Chapter 35: The Child with Neuromuscular or Muscular Dysfunction

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, which should the next priority assessment be? 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

The clinic nurse is assessing infant reflexes. What assessment indicates a persistence of primitive reflexes? a. Tonic neck reflex at 8 months of age b. Palmar grasp at 4 months of age c. Plantar grasp at 9 months of age d. Rooting reflex at 3 months of age

A Persistence of primitive reflexes is one of the earliest clues to CP (e.g., obligatory tonic neck reflex at any age or nonobligatory persistence beyond 6 months of age and the persistence or even hyperactivity of the Moro, plantar, and palmar grasp reflexes). The palmar grasp disappears by 6 months, the plantar grasp disappears by 12 months, and the rooting reflex disappears at 4 months, so these are normal findings.

The nurse is teaching the family of an infant with cerebral palsy how to administer a diazepam (Valium) pill by gastrostomy tube. What should the nurse include in the teaching session? a. The pill should be crushed and mixed with a small amount of water. b. The pill should be crushed and mixed with the infant's formula. c. After administering the medication, flush the tube with air. d. Before administering the medication, check the placement of the tube.

A Pills may be crushed and mixed with small amounts of water but not other liquids, such as formula or elixir medications, because these may act together to form a sludge that can interfere with gastrostomy tube function. When crushed pills or tablets are administered, flush the feeding tube with more water after instilling the dissolved pill in water. The tube should not be flushed with air, and placement does not need to be checked because it is directly into the stomach.

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. What care is necessary for therapeutic management of this adolescent to prevent tetanus? 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.

The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. What is the most appropriate way to position and feed this neonate? a. Prone with the head turned to the side b. On the side c. Supine in an infant carrier d. Supine, with defect supported with rolled blankets

A The prone position with the head turned to the side for feeding is the optimum position for the infant. It protects the spinal sac and allows the infant to be fed without trauma. The side-lying position is avoided preoperatively. It can place tension on the sac and affect hip dysplasia if present. The infant should not be placed in a supine position

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 disease) is made. What should be included in the nursing care for this child? 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 are also included. Contractures do not occur because of muscular atrophy. Sensation is normal in children with this disorder. Frequent touch is necessary as part of the stimulation. Werdnig-Hoffmann disease is inherited as an autosomal recessive trait. Parents should be referred for genetic counseling.

What refers to a hernial protrusion of a saclike cyst of meninges, spinal fluid, and a portion of the spinal cord with its nerves through a defect in the vertebral column? a. Rachischisis b. Meningocele c. Encephalocele d. Myelomeningocele

D A myelomeningocele has a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac.

The nurse should suspect a child has cerebral palsy (CP) if the parent says what? a. "My 6-month-old baby is rolling from back to prone now." b. "My 4-month-old doesn't lift his head when on his tummy." c. "My 8-month-old can sit without support." d. "My 10-month-old is not walking."

ANS: B Delayed gross motor development is a universal manifestation of CP. The child shows a delay in all motor accomplishments, and the discrepancy between motor ability and expected achievement tends to increase with successive developmental milestones as growth advances. The infant who does not lift his head when on the tummy is showing a gross motor delay, as that is seen at 0 to 3 months. The other statements are within normal growth and development expectations.

What functional goal should the nurse expect for a child who has a T1 to T10 spinal cord injury? (Select all that apply.) a. May be braced for standing b. Able to drive automobile with hand controls c. Can manage adapted public transportation d. Some able to use regular public transportation e. Ambulates well, often with short leg braces with or without cane

A, B, C A child with a T1 to T10 spinal cord injury may be braced for standing, is able to drive an automobile with hand controls, and can manage adapted public transportation. The ability to use regular public transportation and ambulation with bilateral long braces using four-point or swing-through crutch gait are functional goals for individuals with a T10 to L2 injury

The nurse is teaching the family with a child with cerebral palsy (CP) strategies to prevent constipation. What should the nurse include in the teaching session? (Select all that apply.) a. Increase fluid intake. b. Increase fiber in the diet. c. Administer stool softeners daily as prescribed. d. Increase the amount of dairy products in the diet. e. Allow the child to decide when to try to have a bowel movement.

