FINAL 132

Match the medications with the appropriate action . -Baclofen -Corticosteroids -Botulin toxin -Benzodiazepines -Oxybutynin

Baclofen- Central acting skeletal muscle relaxant -Corticosteroids-Anti-inflammatory -Botulin toxin- Neurotoxin -Benzodiazepines- Anticonvulsant -Oxybutynin-Antispasmodic

Which of the following images provides an appropriate label for meningocele. -A -B -C -D

C

Which instruction would the nurse provide for the patient when testing the trigeminal nerve? -"Stick out your tongue." -"Close your eyes and tell me where you feel the cotton touching your face." -"Turn your head side to side." -"I am going to shine a light into your eyes and observe your pupils."

-"Close your eyes and tell me where you feel the cotton touching your face."

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? - Airway, breathing, and circulation -Level of consciousness -Vital signs -Pupillary response

- Airway, breathing, and circulation With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway, breathing, and circulation are the priority assessments for which the nurse would institute resuscitative measures. Other assessments such as level of consciousness, vital signs, and papillary response would be done once the child's airway, breathing, and circulation are assessed and emergency interventions are instituted.

A nurse is preparing a presentation for an expectant parent group about neural tube defects and prevention. Which would the nurse emphasize? -Smoking cessation -Aerobic exercise -Increased calcium intake -Folic acid supplementation

- Folic acid supplementation. The cause of neural tube defects is unknown, but there is strong evidence to support the use of folic acid supplementation for prevention. Smoking cessation and aerobic exercise are general health recommendations unrelated to neural tube defects. Increased calcium intake is important for fetal growth and development, but it is not linked to preventing neural tube defects

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? -I -II -IV -III

- I

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse checking when using the chart? -III -IV -I -II

- II

A patient who has had a generalized tonic-clonic seizure is sound asleep 30 minutes after the seizure. Meals are about to be delivered. Which nursing action is the most appropriate? -Wake the patient because nourishment is essential following a seizure. -Wake the patient to do a neurological assessment before the meal. -Let the patient sleep during the postictal state and keep the meal warm. -Do not attempt to wake the patient because of the risk of a repeat seizure.

- Let the patient sleep during the postictal state and keep the meal warm.

In providing safety of the client during a seizure, the nurse should perform what interventions? Select all that apply. -Position the client on his back. -Gently place a padded tongue blade between the teeth. -Remove nearby objects that could lead to client injury. -Apply oxygen immediately via mask. -Note the length of and progression of the seizure.

- Remove nearby objects that could lead to client injury. -Note the length of and progression of the seizure.

The nurse is caring for a client who has severe craniocerebral trauma. What finding indicates that the client is developing Diabetes Insipidus? -Urine specific gravity at 1.042 -Somnolent when previously alert -Urinary output 1500 mL over 4 hours -Blood glucose level at 230 mg/dL

- Urinary output 1500 mL over 4 hours

The nurse knows the patient understands teaching about an angiogram when the patient makes which of the following statements? -"I will be in a large machine that uses magnetic energy to create images; it has a noisy knocking sound." -"A small needle will be inserted into my spinal column to withdraw fluid for examination." -"A catheter will be placed in an artery in my groin, and dye will be injected that will make my vessels show up on x-ray." -"Electrodes will be placed on my head to monitor electrical activity in my brain."

-"A catheter will be placed in an artery in my groin, and dye will be injected that will make my vessels show up on x-ray."

A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they make what statement? -"Having the shunt put in decreases his risk for developmental problems." -"If he doesn't get an infection in the first week, the risk is greatly reduced." -"He will need more surgeries to replace the shunt as he grows." -"The shunt will help to prevent any further complications from his disease."

-"He will need more surgeries to replace the shunt as he grows." Parents need to know that hydrocephalus is a chronic illness that requires lifelong follow-up and regular evaluations, including future surgeries as the child grows. The risk for infection is ever present, but is most common 1 to 2 months after shunt placement. The child with a shunt and hydrocephalus is at risk for potential growth and developmental disabilities as well as complications such as infection and malfunction of the shunt.

A 6-year-old boy with cerebral palsy has been admitted to the hospital for some tests. His condition is stable. The boy's mother remains with her son, but she is obviously exhausted and stressed. Which response by the nurse would be most appropriate? -"Would you like me to bring you a blanket and pillow?" -"You are doing such a wonderful job with your son." -"He's in good hands; consider going home to get some sleep." -"Are you planning to spend the night or to go home?"

