chap 40 child with neuromuscular
Client Needs: Physiological Integrity: Physiologic Adaptation
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Client Needs: Physiological Integrity: Physiologic Adaptation 12. A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, the priority assessment includes: a. swallowing ability. b. parental involvement. c. level of consciousness. d. antecedent viral infections.
A Assessment of swallowing is essential. Both pharyngeal involvement and respiratory function are usually involved at the same time. The child may require ventilatory support. The inability to swallow also contributes to aspiration pneumonia. Parental involvement is important after the physiologic assessment is complete. The child is answering questions and describing the onset of the illness, which demonstrates she is alert and oriented. Information regarding antecedent viral infections can be obtained after the child is assessed and stabilized. DIF: Cognitive Level: Application REF: p. 1706 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Physiologic Adaptation 14. An adolescent whose leg was crushed when she fell off a horse is admitted to the emergency department. She has completed the tetanus immunization series, receiving the last tetanus toxoid booster 8 years ago. The therapeutic management of this adolescent to prevent tetanus should include which of the following? a. Tetanus toxoid booster is needed because of the type of injury. b. Human tetanus immunoglobulin is indicated for immediate prophylaxis. c. Concurrent administration of both tetanus immunoglobulin and tetanus antitoxin is needed. d. No additional tetanus prophylaxis is indicated. The tetanus toxoid booster is protective for 10 years.
A Protective levels of antibody are maintained for at least 10 years. Children with serious "tetanus-prone" wounds, including contaminated, crush, puncture, or burn wounds, should receive a tetanus toxoid booster prophylactically as soon as possible. This adolescent has circulating antibodies. The immunoglobulin is not indicated. DIF: Cognitive Level: Comprehension REF: p. 1707 TOP: Nursing Process: Implementation
Client Needs: Psychosocial Integrity 10. A 4-month-old with significant head lag meets the criteria for floppy infant syndrome. A diagnosis of progressive infantile spinal muscular atrophy (Werdnig-Hoffmann) is made. Nursing care for this child includes: a. infant stimulation program. b. stretching exercises to decrease contractures. c. limited physical contact to minimize seizures. d. encouraging parents to have additional children.
A Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). An infant stimulation program is essential. Frequent position changes, including changes in environment, provide the child with more physical contacts. Verbal, tactile, and auditory stimulation is also included. Contractures do not occur due to the muscular atrophy. Sensation is normal in children with this disorder. Frequent touch is necessary as part of the stimulation. Werdnig-Hoffmann is inherited as an autosomal recessive trait. Parents should be referred for genetic counseling. DIF: Cognitive Level: Application REF: p. 1705 TOP: Nursing Process: Planning
Client Needs: Physiological Integrity: Physiologic Adaptation 21. The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). Which of the following statements should the nurse include in the training? a. Children with dyskinetic CP have a wide-based gait and repetitive movements. b. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus. c. Children with hemiplegia CP have mouth muscles and one lower limb affected. d. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria.
B CP has a variety of clinical classifications. Spastic pyramidal CP includes manifestations such as a positive Babinski sign and ankle clonus; ataxic CP has the wide-base gait and repetitive movements; hemiplegia CP is characterized by motor dysfunction on one side of the body with upper extremity more affected than lower limbs; and dyskinetic CP involves the pharyngeal and oral muscles, causing drooling and dysarthria. DIF: Cognitive Level: Application REF: p. 1693 TOP: Integrated Process: Teaching/Learning
Client Needs: Physiological Integrity: Physiologic Adaptation 8. A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. Which of the following is the most appropriate nursing action related to feeding Jason? a. Bottle- or tube-feed him a specialized formula until he gains sufficient weight. b. Stabilize his jaw with caregiver's hand (either from a front or side position) to facilitate swallowing. c. Place him in well-supported, semireclining position. d. Place him in a sitting position with his neck hyperextended to make use of gravity flow.