A, B, C A variety of factors, including decreased mobility, decreased fluid intake, a fear of toileting, poor positioning on the toilet, and lack of fiber intake may be responsible for constipation for a child with CP. Stool softeners, laxatives, and a bowel management program may be required to prevent chronic constipation. The child should be placed on the toilet or encouraged to have a bowel movement at the same time each day. Dairy products can cause constipation.

The nurse is preparing to admit a 2-year-old child with spina bifida occulta. What clinical manifestations of spina bifida occulta should the nurse expect to observe? (Select all that apply.) a. Dark tufts of hair b. Skin depression or dimple c. Port-wine angiomatous nevi d. Soft, subcutaneous lipomas e. Bladder and sphincter paralysis

A, B, C, D Clinical manifestations of spina bifida occulta include dark tufts of hair; skin depression or dimple; port-wine angiomatous nevi; and soft, subcutaneous lipomas. Bladder and sphincter paralysis are present with spina bifida cystica but not occulta.

What are some of the associated disabilities seen with cerebral palsy? (Select all that apply.) a. Visual impairment b. Hearing impairment c. Speech difficulties d. Intellectual impairment e. Associated heart defects

A, B, C, D Some of the disabilities associated with CP are visual impairment, hearing impairment, behavioral problems, communication and speech difficulties, seizures, and intellectual impairment. Additional sensory deficits such as hypersensitivity, hyposensitivity, and balance difficulties may occur in children with CP.

The nurse is preparing to admit a 7-year-old child with ataxic cerebral palsy. What clinical manifestations of ataxic cerebral palsy should the nurse expect to observe? (Select all that apply.) a. Wide-based gait b. Rapid, repetitive movements performed poorly c. Slow, twisting movements of the trunk or extremities d. Hypertonicity with poor control of posture, balance, and coordinated motion e. Disintegration of movements of the upper extremities when the child reaches for objects

A, B, E Clinical manifestations of ataxic cerebral palsy include a wide-based gait; rapid, repetitive movements performed poorly; and disintegration of movements of the upper extremities when the child reaches for objects. Slow, twisting movements of the trunk are seen with dyskinetic cerebral palsy, and hypertonicity with poor control of posture, balance, and coordinated motion are seen with spastic cerebral palsy.

The nurse is preparing to admit a 5-year-old child with a lower motor neuron syndrome. What clinical manifestations of a lower motor neuron syndrome should the nurse expect to observe? (Select all that apply.) a. Loss of hair b. Babinski reflex present c. Skin and tissue changes d. Marked atrophy of atonic muscle e. Hyperreflexia with tendon reflexes exaggerated

A, C, D Clinical manifestations of a lower motor neuron syndrome include loss of hair, skin and tissue changes, and marked atrophy of atonic muscle. Babinski reflex present and hyperreflexia with tendon reflexes exaggerated are manifestations of an upper motor neuron syndrome

The nurse is preparing to admit a 10-year-old child with Duchenne muscular dystrophy. What clinical features of Duchenne muscular dystrophy should the nurse recognize? (Select all that apply.) a. Calf muscle hypertrophy b. Late onset, usually between 6 and 8 years of age c. Progressive muscular weakness, wasting, and contractures d. Loss of independent ambulation by 9 to 12 years of age e. Slowly progressive, generalized weakness during adolescence

A, C, D, E Clinical features of Duchenne muscular dystrophy include calf muscle hypertrophy; progressive muscular weakness; wasting and contractures; loss of independent ambulation by 9 to 12 years of age; and slowly progressive, generalized weakness during adolescence. The onset is early, not late, usually between 3 and 5 years of age.