-"He's in good hands; consider going home to get some sleep." Providing daily, intense care can be quite demanding and tiring. When a child with cerebral palsy is admitted to the hospital, this may serve as a time of respite for family and primary caregivers. The nurse should remind the mother that her son is in good hands and urge her to go home. Asking her whether she is planning to stay might make the mother feel obligated to stay. Asking if she wants a blanket or pillow does not encourage the mother to leave the hospital. Telling the mother she is doing a good job is nice, but does not encourage her to take a break.

The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate? -"I will help you become comfortable in caring for your daughter." -"You must learn how to care for your daughter at home." -"You will need to learn to collaborate with all the caregivers." -"There is a lot to learn, and you need a positive attitude."

-"I will help you become comfortable in caring for your daughter." The nurse needs to empower families to become the experts on their child's needs and conditions via education and participation in care. The most positive approach is to let the mother know the nurse will support her and help her become an expert on her daughter's care. Telling the mother that she must learn how to care for her daughter or that she must have a positive attitude is not helpful. Telling her that she needs to collaborate with the caregivers is true, but does not address her fears.

A patient makes an appointment to see a health care provider for recurrent severe headaches. Which instruction by the nurse will help gather the best additional data before the appointment? -"Try relaxation and warm moist compresses for your headaches and document your response." -"Call and come in the next time you have a headache so you can be examined." -"Keep track of how many headaches you have before you come in." -"Keep a diary of your headaches, recording symptoms, timing, and headache triggers."

-"Keep a diary of your headaches, recording symptoms, timing, and headache triggers."

The young child is experiencing muscle spasms and has been given lorazepam. Which statements by the child indicate that the child may be experiencing some common side effects? Select all that apply -"My belly hurts." -"I feel sort of dizzy." -"I need to take a nap." -"My muscle cramps are getting worse."

-"My belly hurts." Common side effects associated with this medication. The muscle cramps should diminish. Nausea, vomiting and abdominal pain are not associated with. side effects.

The community health nurse has just completed a presentation to a group of parents regarding drowning prevention. Which statements by the parents indicate understanding of the teaching? Select all that apply. -"I am so glad our 6-year-old child had swim lessons. We really can't afford a fence around our pool." -"Since we have a 16-year-old I am really concerned about supervision when our child is swimming in the ocean." -"We always make sure our babysitter keeps her CPR training up to date." -"It is scary to think that we have a pool and drowning is the second leading cause of accidental death in children." -"We make sure to keep our bathroom door closed when our 10-month-old is walking around the house since the door handle is too high to reach."

-"Since we have a 16-year-old I am really concerned about supervision when our child is swimming in the ocean." -"We always make sure our babysitter keeps her CPR training up to date." -"It is scary to think that we have a pool and drowning is the second leading cause of accidental death in children." -"We make sure to keep our bathroom door closed when our 10-month-old is walking around the house since the door handle is too high to reach." In children older than 15 years of age, most drownings occur in natural water settings, such as oceans or lakes. Most incidents of drowning are accidental and result from inadequately supervising children of any age. It is important for any caregivers of children to be current on CPR in case of any accident. Children younger than 1 year old most often drown in bathtubs, buckets, or toilets, so keeping the bathroom door closed helps decrease the risk of drowning.

A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions? -"Expect his headache to get worse initially and then disappear." -"Wake him every 2 hours to check his movement and responses." -"Call your medical provider if he vomits more than five times." -"Any watery fluid draining from his ears is normal."

-"Wake him every 2 hours to check his movement and responses." The nurse should instruct the parents to wake the child every 2 hours to ensure that he moves normally and wakes enough to recognize and respond appropriately to them. The parents should be instructed to call the physician or nurse practitioner or bring the child back to the emergency department if he experiences a constant headache that gets worse, vomits more than two times, or has oozing of blood or watery fluid from his ears or nose.

A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching? -"We should give this drug before he eats anything." -"We need to watch carefully for possible infection." -"The drug should not be stopped suddenly." -"He might gain some weight with this drug."

-"We should give this drug before he eats anything." Corticosteroids such as prednisone can cause gastric upset, so the medication should be given with food to reduce this risk. The drug may mask the signs of infection, so the parents need to monitor the child closely for any changes. Treatment with this drug should not be stopped abruptly due to the risk for acute adrenal insufficiency. Common side effects of this drug include weight gain, osteoporosis, and mood changes.

A child with a ventriculoperitoneal (VP) shunt complains of headache and blurry vision and now experiences irritability and sleeping more than usual. The parents ask the nurse what they should do. Select the nurse's office." -"Give her some acetaminophen, and see if her symptoms improve. If they do not improve, bring her to the pediatrician's office." -"It is common for girls to have these symptoms, especially prior to beginning their menstrual cycle. Give her a few days, and see if she improves. -"You are probably worried that she is having a problem with her shunt. This is very unlikely as it has been working well for 9 years." -"You should immediately take her to the emergency room as these may be symptoms of a shunt malfunction."

