PediNeuro QUESTIONS-- Chs. 52,54

2. A 62-pound child has a spinal cord injury and has completed the bolus dose of IV steroids. The nurse is preparing to hang an IV infusion of steroids for the next 23 hours. How much medication should this child get per hour? Record your answer using 1 decimal place. Administer _______ mg/hour.

ANS: 152.2 First calculate the child's weight in kilograms: 62/2.2 = 28.181818 kilograms. Next multiply the weight by the standard dose of 5.4 mg/kg/hour 28.181818 = 152.181818. Last, round to 1 decimal place = 152.2 mg/hour. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1294 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION 1. A 62-pound child has a spinal cord injury and is to receive steroid therapy. How much medication does the nurse draw up for the bolus dose? Record your answer in a whole number. Administer _____ mg.

ANS: 845 First calculate the child's weight in kilograms: 62/2.2 = 28.181818 kilograms. Next multiply the child's weight by the standard bolus dose: 28.181818 30 = 845.454545 mg. Round to the nearest whole number = 845 mg. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1294 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

25. What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss the teeth after every meal. b. The child will require monitoring of renal function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.

ANS: A A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1298 | Table 52.3 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

14. A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial

ANS: A Absence seizures are very brief episodes of altered awareness. The child has a blank expression. Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1296 | Box 52.5 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

9. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which of the following? a. Avoiding using any latex product b. Using only non-allergenic latex products c. Administering medication for long-term desensitization d. Teaching family about long-term management of allergic manifestations

ANS: A Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75% of this patient population. There are no non-allergenic latex products. At this time, desensitization is not an option. There are no treatment options for long-term management of allergic symptoms for latex allergy. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1285 OBJ: Nursing Process: Intervention MSC: Client Needs: Physiologic Integrity

Chapter 52: The Child with a Neurologic Alteration McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition MULTIPLE CHOICE 1. What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference

ANS: A Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. Bulging fontanel or increased head circumference is seen in infants. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1279 | Box 52.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis? a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.

ANS: A In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually decreased compared with the serum glucose level. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1302 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. The most common problem of children born with a myelomeningocele is a. bladder incontinence. b. intellectual impairment. c. respiratory compromise. d. cranioschisis.

ANS: A Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children, leading to incontinence. Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1286 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. What should be the major consideration when selecting toys for a child with an intellectual or developmental disability? a. Safety b. Age appropriateness c. Ability to provide exercise d. Ability to teach useful skills

ANS: A Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are intellectually disabled. Age appropriateness should be considered in the selection of toys, but safety is of paramount importance since their intellectual age will be less than their chronological age. Ability to provide exercise and teach skills is also important but not as vital as safety. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1341 | Safety Alert Box OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

20. Parents have learned that their 6-year-old child has autism. The nurse may help the parents to cope by explaining that the child may a. have an extremely developed skill in a particular area. b. outgrow the condition by early adulthood. c. have average social skills. d. have age-appropriate language skills.

ANS: A Some children with autism have an extremely developed skill in a particular area such as mathematics or music. This information may be comforting, although the nurse should avoid giving false hope. No evidence supports that autism is outgrown. Autistic children have abnormal ways of relating to people (social skills). Speech and language skills are usually delayed in autistic children. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1352 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

28. The nurse should expect a child who has frequent tension-type headaches to describe headache pain as which of the following? a. "There is a rubber-band squeezing my head." b. "It's a throbbing pain over my left eye." c. "My headaches are worse in the morning and get better later in the day." d. "I have a stomachache and a headache at the same time."

ANS: A The child who has tension-type headaches may describe the pain as a bandlike tightness or pressure, tight neck muscles, or soreness in the scalp. A common symptom of migraines is throbbing headache pain, typically on one side of the eye. A headache that is worse in the morning and improves throughout the course of the day is typical of ICP. Abdominal pain may accompany headache pain in migraines. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1307 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

10. When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of which disorder? a. Hydrocephalus b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Cerebral palsy d. Reye's syndrome

ANS: A The combination of signs is strongly suggestive of hydrocephalus. SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reye's syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1287 | Table 52.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. "You won't be able to move your head during the procedure." b. "You will have to drink a special fluid before the test." c. "You will have to lie flat after the test is finished." d. "You will have electrodes placed on your head with glue."