B Jaw control is compromised in many children with CP. More normal control is achieved if the feeder stabilizes the oral mechanisms from the front or side of the face. Bottle- or tube-feeding will not improve feeding without jaw support. The semireclining position and hyperextended neck position increase the chances of aspiration. DIF: Cognitive Level: Comprehension REF: p. 1698 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Physiologic Adaptation 5. Gingivitis is a common problem in children with cerebral palsy (CP). Preventive measures include: a. high-carbohydrate diet. b. meticulous dental hygiene. c. minimum use of fluoride. d. avoidance of medications that contribute to gingivitis.
B Meticulous oral hygiene is essential. Many children with CP have congenital enamel defects, high-carbohydrate diets, poor nutritional intake, and difficulty closing their mouths. These, coupled with the child's spasticity or clonic movements, make oral hygiene difficult. Children with CP have high carbohydrate intake and retention, which contribute to dental caries. Use of fluoride should be encouraged through fluoridated water or supplements and toothpaste. Certain medications such as phenytoin do contribute to gingival hyperplasia. If that is the drug of choice, then meticulous oral hygiene must be used. DIF: Cognitive Level: Analysis REF: p. 1701 TOP: Nursing Process: Implementation
Client Needs: Physiological Integrity: Reduction of Risk Potential 7. The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes teaching on: a. patterning. b. positions to reduce spasticity. c. stretching exercises after meals. d. topical analgesics for muscle spasms.
B Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy of Pediatrics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not effective for the muscle spasms of spastic CP. DIF: Cognitive Level: Application REF: p. 1703 TOP: Integrated Process: Teaching/Learning
Client Needs: Physiological Integrity: Physiologic Adaptation 3. Which of the following is the most common type of cerebral palsy (CP)? a. Ataxic b. Spastic c. Dyskinetic d. Mixed type
B Spastic CP is the most common clinical type. Early manifestations are usually generalized hypotonia, or decreased tone that lasts for a few weeks or may extend for months or as long as a year. It is replaced by increased stretch reflexes, increased muscle tone, and weakness. Ataxic, dyskinetic, and mixed type are less common forms of CP. DIF: Cognitive Level: Comprehension REF: p. 1693 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Physiologic Adaptation 4. The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurse's response should be based on which of the following? a. Affected children have some degree of cognitive impairment. b. Around 20% of affected children have normal intelligence. c. About 45% of affected children have normal intelligence. d. Cognitive impairment is expected if motor and sensory deficits are severe.
C Children with CP have a wide range of intelligence, and 40% to 50% are within normal limits. A large percentage of children with CP do not have mental impairment. Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise. DIF: Cognitive Level: Comprehension REF: p. 1694 TOP: Nursing Process: Assessment
Client Needs: Psychosocial Integrity 20. Which of the following statements best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)? a. It has an autosomal dominant inheritance pattern. b. Onset occurs in later childhood and adolescence. c. It is characterized by presence of Gower sign, waddling gait, and lordosis. d. Disease stabilizes during adolescence, allowing for life expectancy to approximately age 40 years.