-"You should immediately take her to the emergency room as these may be symptoms of a shunt malfunction." These are symptoms of a shunt malfunction and should be evaluated immediately.

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes hypoactive reflexes. How will the nurse document this assessment? -3+ -0 -2+ -1+

-1+

How many cranial nerves does the nurse have to assess? -10 -13 -11 -12

-12

The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which response from his mother indicates a need for further teaching? -"He needs to get a medical alert identification." -"I will need to discuss this with his caregivers." -A product's label indicates whether it is latex-free." -"He must avoid all contact with latex."

-A product's label indicates whether it is latex-free." The Food and Drug Administration (FDA) requires that all medical supplies be labeled if they contain latex, but this is not the case with consumer products. The mother must be familiar with products that contain latex. The Spina Bifida Association of America maintains an updated list of latex-containing products. Getting a medical alert identification, talking with his caregivers, and avoiding all contact with latex are correct.

A child with a seizure disorder has been having episodes during which she drops her pencil and simply appears to be daydreaming. This is most likely a/an: -Absence seizure -Akinetic seizure -Non-epileptic seizure -Simple spasm seizure

-Absence seizure A simple spasm seizure is not a diagnosis.

The nurse is providing care for a patient with an altered level of consciousness. Upon assessment, the nurse notes the patient is unresponsive to the environment and makes no voluntary movement or sounds, however sometimes opens her eyes. This state of consciousness would be considered as _____________. -Akinetic mutism -Persistent vegetative state -Locked-In syndrome -Brain death

-Akinetic mutism

Which sign or symptom is not an indication of leakage of cerebral spinal fluid? -Patient complains of a salty taste in the mouth. -Patient complains of postnasal drip. -Clear fluid draining from the nose. -Alteration in level of consciousness.

-Alteration in level of consciousness.

The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. What word would the nurse use when documenting these observations? -Spastic -Athetoid -Ataxic -Mixed

-Athetoid Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It affects all four extremities with possible involvement of the face, neck, and tongue. The movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and wide-based gait.

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs? -B/P 190/84, HR 150, and an irregular respiration pattern -B/P 80/50, HR 50, and Kussmaul respirations -B/P 80/50, HR 150, and Cheyne-Stokes respirations - B/P 190/84, HR 50, and an irregular respiratory pattern

-B/P 190/84, HR 50, and an irregular respiratory pattern

The nurse is aware that cloudy cerebrospinal fluid (CSF) most likely indicates: -Viral meningitis -Bacterial meningitis -No infection, as CSF is usually cloudy. -Sepsis

-Bacterial meningitis The CSF in bacterial meningitis is usually cloudy. No infection, as CSF is usually cloudy. Sepsis

The nurse is caring for a 6-month-old infant diagnosed with meningitis. When the child is placed in the supine position and flexes his neck, the nurse notes he flexes his knees and hips. This is referred to as: -Brudzinski sign -Cushing triad -Kernig sign -Nuchal rigidity

-Brudzinski sign Brudzinski signs occurs when the child responds to a flexed neck with an involuntary flexion of the hips and/ or knees.

The portion of the brain which enables learning, memory, and thought is the ____________. -Cerebral Cortex -Hypothalamus -Cerebellum -Cerebrum

-Cerebrum

The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign to indicate to the nurse that increased ICP may be developing? -Change in the level of consciousness -Sudden drop in the blood pressure -Experiencing diminished sensation -Change in pupil size and reaction

-Change in the level of consciousness

The following are classifications of cerebral palsy, except -Spastic -Mixed -Athetoid -Ataxic -Clonus

-Clonus

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply. -Complaints of stiff neck -Photophobia -Absent headache -Negative Brudzinski sign -Vomiting

-Complaints of stiff neck. -Photophobia -Vomiting In addition to the adolescent's complaints and history, other findings suggesting bacterial meningitis include complaints of a stiff neck, photophobia, headache, positive Brudzinski sign, and vomiting.

What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele? -Positioning supine with a pillow under the buttocks -Covering the sac with saline-soaked nonadhesive gauze -Wrapping the infant snugly in a blanket -Applying a diaper to prevent fecal soiling of the sac

-Covering the sac with saline-soaked nonadhesive gauze For the infant with a myelomeningocele, saline-soaked nonadhesive gauze or antibiotic-soaked gauze is used to keep the sac moist. The infant is positioned prone, with a folded towel under the abdomen, so that the urine and feces flow away from the sac. A warmer or isolette is used to keep the infant warm. Blankets are avoided because they could place excess pressure on the sac. Diapering may be contraindicated to avoid placing pressure on the sac.