A goal for children with spina bifida is to reduce the chance of allergy development. What is a priority nursing intervention? a. Recommend allergy testing. b. Provide a latex-free environment. c. Use only powder-free latex gloves. d. Limit use of latex products as much as possible.

B A latex-free environment is the goal. This includes eliminating the use of latex gloves and other medical devices containing latex. Allergy testing would provide information about whether the allergy has developed. It will not reduce the chances of developing the allergy. Although powder-free latex gloves are less allergenic, latex should not be used. Limiting the use of latex products is one component of providing a latex-free environment, but latex products should not be used.

The nurse is caring for a family whose infant was just born with anencephaly. What is the most important nursing intervention? a. Implement measures to facilitate the attachment process. b. Help the family cope with the birth of an infant with a fatal defect. c. Prepare the family for extensive surgical procedures that will be needed. d. Provide emotional support so the family can adjust to the birth of an infant with problems.

B Anencephaly is the most serious neural tube defect. The infants have an intact brainstem and, if born alive, may be able to maintain vital functions for a few hours to several weeks. The family requires emotional support and counseling to cope with the birth of an infant with a fatal defect. The parents should be encouraged to hold their infant and provide comfort measures. This facilitates the grieving process because the infant has a limited life expectancy. Infants with anencephaly do not have cerebral hemispheres. There is no surgical correction available for this defect. Emotional support is needed as the family adjusts to the birth of a child who has a fatal defect.

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). What statement 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 a wide-based 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

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. What is the most appropriate nursing action related to feeding this child? 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 a 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.

Gingivitis is a common problem in children with cerebral palsy (CP). What preventive measure should be included in the plan of care? 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.

What is the rationale for orthopedic surgery for a child with cerebral palsy? a. To cure spasticity b. To improve function c. For cosmetic purposes d. To prevent the need of physical therapy

B Orthopedic surgery is used primarily to improve function rather than for cosmetic purposes and is followed by physical therapy. It will not cure spasticity

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 which teaching? 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.

What type of cerebral palsy (CP) is the most common type? 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 1 year. It is replaced by increased stretch reflexes, increased muscle tone, and weakness. Ataxic, dyskinetic, and mixed type are less common forms of CP

The most important nursing intervention when caring for an infant with myelomeningocele in the preoperative stage is which? a. Take vital signs every hour. b. Place the infant on the side to decrease pressure on the spinal sac. c. Watch for signs that might indicate developing hydrocephalus. d. Apply a heat lamp to facilitate drying and toughening of the sac.

B The spinal sac is protected from damage until surgery is performed. Early surgical closure is recommended to prevent local trauma and infection. Monitoring vital signs and watching for signs that might indicate developing hydrocephalus are important interventions, but preventing trauma to the sac is a priority. The sac is kept moist until surgical intervention is done.

A recommendation to prevent neural tube defects (NTDs) is the supplementation of what? a. Vitamin A throughout pregnancy b. Folic acid for all women of childbearing age c. Folic acid during the first and second trimesters of pregnancy d. Multivitamin preparations as soon as pregnancy is suspected

B The widespread use of folic acid among women of childbearing age has decreased the incidence NTDs. In the United States, the rates of NTDs have declined from 1.3 per 1000 births in 1990 to 0.3 per 1000 after the introduction of mandatory folic acid supplementation in food in 1998. Vitamin A is not related to the prevention of NTDs. Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy. The NTD is a failure of neural tube closure during early development, the first 3 to 5 weeks.

What functional goal should the nurse expect for a child who has a C7 spinal cord injury? (Select all that apply.) a. Able to drive automobile with hand controls b. Complete independence within limitations of a wheelchair c. Can roll over in bed, sit up in bed, and eat independently d. Requires some assistance in transfer and lower extremity dressing e. Ambulation with bilateral long braces using four-point or swing-through crutch gait

B, C, D A child with a C7 spinal cord injury can expect to be completely independent within the limitations of a wheelchair, can roll over in bed, sit up in bed, and eat independently, and will require some assistance in transfer and lower extremity dressing. The ability to drive an automobile with hand controls is a functional goal for a T1 to T10 spinal cord injury. Ambulation with bilateral long braces using four-point or swing-through crutch gait is a functional goal for a T10 to L2 injury.