ANS: A To reduce fear and enhance cooperation during the MRI, the child should be made aware that head movement will be restricted to obtain accurate information. The child does not need to drink special liquids, lie on the back afterward, or have electrodes placed. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1278 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

2. A nurse is assessing a newborn for facial feature characteristics associated with fetal alcohol syndrome. Which characteristics should the nurse expect to assess? (Select all that apply.) a. Short palpebral fissures b. Smooth philtrum c. Low-set ears d. Inner epicanthal folds e. Thin upper lip

ANS: A, B, C, E Infants with fetal alcohol syndrome may have characteristic facial features, including short palpebral fissures, a smooth philtrum (the vertical groove in the median portion of the upper lip), low-set ears, and a thin upper lip. Low-set ears and inner epicanthal folds are associated with Down syndrome. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1348 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE 1. The nurse is assessing a 3-year-old child who has characteristics of autism. Which observed behaviors are associated with autism? (Select all that apply.) a. The child flicks the light in the examination room on and off repetitiously. b. The child has a flat affect. c. The child demonstrates imitation and gesturing skills. d. The mother reports the child has no interest in playing with other children. e. The child is able to make eye contact.

ANS: A, B, D Self-stimulation is common and usually involves repetition of a sensory stimulus. Autistic children show a fixed, unchanging response to a particular stimulus. Autistic children play alone or involve others only as mere objects. Autistic children lack imitative skills. These children lack social ability and make poor eye contact. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: pp. 1351-1352 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. A 14-year-old is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes (Select all that apply.) a. monitoring and maintaining systemic blood pressure. b. administering corticosteroids. c. minimizing environmental stimuli. d. discussing long-term care issues with the family. e. monitoring for respiratory complications.

ANS: A, B, E Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. Spinal cord injury is a catastrophic event. Discussion of long-term care should be delayed until the child is stable. PTS: 1 DIF: Cognitive Level: Application/Applying REF: pp. 1294-1295 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? (Select all that apply.) a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)

ANS: A, C, D The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1302 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. A nurse should plan to implement which interventions for a child admitted with inorganic failure to thrive? (Select all that apply.) a. Observation of parent-child interactions b. Assignment of different nurses to care for the child from day to day c. Use of 28-calorie-per-ounce concentrated formulas d. Administration of daily multivitamin supplements e. Role-modeling appropriate adult-child interactions

ANS: A, D, E The nurse should plan to assess parent-child interactions when a child is admitted for nonorganic failure to thrive. The observations should include how the child is held and fed, how eye contact is initiated and maintained, and the facial expressions of both the child and the caregiver during interactions. Role-modeling and teaching appropriate adult-child interactions (including holding, touching, and feeding the child) will facilitate appropriate parent-child relationships, enhance parents' confidence in caring for their child, and facilitate expression by the parents of realistic expectations based on the child's developmental needs. Daily multivitamin supplements with minerals are often prescribed to ensure that specific nutritional deficiencies do not occur in the course of rapid growth. The nursing staff assigned to care for the child should be consistent. Providing a consistent caregiver from the nursing staff increases trust and provides the child with an adult who anticipates his or her needs and who is able to role-model child care to the parent. Caloric enrichment of food is essential, and formula may be concentrated in titrated amounts up to 24 calories per ounce. Greater concentrations can lead to diarrhea and dehydration. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1351 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

19. Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.

ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1291 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

33. 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? a. Immobilize the child's neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

ANS: B Any indication of ICP such as double vision, headache, or vomiting should be promptly reported to the physician. Stabilizing the child's neck does not address the child's symptoms. Darkening the room and giving a cool cloth are comfort measures. A fluid restriction is not needed. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1279 | Box 52.1 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

21. A child with autism is hospitalized with asthma. The nurse should plan care so that the a. parents' expectations are met. b. child's routine habits and preferences are maintained. c. child is supported through the autistic crisis. d. parents need not be at the hospital.

ANS: B Children with autism are often unable to tolerate even slight changes in routine. The child's routine habits and preferences are important to maintain. Focus of care is on the child's needs rather than on the parent's desires. Autism is a life-long condition. The presence of the parents is almost always required when an autistic child is hospitalized. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1352 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

2. A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on the knowledge that routine developmental assessments during well-child visits are a. not necessary unless the parents request them. b. the best method for early detection of cognitive disorders. c. frightening to parents and children and should be avoided. d. valuable in measuring intelligence in children.