A nurse caring for a patient with ALOC notes when entering the patient room that the patient, in supine position in bed, is in a posturing position with both arms and legs extended, and the arms internally rotated. The nurse would recognize this as ___________ posturing. -Decorticate -Decerebrate

-Decerebrate

A nurse is taking care of a patient with altered level of consciousness. The nurse notes that patient's arms are flexed at the elbow, the hands are raised towards the chest, and the legs are extended. This posture, indicative of significant cerebral impairment, is called what? -Decorticate -Decerebrate

-Decorticate

When performing a neurological assessment, which of the following is a symptom of increasing intracranial pressure should the nurse immediately report to the primary care provider? -Decreased LOC -Bradypnea -Narrowing pulse pressure -Constricted pupils

-Decreased LOC

The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated? -Increase in serum pH level -Leakage of cerebrospinal fluid -Displacement of brain tissue -Increase in cerebral perfusion

-Displacement of brain tissue

A patient has returned from having a routine computed tomography scan with contrast . Which of the following should be a priority in the hours after the scan? -Coughing and deep breathing -Turning side-to-side -Ambulation -Drinking fluids

-Drinking fluids

A nurse is testing a patient to determine if the gag reflex is present. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What cranial nerve has a dysfunction? -Dysfunction of the acoustic nerve. -Dysfunction of the facial nerve. -Dysfunction of the spinal accessory nerve. -Dysfunction of the vagus nerve.

-Dysfunction of the vagus nerve.

A nurse is collecting data from a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test for corneal reflexes? -Examine the eye with a penlight. -Instill drops of dye into the eye. -Visualize the red reflex of the eye. -Lightly touch the eye with a wisp of cotton.

-Examine the eye with a penlight.

A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion? -The child's risk for cognitive problems is greatly increased. -Structural damage occurs with febrile seizure. -The child's risk for epilepsy is now increased. -Febrile seizures are benign in nature.

-Febrile seizures are benign in nature. Parents need reassurance that febrile seizures, although frightening, are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural damage or cognitive declines.

A patient had a lumbar puncture 3 days ago in the outpatient clinic and call the nurse to report a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort? (Select all that apply). -Force fluids (unless contraindicated) -Get plenty of rest -Ambulate. -Limit fluid intake to decrease cerebral edema -Take an over-the-counter analgesics

-Force fluids (unless contraindicated) -Get plenty of rest -Take an over-the-counter analgesics

A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which food selection would be most appropriate for his lunch? -Fried eggs, bacon, and iced tea. -A hamburger on a bun, French fries, and milk -Spaghetti with meatballs, garlic bread, and a cola drink -A grilled cheese sandwich, potato chips, and a milkshake

-Fried eggs, bacon, and iced tea. The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal.

The nurse is caring for a 5 year old child with Guillain - Barré syndrome. Which would be the best way to assess the level of parathyroid? -Gentle tickling -Observe for symmetrical flaccid weakness -Monitor for ataxia -Inquire about sensory disturbances

-Gentle tickling

The nurse is conducting a physical examination of a school age child with a suspected neuromuscular disorder. Which finding is a sign of Duchenne muscular dystrophy? -Apperance of smaller than normal calf muscles -Lordosis -Gowers sign -Indications of hydrocephalus

-Gowers sign

The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function? -With the client's eyes shut, ask whether the touch with a cotton applicator is dull or sharp. -Ask the client to close the eyes, then hold hands with palms up perpendicular to the body. -Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse. -Have the client place the hands on the thighs, then quickly turn the palms up and then down.

-Have the client place the hands on the thighs, then quickly turn the palms up and then down.

A patient is having a lumbar puncture and the healthcare provider has removed 20 mL of CSF. What nursing intervention is a priority after the procedure? -Have the patient lie in Semi-Fowler position with the HOB at 30 degrees. -Have the patient lie flat for 6 hours -Early ambulation -Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating.

-Have the patient lie flat for 6 hours

The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which problem? -Febrile seizures -Head trauma -Caput succedaneum -Posterior plagiocephaly

-Head trauma The larger head size in relation to the body, coupled with a higher center of gravity, causes children to hit their head more readily when involved in motor vehicle accidents, bicycle accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture.

An early indicator of increased intracranial pressure is: -Equal bilateral grasp of the hands -Bradypnea -Headache -Pupils are equally reactive to light

-Headache

A patient with a history of seizures reports experiencing an aura and is concerned about an impending seizure. What would be the FIRST nursing intervention? -Document the events of the seizure. -Protect the patient from injury during the seizure. -Help the patient lie down in a safe place. -Turn the patient on his or her side to sleep.