C DMD is characterized by a waddling gait and lordosis. Gower sign is a characteristic way of rising from a squatting or sitting position on the floor. DMD is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. Onset occurs usually between ages 3 and 5 years. DMD has a progressive and relentless loss of muscle function until death by respiratory or cardiac failure. DIF: Cognitive Level: Comprehension REF: p. 1726 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Physiologic Adaptation 19. An adolescent with a spinal cord injury is admitted to a rehabilitation center. Her parents describe her as being angry, hostile, and uncooperative. The nurse should recognize that this is suggestive of which of the following? a. Normal phase of adolescent development b. Severe depression that will require long-term counseling c. Normal response to her situation that can be redirected in a healthy way d. Denial response to her situation that makes rehabilitative efforts more difficult
C During the rehabilitation phase it is desirable for adolescents to begin to express negative feelings toward the situation. The rehabilitation team can redirect the negative energy toward learning a new way of life. The injury has interrupted the normal adolescent process of achieving independence, triggering these negative behaviors. Severe depression can occur, but it indicates that the child is no longer in denial. Long-term therapy is not indicated. Being angry, hostile, and uncooperative are behaviors that are indications that the adolescent understands the severity of the injury and need for rehabilitation. DIF: Cognitive Level: Application REF: p. 1723 TOP: Integrated Process: Teaching/Learning
Client Needs: Physiological Integrity: Physiologic Adaptation 2. Spastic cerebral palsy (CP) is characterized by which of the following? a. Athetosis, dystonic movements b. Tremors, lack of active movement c. Hypertonicity; poor control of posture, balance, and coordinated motion d. Wide-based gait; poor performance of rapid, repetitive movements
C Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic CP. Athetosis and dystonic movements are part of the classification of dyskinetic or athetoid CP. Tremors and lack of active movement may indicate other neurologic disorders. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic CP. DIF: Cognitive Level: Comprehension REF: p. 1693 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies 15. During a well-child visit, the mother tells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the child's diet. Which of the following might support this diagnosis? a. Breast-feeding b. Commercial formula c. Infant cereal with honey d. Improperly sterilized bottles
C Ingestion of honey is a risk factor for infant botulism in the United States. Honey should not be given to children under the age of 1 year. Botulism is not found in commercial infant cereals. Although there is a slight increase in botulism in breast-fed infants when compared with formula-fed infants, there is not sufficient evidence to support formula-feeding as prevention. Thoroughly cleaning bottles used for formula feeding is sufficient for botulism prevention. Inadequate sterilization of home-canned foods can contribute to botulism. DIF: Cognitive Level: Comprehension REF: p. 1709 TOP: Integrated Process: Teaching/Learning
Client Needs: Psychosocial Integrity 17. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Priority nursing interventions for this child includes which of the following? a. Minimizing environmental stimuli b. Administering immunoglobulin c. Monitoring and maintaining systemic blood pressure d. Discussing long-term care issues with the family
C Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Increased blood pressure may be an indication of autonomic dysreflexia. It is not necessary to minimize environmental stimuli for this type of injury. Spinal cord injury is not an infectious process. Immunoglobulin is not indicated. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover. DIF: Cognitive Level: Application REF: p. 1717 TOP: Nursing Process: Implementation
Client Needs: Physiological Integrity: Physiologic Adaptation 13. Which of the following statements is most accurate in describing tetanus? a. Inflammatory disease that causes extreme, localized muscle spasm b. Disease affecting the salivary gland with resultant stiffness of the jaw c. Acute infectious disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus d. Acute infection that causes meningeal inflammation resulting in symptoms of generalized muscle spasm
C Tetanus results from an infection by the anaerobic spore-forming, gram-positive bacillus Clostridium tetani. The organism forms two exotoxins that affect the central nervous system to produce the clinical manifestations of the disease. Tetanus is not an inflammatory process. The toxin acts at the neuromuscular junction to produce muscular stiffness and to lower the threshold for reflex excitability. It is usually a systemic disease. Initial symptoms are usually a progressive stiffness and tenderness of the muscles of the neck and jaw. The sustained contraction of the jaw-closing muscles provides the name lockjaw. Meningeal inflammation is not the cause of the muscle spasms. DIF: Cognitive Level: Comprehension REF: p. 1707 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential 16. An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, "How bad is it?" The nurse's response should be based on which of the following? a. Families adjust better to life-threatening injuries when information is given over time. b. Immediate loss of function is indicative of the long-term consequences of the injury. c. Extent and severity of damage cannot be determined for several weeks, or even months. d. Numerous diagnostic tests will be done immediately to determine extent and severity of damage.