What findings should 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

B, 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.

The nurse is preparing to admit a 7-year-old child with an upper motor neuron syndrome. What clinical manifestations of an upper motor neuron syndrome should the nurse expect to observe? (Select all that apply.) a. No flexor spasms b. Babinski reflex present c. No wasting of muscle mass d. Marked atrophy of atonic muscle e. Hyperreflexia with tendon reflexes exaggerated

B, C, E Clinical manifestations of an upper motor neuron syndrome include Babinski reflex present, no wasting of muscle mass, and hyperreflexia with tendon reflexes exaggerated. No flexor spasms and marked atrophy of atonic muscle are manifestations of a lower motor neuron syndrome.

The nurse is preparing to admit a 5-year-old with spina bifida cystica that was below the second lumbar vertebra. What clinical manifestations of spina bifida cystica below the second lumbar vertebra should the nurse expect to observe? (Select all that apply.) a. No motor impairment b. Lack of bowel control c. Soft, subcutaneous lipomas d. Flaccid, partial paralysis of lower extremities e. Overflow incontinence with constant dribbling of urine

B, D, E The clinical manifestations of spina bifida cystica below the second lumbar vertebra include lack of bowel control, flaccid, partial paralysis of lower extremities, and overflow incontinence with constant dribbling of urine. No motor impairment occurs with spina bifida cystica that was below the third lumbar vertebra, and soft, subcutaneous lipomas occur with spina bifida occulta.

A toddler with spastic cerebral palsy needs to be transported to the radiology department. What transportation method should the nurse use to take the toddler to the radiology department? a. A stretcher b. A wheelchair c. A wagon with pillows d. Carried in the nurse's arms

C A wagon with pillows would support the child with spastic cerebral palsy better than a stretcher or wheelchair. A wagon would give the child a "wheelchair" experience, so the nurse should not carry the child.

A mother tells the clinic nurse that she often puts honey on her infant's pacifier to soothe the infant. What response should the nurse make to the mother? a. "That is a good way to soothe your baby." b. "Honey does not have any soothing effects." c. "There is still a risk for infant botulism from honey." d. "Honey is OK, but it should not be put on the pacifier."

C Although the precise source of Clostridium botulinum spores has not been identified as originating from honey in many cases of infant botulism in the United States, it is still recommended that honey not be given to infants younger than 12 months because the spores have been found in honey.

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 knowledge? 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.

What statement 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, a 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.

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 psychosocial state? 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.

A feeding technique the nurse can teach to parents of a child with cerebral palsy to improve use of the lips and the tongue to facilitate speech is which? a. Feeding pureed foods b. Placing food on the tongue c. Placing food at the side of the tongue d. Placing food directly into the mouth with a spoon

C Feeding techniques such as forcing the child to use the lips and tongue in eating facilitate speech. An example of this technique is placing food at the side of the tongue, first one side and then the other, and making the child use the lips to take food from a spoon rather than placing it directly on the tongue. Feeding pureed foods would not encourage use of the lips and tongue.

Spastic cerebral palsy (CP) is characterized by which clinical manifestations? 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. A wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic CP.

The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what? a. Playing "pat-a-cake" with the child b. None so the child does not become overstimulated c. Putting a colorful mobile with music on the bed d. Giving the child a coloring book and crayons

C Incorporating play into the therapeutic program for a child with CP often requires great ingenuity and inventiveness from those involved in the child's care. Objects and toys are chosen for the child's developmental stage to provide needed sensory input using a variety of shapes, forms, and textures. Nurses can help parents integrate therapy into play activities in natural ways.