-Help the patient lie down in a safe place.

Which of the signs best indicate increased intracranial pressure (ICP) in an infant? Select all that apply. -Sunken anterior fontanel -Complains of blurred vision -High-pitched cry. -Increased appetite -Sleeping more than usual

-High-pitched cry. A high-pitched cry is often indicative of increased ICP in infants.

When performing a cranial nerve assessment, the nurse asks the patient to stick out his tongue and move it side to side. This request is to assess if which cranial nerve is intact? -Hypoglossal -Glossopharyngeal -Olfactory -Trigeminal

-Hypoglossal

A patient arrives to have an MRI done as an outpatient diagnostic test. What information provided by the patient warrants further assessment to prevent complications related to the MRI? -"My legs go numb sometimes when I sit too long." -"I have been trying to get an appointment for so long." -"I have not had anything to eat or drink since 3 hours ago." -I am trying to quit smoking and have a patch on."

-I am trying to quit smoking and have a patch on."

Decreased cerebral perfusion, ischemia, cell death, and further edema may be contributed to what factor? -Increased Intracranial Pressure -Compensation -Vasoconstriction -Autoregulation

-Increased Intracranial Pressure

A nurse is preparing a program for a group of parents about injury prevention. What would the nurse include as an important contributing factor for cervical spine injury in a child? -Exposure to teratogens while in utero -Immaturity of the central nervous system -Increased mobility of the spine -Incomplete myelinization

-Increased mobility of the spine. Compared to the adult, a child's spine is very mobile, especially in the cervical spine region, resulting in a higher risk for cervical spine injury. Exposure to teratogens in utero may lead to altered growth and development of the brain or spinal cord. Immaturity of the central nervous system places the infant at risk for insults that may result in delayed motor skill attainment or cerebral palsy. Incomplete myelinization reflects the lack of motor control.

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? -Indications of increased intracranial pressure -An increase in the blood glucose level -A decrease in the liver enzymes -A presence of protein in the urine

-Indications of increased intracranial pressure Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness.

When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of what condition? -Neonatal conjunctivitis -Facial deformities -Intracranial hemorrhage -Incomplete myelinization

-Intracranial hemorrhage Premature infants have more fragile capillaries in the periventricular area than term infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.

A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? -Oral -Subcutaneous injection -Intramuscular injection -Intravenous infusion.

-Intramuscular injection. Botulin toxin is administered by injection into the muscle. It may cause dry mouth. It is not administered orally, by subcutaneous injection, or by intravenous infusion.

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands that after this treatment: -PaCO2 levels decrease, causing vasoconstriction. -drainage of cerebrospinal fluid occurs. -activity is controlled via a stimulator. -hyperexcitability of the nerves is reduced.

-PaCO2 levels decrease, causing vasoconstriction. Hyperventilation decreases PaCO2, which results in vasoconstriction and therefore decreases intracranial pressure. A shunt would allow for drainage of cerebrospinal fluid. A vagal nerve stimulator is used to provide an appropriate dose of stimulation to manage seizure activity. Anticonvulsants decrease the hyperexcitability of nerves.

During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response? -Strokes in children often have an identifiable cause. -The signs and symptoms in children are different from an adult. -Research has identified specific treatments for children -Ischemic strokes are more common than hemorrhagic strokes.

-Ischemic strokes are more common than hemorrhagic strokes. In children, ischemic strokes are more common than hemorrhagic strokes. However, the cause of the stroke in many children remains unidentified. Signs and symptoms are similar to those in adults and will vary based on age; underlying cause, if known; and location of the stroke. Historically, children have been excluded from adult stroke studies and thus, many treatments used have had to be adapted from adult studies.

Which of the following are risk factors of a fetus developing a neural tube defect? Select all that apply. -Lack of prenatal care -Insufficient intake of folic acid preconception and or prenatally -Previous history of a child born with a neural tube defect or a positive family history of neural tube defects. -Anticonvulsants taken during pregnancy -Malnutrition -Genetics

-Lack of prenatal care -Insufficient intake of folic acid preconception and or prenatally -Malnutrition

What is the most important indicator of a patient's condition?

-Level of Consciousness (LOC) -Vital signs -SpO2 -Arterial Blood Gas level

A nurse is assisting with a lumbar puncture and observes that when the healthcare provider obtains cerebrospinal fluid it is lightly blood-tinged. What does this finding indicate? -Severe sepsis -Local trauma from the insertion of the needle. -A subarachnoid hemorrhage -A normal finding; the fluid will be sent to the lab for analysis to determine other factors.

