we can discontinue the medication."

2. "We will make appointments for follow-up blood work and care as directed."

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

3. Cloudy CSF, elevated protein, and decreased glucose levels

The nurse is monitoring a child with a brain tumor for complications associated with increased intracranial pressure (ICP). Which finding, if noted by the nurse, would indicate the presence of diabetes insipidus (DI)? 1. Weight gain 2. Hypertension 3. High urine output 4. Urine specific gravity greater than 1.020

3. High urine output

The nurse is assessing a client with fragile X syndrome. The nurse anticipates to note which physical assessment finding? 1. Low, straight palate 2. Short, narrow protruding ears 3. Long, narrow face with a prominent jaw 4. Short, rounded face with an indiscernible jaw

3. Long, narrow face with a prominent jaw

A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and the nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

4. Bradycardia

The nurse assists a health care provider in performing a lumbar puncture on a 3-year-old child with leukemia in whom central nervous system disease is suspected. In which position will the nurse place the child during this procedure? 1. Lithotomy position 2. Modified Sims position 3. Prone with knees flexed to the abdomen and head bent with chin resting on the chest 4. Lateral recumbent position with the knees flexed to the abdomen and head bent with the chin resting on chest

4. Lateral recumbent position with the knees flexed to the abdomen and head bent with the chin resting on chest

The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. Which action should the nurse perform for this test? 1. Tap the child's facial nerve and assess for spasm. 2. Compress the child's upper arm and assess for tetany. 3. Bend the child's head toward the knees and hips and assess for pain. 4. Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain.

4. Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain.

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4. Suctioning equipment and oxygen

A nursing student is assisting a school nurse in performing scoliosis screening on the children in the school. The nurse assesses the student's preparation for conducting the screening. The nurse determines that the student demonstrates understanding of the disorder when the student states that scoliosis is characterized by which finding? 1.Abnormal lateral curvature of the spine 2.Abnormal anterior curvature of the lumbar spine 3.Excessive posterior curvature of the thoracic spine 4.Abnormal curvature of the spine caused by inflammation

1.Abnormal lateral curvature of the spine

The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is characteristic of this sign? 1. The child complains of muscle and joint pain. 2. Petechial and purpuric rashes are noted on the child's trunk. 3. Neck flexion causes adduction and flexion movements of the lower extremities. 4. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.

4. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. 1. Remain calm. 2. Time the seizure. 3. Ease the child to the floor. 4. Loosen restrictive clothing. 5. Keep the child on her back. 6. Place a pillow under the child's head.

1. Remain calm. 2. Time the seizure. 3. Ease the child to the floor. 4. Loosen restrictive clothing. 6. Place a pillow under the child's head.

The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse should include which instruction? 1. Expect an increased urine output from the shunt. 2. Notify the health care provider if the infant is fussy. 3. Call the health care provider if the infant has a high-pitched cry. 4. Position the infant on the side of the shunt when the infant is put to bed.

3. Call the health care provider if the infant has a high-pitched cry.