ANS: B Early detection of cognitive disorders can be facilitated through assessment of development at each well-child examination. Developmental assessment is a component of all well-child examinations. Developmental assessments are not as frightening when the parent and child are educated about the purpose of the assessment. Developmental assessments are not intended to measure intelligence. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1340 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

35. 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? a. "Pain medication will be given." b. "The scan will not hurt." c. "You will be able to move once the equipment is in place." d. "Unfortunately no one can remain in the room with you during the test."

ANS: B For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. The child will not be allowed to move and will be immobilized. Someone is able to remain with the child during the procedure. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1278 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

24. After a tonic-clonic seizure, it would not be unusual for a child to display a. irritability and hunger. b. lethargy and confusion. c. nausea and vomiting. d. nervousness and excitability.

ANS: B In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. The other manifestations are not normally seen after a seizure. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1296 | Box 52.5 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. How much folic acid does the nurse tell female patients is recommended for women of childbearing age? a. 1.0 mg b. 0.4 mg c. 1.5 mg d. 2.0 mg

ANS: B It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age has contributed to a reduction in the number of children with neural tube defects. The other doses are not the recommended dose. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1285 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child's level of consciousness? a. Disoriented b. Obtunded c. Lethargic d. Stuporous

ANS: B Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1282 | Nursing Quality Alert Box OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

23. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if standing and go for help. b. Turn the child's body on the side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the child's wrists.

ANS: B Positioning the child on his side will prevent aspiration. It is inappropriate to leave the child during the seizure. Nothing should be inserted into the child's mouth during a seizure to prevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1301 | Nursing Quality Alert Box OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

5. Anticipatory guidance for the family of a preadolescent with a cognitive dysfunction should include information about a. institutional placement. b. sexual development. c. sterilization. d. appropriate clothing.

ANS: B Preadolescents who have a cognitive dysfunction may have normal sexual development without the emotional and cognitive abilities to deal with it. It is important to assist the family and child through this developmental stage. The child may or may not need institutional placement at some point. Sterilization is not an appropriate intervention when a child has a cognitive dysfunction. By the time a child reaches preadolescence, the family should have received counseling on age-appropriate clothing. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1342 | Nursing Care Plan OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

11. What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements

ANS: B Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The child's muscles are very tight, and any stimuli may cause a sudden jerking movement. Tremulous movements, slow writhing movements, and loss of kinesthetic sense are not manifestations of spastic cerebral palsy. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1289 | Pathophysiology Box OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

31. What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)? a. Immunosuppressive medications b. Respiratory assessment c. Passive range-of-motion exercises d. Anticoagulant therapy

ANS: B Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This is not the priority nursing intervention. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1304 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

3. Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1282 | Nursing Quality Alert Box OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. The Glasgow Coma Scale consists of an assessment of a. pupil reactivity and motor response. b. eye opening and verbal and motor responses. c. level of consciousness and verbal response. d. ICP and level of consciousness.

ANS: B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness is not a part of the Glasgow Coma Scale. Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1282 | Table 52.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. Appropriate interventions to facilitate socialization of the cognitively impaired child include a. providing age-appropriate toys and play activities. b. providing peer experiences, such as scouting, when older. c. avoiding exposure to strangers who may not understand cognitive development. d. emphasizing mastery of physical skills because they are the most delayed.

ANS: B The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to other children such as group outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is important. However, peer interactions will better facilitate social development. Parents should expose the child to strangers so that the child can practice social skills. Verbal skills are delayed more than physical skills. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1343 | Nursing Care Plan OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

13. A nurse is giving a parent information about autism. Which statement made by the parent indicates understanding of the teaching? a. Autism is characterized by periods of remission and exacerbation. b. The onset of autism usually occurs before 3 years of age. c. Children with autism have imitation and gesturing skills. d. Autism can be treated effectively with medication.

ANS: B The onset of autism usually occurs before 3 years of age. Autism does not have periods of remission and exacerbation. Autistic children lack imitative skills. Medications are of limited use in children with autism. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: p. 1350 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Chapter 54: The Child With an Intellectual Disability or Developmental Disability McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition MULTIPLE CHOICE 1. A parent whose child has been diagnosed with a cognitive deficit should be counseled that intellectual impairment a. is usually due to a genetic defect. b. may be caused by a variety of factors. c. is rarely due to first trimester events. d. is usually caused by parental intellectual impairment.