-Local trauma from the insertion of the needle.

Hydrocephalus is suspected in a 4-month-old infant. Which would the nurse expect to assess? -Lower extremity spasticity -Sunken fontanels -Diminished reflexes -Skull symmetry

-Lower extremity spasticity. Hydrocephalus is manifested by spasticity of lower extremities, bulging fontanels, brisk reflexes, and skull asymmetry.

A patient is awakening after being in a comatose state. What would be a priority action to keep in mind for this patient? -Discharge planning -Allow all family at the bedside -Keep the television on -Minimize stimulation

-Minimize stimulation

The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents? -Monitor their child's level of sedation. -Watch for fever indicating infection. -Gradually reduce the dosage as seizures stop. -Monitor for an allergic reaction to the medication.

-Monitor their child's level of sedation. Diazepam is useful for home management of prolonged seizures and requires that the parents be educated on its proper administration. Monitoring the child's level of sedation is key when giving diazepam because it slows the central nervous system. Parents need to monitor the overall health of the child, including temperature when needed, but that has nothing to do with the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is necessary to prevent seizures or status epilepticus. This is not done without a physician's order. Monitoring for allergic reactions is necessary when any medications have been prescribed, but is not specific to diazepam.

A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates? -Tonic -Focal clonic -Multifocal clonic -Myoclonic

-Myoclonic. Five major types of seizures have been recognized in the neonatal period: subtle, tonic, focal clonic, multifocal clonic, and myoclonic. Of these, myoclonic seizures rarely occur during the neonatal period. Subtle seizures affect preterm and full-term neonates. Tonic seizures primarily occur in preterm neonates. Focal clonic and multifocal clonic are more common in full-term neonates.

The structural disorders of spina bifida occulta, meningocele, and myelomengocele are all considered ______________________. -Involuntarily muscle movements -Neural tube defects -Muscular dystrophy defects -Primitive spontaneously abnormalities

-Neural tube defects

The nurse is caring for a child who has been in a motor vehicle accident (MVA). The child falls asleep unless her name is called or she is gently shaken. This state of consciousness is referred as: -Coma -Delirium -Obtunded -Confusion

-Obtunded Obtunded describes a state of consciousness in which the child has a limited response to the environment and can nbe aroused by verbal or tactile stimulation.

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child's level of consciousness? -Confusion -Obtunded -Stupor -Coma

-Obtunded Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli.

A nurse is preparing a school-aged child for a lumbar puncture. The nurse would expect to position the child in which manner? -On her side with the head flexed forward and knees flexed to the abdomen -Sitting upright with the head flexed forward to the chest -Supine with arms and legs pronated and extended -Prone with the arms flexed under the chest

-On her side with the head flexed forward and knees flexed to the abdomen. When a lumbar puncture is performed on a child, the child is placed on his or her side with the head flexed forward and knees flexed to the abdomen. An infant would be positioned sitting upright with the head flexed forward. A supine position with the arms and legs pronated and extended suggests decerebrate posturing. A prone position is not used for a lumbar puncture.

The brainstem includes three major structures. These include the Medulla Oblongata, Midbrain, and _____________. -Diencephalon -Occipital Lobe -Pons -Temporal Lobe

-Poins

The nurse is caring for a 19-month-old boy who has been admitted to the emergency department with a skull fracture. The parents state that the child fell down when running through the house and hit his head on the floor. Based on normal characteristics of skull fractures, what should be the initial focus of the assessment? -Possible physical abuse -Possible bone cancer -Possible chronic neurological disease -Possible developmental delay

-Possible physical abuse. Physical abuse must be investigated first because it takes a great deal of force to produce a skull fracture in infants and children younger than 2 years old. Due to the flexibility of the immature skull, it is able to withstand a great degree of deformation before a fracture will occur.

The nurse is providing pre-surgical care for a newborn with myelomeningocele. Which action is central nursing priority? -Prevent rupture ofr leaking of cerebrospinal fluid. -Maintain infant's body temperature -Mantain infant in prone prositions. -Keep lesion free from fecal matter or urine

-Prevent rupture ofr leaking of cerebrospinal fluid.

A patient has been admitted to the ICU with increased intracranial pressure. Upon initial assessment the patient is alert, arousable, and has an appropriate affect. When reassessed one hour later the nurse notes the patient "acting different." What clinical sign would be a late indicator of increased intracranial pressure the nurse would monitor for? -Reactive pupil activity -Projectile vomiting -Tachycardia -Nausea

-Projectile vomiting

What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure? -Bradycardia -Cheyne-Stokes respirations -Fixed, dilated pupils -Projectile vomiting

-Projectile vomiting Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia, Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial pressure.