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. What factor should support this diagnosis? a. Breastfeeding 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 younger than the age of 1 year. Botulism is not found with the use of commercial infant cereals. Although there is a slight increase in botulism in breastfed 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.

A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child? 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.

What statement 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.

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 knowledge? 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.

What most accurately describes bowel function in children born with a myelomeningocele? a. Incontinence cannot be prevented. b. Enemas and laxatives are contraindicated. c. Some degree of fecal continence can usually be achieved. d. Colostomy is usually required by the time the child reaches adolescence.

C With a combination of dietary modification, regular toilet habits, and prevention of constipation and impaction, some degree of fecal continence can usually be achieved. Incontinence can be minimized with the development of a regular bowel training program. A surgical intervention can assist with continence. Enemas and laxatives are part of a bowel training program. Colostomies are not indicated in children with myelomeningocele

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 which knowledge? 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.

What is the most common cause of cerebral palsy (CP)? 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.

The nurse is caring for a child with myasthenia gravis (MG). What health care prescription should the nurse verify before administering? a. Ceftizoxime (Cefizox) b. Cefotaxime (Claforan) c. Ceftriaxone (Rocephin) d. Garamycin (gentamicin)

D Avoid aminoglycoside antibiotics such as gentamicin because they potentiate MG symptoms. Cefizox, Claforan, and Rocephin are cephalosporin antibiotics.

The nurse is caring for a child with tetanus during the acute phase. What should the nurse plan in the care for this child? a. Playing music on a radio b. Giving frequent back rubs c. Providing bright lighting in the room d. Clustering nursing care to limit distractions

D In caring for a child with tetanus during the acute phase, every effort should be made to control or eliminate stimulation from sound, light, and touch. Although a darkened room is ideal, sufficient light is essential so that the child can be carefully observed; light appears to be less irritating than vibratory or auditory stimuli. The infant or child is handled as little as possible, and extra effort is expended to avoid any sudden or loud noise to prevent seizures

What functional ability should 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 rolling over or sitting.

Neuropathic bladder disorders are common among children with which disorder? a. Plagiocephaly b. Meningocele c. Craniosynostosis d. Myelomeningocele

D Myelomeningocele is one of the most common causes of neuropathic bladder dysfunction among children. Plagiocephaly is the flattening of a side of the child's head. This is not associated with neuropathic bladder. Children with meningocele usually do not have neuropathic bladder. Craniosynostosis is the premature closure of one or more cranial sutures. It is not associated with neuropathic bladder.

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider? 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.

What is a major goal of therapy for children with cerebral palsy (CP)? a. Cure the underlying defect causing the disorder. b. Reverse the degenerative processes that have occurred. c. Prevent the spread to individuals in close contact with the 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

When a child develops latex allergy, which food may also cause an allergic reaction? a. Yeast b. Wheat c. Peanuts d. Bananas

D There are cross-reactions between allergies to latex and to a number of foods such as bananas, avocados, kiwi, and chestnuts. Although yeast, wheat, and peanuts are potential allergens, currently they are not known to cross-react with latex allergy.

A woman who is 6 weeks pregnant tells the nurse that she is worried that, even though she is taking folic acid supplements, the baby might have spina bifida because of a family history. The nurse's response should be based on what? a. Prenatal detection is not possible yet. b. There is no genetic basis for the defect. c. Chromosome studies done on amniotic fluid can diagnose the defect prenatally. d. Open neural tube defects (NTDs) result in elevated concentrations of -fetoprotein in amniotic fluid.

D Ultrasound scanning and measurement of -fetoprotein may indicate the presence of anencephaly or myelomeningocele. The optimum time for performing this analyzing is between 16 and 18 weeks. Prenatal diagnosis is possible through amniocentesis. A multifactorial origin is suspected, including drugs, radiation, maternal malnutrition, chemicals, and possibly a genetic mutation. Chromosome abnormalities are not present in NTDs.