Alteration in Neurological Adaptation
a
A 10-month-old is brought to the emergency department by her parents after they found her face down in the bathtub. The mother said, "I just left the bathroom to answer the phone. When I came back, I found her." Which assessment would be the priority? a. Airway, breathing, and circulation b. Level of consciousness c. Vital signs d. Pupillary response
d
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room? a. A room with a 12-month-old infant with a urinary tract infection b. A room with an 8-month-old infant with failure to thrive c. A two-bed room in the middle of the hall d. A private room near the nurses' station
a
A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement? a. "You look funny. Well, both of you do. I see two of you." b. "My stomach is upset. I feel like I might throw up." c. "I am glad that my headache is getting better." d. "It will be nice when you will let me take a long nap. I am sleepy."
b
During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? a. Pupil of one eye dilated and reactive b. Dramatic increase in head circumference c. Vertical nystagmus d. Posterior fontanel is closed
d
In caring for a child with a seizure disorder, the primary goal of treatment is: a. the family caregivers' anxiety will be reduced. b. the child will have an understanding of the disorder. c. the family will understand seizure precautions. d. the child will be free from injury during a seizure.
a
The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform? a. Assess the child's level of consciousness. b. Monitor core body temperature. c. Pull up the side rails on the bed. d. Help the child cope with an altered appearance.
a
The mother of a 12-year-old with Reye syndrome approaches the nurse wanting to know how this happened to her child, saying, "I never give my kids aspirin!" What could the nurse say to begin educating the woman? a. "Sometimes it's hard to tell what products may contain aspirin." b. "Do you think that maybe your child took aspirin on his own?" c. "Don't worry; you're in good hands. We have it under control now." d. "Aspirin in combination with the virus will make the brain swell and the liver fail."
c
The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history? a. Neonatal conjunctivitis b. Facial deformities c. A neural tube defect d. Incomplete myelinization
b
The nurse is observing an infant who may have acute bacterial meningitis. Which finding might the nurse look for? a. Flat fontanel b. Irritability, fever, and vomiting c. Jaundice, drowsiness, and refusal to eat d. Negative Kernig's sign
b
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority? a. Risk for delayed development b. Risk for injury c. Risk for ineffective tissue perfusion: cerebral d. Risk for self-care deficit: bathing and dressing
c
The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position? a. Lying prone, with the neck flexed b. Sitting up, with the back straight c. Lying on one side, with the back curved d. Lying prone, with the feet higher than the head
a
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session? a. "What questions or concerns do you have about this device?" b. "Do you understand why you clamp the drain before she sits up?" c. "What do you know about her autoregulation mechanism failing?" d. "Why do you always keep her head raised 30 degrees?"
c
A mother has just given birth to an infant born with anencephaly. The mother states, "With all of the technological advances in medicine, I am hopeful of a good prognosis for my baby." How should the nurse respond? a. "We will all hope for the best that your baby will be just fine." b. "Some babies live for several months. Let's hope this is true for your baby." c. "It must be very difficult to deal with this diagnosis. Tell me what you know about the prognosis." d. "Has your physician led you to believe that the prognosis is good for your baby?"
b
What information is most correct regarding the nervous system of the child? a. The child's nervous system is fully developed at birth. b. As the child grows, the gross and fine motor skills increase. c. The child has underdeveloped fine motor skills and well-developed gross motor skills. d. The child has underdeveloped gross motor skills and well-developed fine motor skills.
d
When assisting a child while she is having a tonic-clonic seizure, it would be important to: a. place a tongue blade between the child's teeth. b. restrain the child from all movement. c. turn the child onto her back and observe her. d. protect the child from hitting her arms against furniture.
a
Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis? a. Avoid making noise when in the child's room. b. Rock the child frequently. c. Have the child's 2-year-old brother stay in the room. d. Keep the lights on brightly so that he can see his mother.