A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority? -Hyperextending the child's head while placing him on his side -Using a tongue blade to pry open the child's jaw -Loosening the child's clothing to ensure a patent airway -Protecting the child from harm during the seizure

-Protecting the child from harm during the seizure. During a seizure, the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is an important intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw.

The nurse has developed a plan of care for a 6-year-old with Spinal Muscular Atrophy (SMA). He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? -Recommend the bed's side rails be raised throughout the day and night. -Suggest a caregiver be present continuously to prevent falls from bed. -Encourage a loose restraint to be used when he is in bed. -Recommend raising the bed's side rails when a caregiver is not present.

-Recommend raising the bed's side rails when a caregiver is not present. The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby."

The nurse identifies which of the following as normal effects of aging on the central nervous system? Select all that apply. -Increased postural stability -Reduced cerebral blood flow -Impaired short-term memory -Sleep disturbances -Loss of deep tendon reflexes

-Reduced cerebral blood flow -Impaired short-term memory -Sleep disturbances -Loss of deep tendon reflexes

The nurse is administering Mannitol IV to decrease the client's ICP. Which laboratory test result should the nurse monitor during the client's treatment with Mannitol? -Serum osmolarity -WBC count -Serum cholesterol -Erythrocyte sedimentation rate (ESR)

-Serum osmolarity

When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely? -Skeletal traction -Physical therapy -Orthotics -Occupational therapy

-Skeletal traction

The nurse is developing a teaching plan for the parents of a child with a myelomeningocele who will require clean intermittent catheterization. What information would the nurse include? -Applying petroleum jelly to lubricate the catheter -Cleaning the reusable catheter with peroxide after each use -Storing the reusable cleaned catheter in a brown paper bag -Soaking the catheter in a vinegar and water solution to sterilize

-Soaking the catheter in a vinegar and water solution to sterilize. When teaching parents how to perform clean intermittent catheterization, the nurse would instruct the parents to apply a water-based lubricant to the catheter, clean the reusable catheter with soap and water after each use, store the reusable clean catheter in a zip-top bag or other clean storage container, and soak the catheter in a 1:1 vinegar and water solution for about 30 minutes weekly, rinsing well before the next use or placing the catheter in boiling water for 10 minutes.

A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes:Streptococcus group BHaemophilus influenzae type BStreptococcus pneumoniaeNeisseria meningitidisWhat would the nurse highlight as the most common cause of meningitis in newborns? -Streptococcus group B -Haemophilus influenzae type B -Streptococcus pneumoniae -Neisseria meningitides

-Streptococcus group B. Meningitis due to Streptococcus group B along with Escherichia coli is most common in newborns and infants. H. influenzae type B is a common cause in infants between the ages of 6 and 9 months. S. pneumoniae and N. meningitides are common causes in children older than 3 months and in adults.

A 16-year-old boy reports to the school nurse of headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? -Fixed and dilated pupils -Frequent urination -Sunset eyes -Sunlight is "too bright"

-Sunlight is "too bright" Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus.

The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as: -Decorticate posturing -Nystagmus -Doll's eye -Sunsetting

-Sunsetting Sunsetting is when the sclera of the eyes is showing over the top of the iris. Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements. Doll's eye is a maneuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction.

The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition? -Multiple corrective surgeries to slowly remove diseased parts of his brain -Physical, occupational, and speech therapy to maximize his potential -Support for maintaining self-esteem because of his altered lifestyle -Hyperventilation therapy to counteract the periods of decreased oxygenation

-Support for maintaining self-esteem because of his altered lifestyle The effects of living with a seizure disorder can be devastating, and it is essential for the child to receive support to maintain self-esteem. While corrective surgery is possible, it would only be performed once. Physical, occupational, speech, and hyperventilation therapy are not indicated for treatment of epilepsy.

A 10-year-old boy is seen in the emergency department after falling down a flight of stairs and hitting his head. The child will be monitored overnight for complications. Which occurrence in the coming hours will warrant further assessment? -The child reports a backache. -The child is increasingly irritable with his mother and caregivers. -The child refuses offers of snacks. -The child reports his stomach is upset.

-The child is increasingly irritable with his mother and caregivers. After a head injury the client should be closely observed for neurological changes. Behavioral changes such as lethargy and irritability should be evaluated for the potential development of complications.

The nurse is assessing a young boy who has been brought to the physician for mobility and balance issues by his parents. Which findings are positively associated with the presence of Duchenne muscular dystrophy? Select all that apply. -Genetic testing indicates the presence of a gene associated with spinal muscular atrophy. -The child is unable to rise easily into a standing position when placed on the floor. -Serum creatine levels are elevated -An electromyogram demonstrates the problem is within the nerves, not the muscles. -A muscle biopsy shows an absence of dystrophin.