ANS: B There are a multitude of causes for intellectual impairment. In most cases, a specific cause has not been identified. Only a small percentage of children with intellectual impairment are affected by a genetic defect. One third of children with intellectual impairment are affected by first trimester events. Intellectual impairment can be transmitted to a child only if the parent has a genetic disorder. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1338 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance

8. A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of a. microcephaly. b. Down syndrome. c. cerebral palsy. d. fragile X syndrome.

ANS: B These are characteristics associated with Down syndrome. The infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth. No characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, and/or protruding ears; long, narrow face with prominent jaw; hypotonia; and high arched palate. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. Developmental delays, self-injury, fecal smearing, and severe temper tantrums in a preschool child are symptoms of a. Down syndrome. b. intellectual disability. c. psychosocial deprivation. d. separation anxiety.

ANS: B These are symptoms of intellectual disability. Down syndrome is often identified at birth by characteristic facial and head features, such as brachycephaly (disproportionate shortness of the head); flat profile; inner epicanthal folds; wide, flat nasal bridge; narrow, high-arched palate; protruding tongue; and small, short ears, which may be low set. Although intellectual impairment may be present, the symptoms listed are not the primary ones expected in the diagnosis of Down syndrome. Psychosocial deprivation may be a cause of mild intellectual disability. The symptoms listed are characteristic of severe intellectual disability. Symptoms of separation anxiety include protest, despair, and detachment. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1340 | Box 54.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

16. The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures? a. Weight loss b. Bruising c. Anorexia d. Drowsiness

ANS: B Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. Weight gain, not loss, is a side effect of valproic acid. Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications. Anorexia is not a side effect of valproic acid. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1298 | Table 52.3 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

4. A nurse is providing anticipatory guidance to parents of a child with an intellectual disability. Which safety information is correct based on the child's age? (Select all that apply.) a. Elementary age: safe use of grooming products b. High school age: safety while cooking c. Preschool age: keep hands inside car d. High school age: stranger danger e. Elementary age: water safety

ANS: B, C, E Many factors related to anticipatory guidance and safety will be similar for the cognitively impaired child as for the other children, based on the child's intellectual age. Teaching high school-age children about safety in the kitchen, preschool-age children to keep their hands inside the car, and elementary-age children water safety are appropriate areas to start with, tailored to intellectual age. Elementary-age children are too young for grooming product safety, and high school-age children are too old for stranger danger. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1341 | Table 54.1 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? (Select all that apply.) a. It must be given with D51/2 NS. b. Occasional blood levels will be assessed. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. e. It must be filtered.

ANS: B, D, E The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D51/2 NS. The IV dose must be filtered. The IV dose must be given in normal saline, not D51/2 NS. Dilantin has not been found to cause gastrointestinal upset, and since it is being given by the IV route, this is not a concern. The medication can be taken without food. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1298 | Table 52.3 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

36. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan b. Echoencephalography c. CT scan d. MRI

ANS: C 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. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1278 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. The child with Down syndrome should be evaluated for which condition before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield spots)

ANS: C Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Although hyperflexibility is characteristic of Down syndrome, it does not affect the child's ability to participate in sports. Although cutis marmorata is characteristic of Down syndrome, it does not affect the child's ability to participate in sports. Although Brushfield spots are characteristic of Down syndrome, they do not affect the child's ability to participate in sports. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. What should the nurse keep in mind when planning to communicate with a child who has autism? a. The child has normal verbal communication. b. Expect the child to use sign language. c. The child may exhibit monotone speech and echolalia. d. The child is not listening if she is not looking at the nurse.

ANS: C Children with autism have abnormalities in the production of speech such as a monotone voice or echolalia or inappropriate volume, pitch, rate, rhythm, or intonation. The child has impaired verbal communication and abnormalities in the production of speech. Some autistic children may use sign language, but it is not assumed. Children with autism often are reluctant to initiate direct eye contact. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1352 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

22. Which type of seizure involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

ANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1296 | Box 52.5 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. Which type of fracture describes traumatic separation of cranial sutures? a. Basilar b. Linear c. Comminuted d. Depressed

ANS: C Comminuted skull fractures include fragmentation of the bone or a multiple fracture line. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A linear fracture includes a straight-line fracture without dural involvement. A depressed fracture has the bone pushed inward, causing pressure on the brain. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1291 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

17. Which statement best describes fragile X syndrome? a. Chromosomal defect affecting only females. b. Chromosomal defect that follows the pattern of X-linked recessive disorders. c. It is a common genetic cause of cognitive impairment. d. Most common cause of noninherited cognitive impairment.