C The extent and severity of damage cannot be determined initially. The immediate loss of function is caused by anatomic and impaired physiologic function, and improvement may not be evident for weeks or months. It is essential to provide information about the adolescent's status to the parents. Immediate treatment information should be provided. Long-term rehabilitation and prognosis can be addressed after the child is stabilized. During the immediate postinjury period, physiologic responses to the injury make an accurate assessment of damage difficult. DIF: Cognitive Level: Application REF: p. 1715 TOP: Integrated Process: Teaching/Learning
Client Needs: Physiological Integrity: Physiologic Adaptation 22. Which of the following findings would the nurse expect to observe in a 7-month-old infant with Werdnig-Hoffman disease? Select all that apply. a. Noticeable scoliosis b. Absent deep tendon reflexes c. Abnormal tongue movements d. Failure to thrive e. Prominent pectus excavatum f. Significant leg involvement
C, D Clinical manifestations of Werdnig-Hoffman disease in an infant include absent deep tendon reflexes, abnormal tongue movements, and failure to thrive. Scoliosis, prominent pectus excavatum, and significant leg involvement are findings observed in a child with intermediate spinal muscular atrophy. DIF: Cognitive Level: Comprehension REF: p. 1704 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Physiologic Adaptation 9. An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurse's response should be based on knowledge that: a. most activities such as Girl Scouts cannot be adapted for children with CP. b. after-school activities usually result in extreme fatigue for children with CP. c. trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP. d. recreational activities often provide children with CP with opportunities for socialization and recreation.
D After-school and recreational activities serve to stimulate children's interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are adapted for children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation. DIF: Cognitive Level: Application REF: p. 1699 TOP: Integrated Process: Teaching/Learning
1. Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is which of the following? a. Central nervous system (CNS) diseases b. Birth asphyxia c. Cerebral trauma d. Neonatal encephalopathy
D Approximately 80% of CP is caused by unknown prenatal causes. Neonatal encephalopathy in term and preterm infants is believed to play a significant role in the development of CP. CNS diseases such as meningitis or encephalitis can result in CP. Birth asphyxia does contribute to some cases of CP. Cerebral trauma, including shaken baby syndrome, can result in CP. DIF: Cognitive Level: Comprehension REF: p. 1692 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential 18. Which of the following would the nurse expect in a child with a spinal cord lesion at C7? a. Complete respiratory paralysis b. No voluntary function of upper extremities c. Inability to roll over or attain sitting position d. Almost complete independence within limitations of wheelchair
D Individuals who sustain injuries at the C7 level are able to achieve a significant level of independence. Some assistance is needed with transfers and lower extremity dressing. Patients are able to roll over in bed and to sit and eat independently. Patients with injuries at C3 or higher have complete respiratory paralysis. Those with injuries at C4 or higher do not have voluntary function of higher extremities. Injuries at C5 or higher prevent this motor rolling over or sitting. DIF: Cognitive Level: Comprehension REF: p. 1713 TOP: Nursing Process: Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential 11. An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, the nurse should consider which of the following? a. Paralysis is progressive with little hope for recovery. b. Disease is inherited as an autosomal, sex-linked, recessive gene. c. Disease results from an apparently toxic reaction to certain medications. d. Muscle strength slowly returns, and most children recover.
D Recovery usually begins within 2 to 3 weeks, and most patients regain full muscle strength. The paralysis is progressive with proximal muscle weakness occurring before distal weakness. The recovery of muscle strength occurs in the reverse order of onset of paralysis. Most individuals regain full muscle strength. Better outcomes are associated with younger ages. GBS is an immune-mediated disease often associated with a number of viral or bacterial infections or the administration of vaccines. DIF: Cognitive Level: Comprehension REF: p. 1706 TOP: Integrated Process: Teaching/Learning
Client Needs: Physiological Integrity: Reduction of Risk Potential 6. The major goals of therapy for children with cerebral palsy (CP) include which of the following? a. Cure underlying defect causing the disorder. b. Reverse degenerative processes that have occurred. c. Prevent spread to individuals in close contact with child. d. Recognize the disorder early and promote optimum development.
D The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious. DIF: Cognitive Level: Comprehension REF: p. 1695 TOP: Nursing Process: Implementation