-The child is unable to rise easily into a standing position when placed on the floor. Significant muscle wasting is associated with this diagnosis. Creatine kinase levels increase with muscle wasting. A muscle biopsy will show an absence of dystrophin. Gowner's sign will be positive. An electromyogram will indicate the problem is with the muscles not the. nerves. Genetic testing will reveal the presence of the gene associated with Duchenne muscular dystrohy.

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect? -The client has a stable neurological status. -The client is alert and oriented. -The client is in a deep coma. -The client requires total nursing care.

-The client requires total nursing care.

What patients should be closely monitored by the nurse for symptoms of increased intracranial pressure? Select all that apply. -The patient admitted with a high fever and severe headache. -The patient in the PACU following a craniotomy. The patient with Alzheimer's disease admitted with a UTI. -The patient who has a history of epilepsy. -The patient with a brain tumor who is admitted for radiation therapy. -The patient with a history of migraine headaches, admitted for orthopedic surger

-The patient admitted with a high fever and severe headache. -The patient in the PACU following a craniotomy. -The patient with a brain tumor who is admitted for radiation therapy.

The nurse is teaching a group of students about myelinization in a child. Which statement by the students indicates that the teaching was successful? -Myelinization is completed by 4 years of age. -The process occurs in a head-to-toe fashion. -The speed of nerve impulses slows as myelinization occurs. -Nerve impulses become less specific in focus with myelinization.

-The process occurs in a head-to-toe fashion. Myelinization occurs in a cephalocaudal, proximodistal manner and is completed by 2 years of age. As myelinization proceeds, nerve impulses become faster and more accurate.

During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve? -Olfactory -Trigeminal -Facial -Accessory

-Trigeminal. To test the trigeminal nerve, the nurse would note the strength of the infant's suck on a pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would be assessed during spontaneous crying or smiling. The accessory nerve is assessed when the infant is in the sitting position and symmetry of the head position is noted.

All types of muscular. dystrophy result in progressive skeletal (voluntary) muscle wasting and weakness. -True -False

-True

The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion? -Deep-breathing exercises -Upright positioning -Coughing -Chest percussion

-Upright positioning The nurse should emphasize that the child's position should be arranged to promote maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest percussion helps loosen secretions in lungs.

A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which information would the instructor include? Select all that apply. -Onset before 6 months of age -Weakness most severe in shoulders and hips -Difficulty with swallowing -Slowly progressing condition -Genetic disease with autosomal recessive inheritance

-Weakness most severe in shoulders and hips. -Slowly progressing condition -Genetic disease with autosomal recessive inheritance Any type of spinal muscular atrophy is a genetic motor neuron disease due to autosomal recessive inheritance. Type 2 SMA usually occurs between 6 and 18 months of age, with weakness that is most severe in the shoulders, hips, thighs, and upper back. It is slower in progression than type 1. Survival into adulthood is common if respiratory status is maintained appropriately. Type 1 SMA occurs before birth to 6 months of age and the child usually has difficulty swallowing, sucking, and breathing.

When teaching a class about trisomy 21, the instructor would identify the cause of this disorder as: -nondisjunction. -X-linked recessive inheritance. -genomic imprinting. -autosomal dominant inheritance.

-autosomal dominant inheritance. Trisomy 21 is an example of a genetic disorder involving an abnormality in chromosomal number due to nondisjunction. X-linked recessive inheritance disorders, such as hemophilia and Duchenne muscular dystrophy, involve altered genes on the X chromosome. Genomic imprinting disorders, such as Prader-Willi syndrome, involve expression of only the maternal or paternal allele, with the other being inactive. Autosomal dominant inheritance disorders, such as neurofibromatosis and achondroplasia, involve a single gene in the heterozygous state that is capable of producing the phenotype, thus overshadowing the normal gene.

After teaching a class of nursing students about muscular dystrophy, the instructor determines that the teaching was successful when the students identify which type of muscular dystrophy as demonstrating an X-linked recessive pattern of inheritance? -Limb-girdle -Myotonic -Distal -Duchenne

Duchenne. Duchenne muscular dystrophy follows an X-linked recessive inheritance pattern. Limb-girdle muscular dystrophy is believed to be autosomal or X-linked inherited. Myotonic and distal muscular dystrophy follow an autosomal dominant inheritance pattern.

Upon assessment of cranial nerves, your client expresses that he is unable to taste anything. This would indicate an impairment of what cranial nerve? -IV -I -II -VII

IV (Trochear)