ANS: C Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common cause of cognitive impairment after Down syndrome. Fragile X primarily affects males. Fragile X follows the pattern of X-linked dominant with reduced manifestation of the syndrome in female and moderate to severe dysfunction in males. Fragile X is inherited. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1346 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

5. Nursing care of the infant who has had a myelomeningocele repair should include a. securely fastening the diaper. b. measurement of pupil size. c. measurement of head circumference. d. administration of seizure medications.

ANS: C Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Seizure medications are not routinely given to infants who do not have seizures. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1286 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

29. What is an appropriate nursing intervention for the child with a tension headache? a. Assess for an aura. b. Maintain complete bed rest. c. Administer mild pain medication. d. Assess for nausea and vomiting.

ANS: C Mild pain relievers like acetaminophen or ibuprofen are appropriate for the child with a tension headache. The other measures are not warranted. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1307 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. Throughout their life span, cognitively impaired children are less capable of managing environmental challenges and are at risk for a. nutritional deficits. b. visual impairments. c. physical injuries. d. psychiatric problems.

ANS: C Safety is a challenge for cognitively impaired children. Decreased capability to manage environmental challenges may lead to physical injuries. Nutritional deficits are related more to dietary habits and the caregivers' understanding of nutrition. Visual impairments are unrelated to cognitive impairment. Psychiatric problems may coexist with cognitive impairment; however, they are not environmental challenges. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1341 | Safety Alert Box OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. What action is contraindicated when a child with Down syndrome is hospitalized? a. Determine the child's vocabulary for specific body functions. b. Assess the child's hearing and visual capabilities. c. Encourage parents to leave the child alone to encourage adaptation. d. Have meals served at the child's usual meal times.

ANS: C The child with Down syndrome needs routine schedules and consistency. Having familiar people present, especially parents, helps to decrease the child's anxiety. To communicate effectively with the child, it is important to know the child's particular vocabulary for specific body functions. Children with Down syndrome have a high incidence of hearing loss and vision problems and should have hearing and vision assessed whenever they are in a health care facility. Routine schedules and consistency are important to children. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1345 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

15. What is the best response to a father who tells the nurse that his son "daydreams" at home and that his teacher has observed this behavior at school? a. "Your son must have an active imagination." b. "Can you tell me exactly how many times this occurs in one day?" c. "Tell me about your son's activity when you notice the daydreams." d. "He is probably overtired and needs more rest."

ANS: C The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained. Describing an active imagination or an overtired child does not address the symptoms of the father's concern. Determining the number of times the behavior occurs is not as helpful as information about the behavior. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1296 | Box 52.5 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

4. The most appropriate nursing diagnosis for a child with a cognitive dysfunction is a. impaired social interaction. b. deficient knowledge. c. risk for injury. d. ineffective coping.

ANS: C The nurse needs to know that limited cognitive abilities to anticipate danger lead to risk for injury. Safety is a priority for all children with cognitive dysfunction. Impaired social interaction is indeed a concern for the child with a cognitive disorder but does not address the limited ability to anticipate danger. Because of the child's cognitive deficit, knowledge will not be retained and will not decrease the risk for injury. Ineffective individual coping does not address the limited ability to anticipate danger. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1341 | Safety Alert Box OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

21. A 5-year-old sustained a concussion after falling out of a tree. In preparation for discharge, the nurse is discussing home care with the parents. Which statement made by the parents indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

ANS: C The parents are advised of probable posttraumatic symptoms. These include behavioral changes and sleep disturbances. Vomiting and diplopia should be reported immediately. Sleep disturbances may occur with postconcussive syndrome, but difficulty waking the child up should be reported. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1293 | Parents Want to Know Box OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

7. A recommendation to prevent neural tube defects is the supplementation of a. vitamin A throughout pregnancy. b. multivitamin preparations as soon as pregnancy is suspected. c. folic acid for all women of childbearing age. d. folic acid during the first and second trimesters of pregnancy.

ANS: C The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. Vitamin A, multivitamins, and folic acid only during specific points during the pregnancy have not been shown to prevent neural tube defects. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1285 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

3. The father of a child recently diagnosed with developmental delay is very rude and hostile toward the nurses. This father was cooperative during the child's evaluation a month ago. What is the best explanation for this change in parental behavior? a. The father is exhibiting symptoms of a psychiatric illness. b. The father may be abusing the child. c. The father is resentful of the time he is missing from work for this appointment. d. The father is experiencing a symptom of grief.

ANS: D After a child is diagnosed with a developmental delay, families typically experience a cycle of grieving that is repeated when developmental milestones are not met. One cannot determine that a parent is exhibiting symptoms of a psychiatric illness on the basis of a single situation. The scenario does not give any information to suggest child abuse. Although the father may have difficulty balancing his work schedule with medical appointments for his child, a more likely explanation for his behavior change is that he is grieving the loss of a normal child. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1342 | Nursing Care Plan OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

19. Which is the best setting for daytime care for a 5-year-old autistic child whose mother works? a. Private day care b. Public school c. His own home with a sitter d. A specialized program that uses behavioral methods

ANS: D Autistic children can benefit from specialized educational programs that address their special needs. Day care programs generally do not have resources to meet the needs of severely impaired children. To best meet the needs of an autistic child, the public school may refer the child to a specialized program. A sitter might not have the skills to interact with an autistic child. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1352 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

10. Many of the physical characteristics of Down syndrome present feeding problems. Care of the infant should include a. delaying feeding solid foods until the tongue thrust has stopped. b. modifying diet as necessary to minimize the diarrhea that often occurs. c. providing calories appropriate to child's age. d. using special bottles that may assist the infant with feeding.

ANS: D Breastfeeding may not be possible if the infant's muscle tone or sucking reflex is immature. Mothers should be encouraged to pump breast milk and use special bottles for assistance with feeding. Some children with Down syndrome can breastfeed adequately. The child has a protruding tongue, which makes feeding difficult. The parents must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is predisposed to constipation. Calories should be appropriate to the child's weight and growth needs, not age. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

32. A child is brought to the emergency department in status epilepticus. Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)

ANS: D Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes. The other drugs are used for seizures but are not the first-line treatment for status. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1301 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

34. 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? a. The infant has 150 mL of CSF compared with 50 mL in the adult. b. Papilledema is a common manifestation of ICP in the very young child. c. The brain of a term infant weighs less than half of the weight of the adult brain. d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

ANS: D 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. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1276 | Pediatric Differences Box OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance

30. Which statement by an adolescent indicates an understanding about factors that can trigger migraine headaches? a. "I should avoid loud noises because this is a common migraine trigger." b. "Exercise can cause a migraine. I guess I won't have to take gym anymore." c. "I think I'll get a migraine if I go to bed at 9 PM on week nights." d. "I am learning to relax because I get headaches when I am worried about stuff."

ANS: D 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. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: p. 1308 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

13. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. "You will be on your knees with your head down on the table." b. "You will be able to sit up with your chin against your chest." c. "You will be on your side with the head of your bed slightly raised." d. "You will lie on your side and bend your knees so that they touch your chin."

ANS: D The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The other positions are not used for a lumbar puncture. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1279 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

27. Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status

ANS: D The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema. Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with ICP. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1279 | Box 52.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

26. The father of a newborn infant with myelomeningocele asks about the cause of this condition. What response by the nurse is most appropriate? a. "One of the parents carries a defective gene that causes myelomeningocele." b. "A deficiency in folic acid in the father is the most likely cause." c. "Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele." d. "There may be no definitive cause identified."

ANS: D The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1285 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity

18. The nurse is providing counseling to the mother of a child diagnosed with fragile X syndrome. She explains to the mother that fragile X syndrome is a. most commonly seen in girls. b. acquired after birth. c. usually transmitted by the male carrier. d. usually transmitted by the female carrier.

ANS: D The gene causing fragile X syndrome is transmitted by the mother. Fragile X syndrome is most common in males. Fragile X syndrome is congenital. Fragile X syndrome is not transmitted by a male carrier. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1347 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity

9. The infant with Down syndrome is closely monitored during the first year of life for what serious condition? a. Thyroid complications b. Orthopedic malformations c. Dental malformation d. Cardiac abnormalities

ANS: D The high incidence of cardiac defects in children with Down syndrome makes assessment for signs and symptoms of these defects important during the first year. Clinicians recommend the child be monitored frequently throughout the first 12 months of life, including a full cardiac workup. Infants with Down syndrome are not known to have thyroid complications although they can manifest later. Orthopedic malformations may be present, but special attention is given to assessment for cardiac and gastrointestinal abnormalities. Dental malformations are not a major concern compared with the life-threatening complications of cardiac defects. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 1344 | Box 54.4 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

20. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 1292 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity