Nuero - NCLEX-Style Questions

The nurse is caring for an 8-year-old client who is being treated for Reye syndrome. Which statement made by the parent indicates the treatment is ineffective? A) "My son was bored so I brought him his video games." B) "My son does not seem to know where he is at." C) "My son has been to the bathroom to urinate twice over the past hour." D) "I am glad my son is able to keep his food down."

B) "My son does not seem to know where he is at."

The nurse is assessing a client being treated for Reye syndrome. Which is a complication the nurse should plan to monitor for in the client? A) Seizures B) Acute pancreatitis C) Pulmonary embolism D) Myalgia

A) Seizures Rationale: The client may experience seizures as a result of cerebral edema. When the hepatocytes can no longer detoxify ammonia, a client with Reye syndrome will develop hyperammonemia, or high ammonia levels in the blood, which is toxic to the brain. This leads to encephalopathy, which causes brain swelling and edema, the intracranial pressure to rise, and seizures.

A nurse is caring for a toddler status post surgery for a brain tumor. During an assessment the nurse notes that the toddler is becoming irritable and the pupils are unequal and sluggish. The most appropriate nursing action is to: A) notify the physician immediately. C) assess for level of consciousness. D) observe closely for signs of increased intracranial pressure (ICP). E) administer pain medication and assess for response.

A) notify the physician immediately. Rationale: The worsening of symptoms may indicate that the ICP is increasing. The physician should be notified immediately.

Which position initially is most beneficial for an infant who has just returned from having a ventriculoperitoneal (VP) shunt placed? 1. Semi-Fowler in an infant seat. 2. Flat in the crib. 3. Trendelenburg. 4. In the crib with the head elevated to 90 degrees.

2. Flat in the crib. Rationale: Flat in the crib is the position usually used initially, with the angle gradually increasing as the child tolerates. A semi-Fowler position in an infant seat may allow the ventricles to drain too rapidly in the immediate postoperative period. The Trendelenburg position is not used immediately after ventriculoperitoneal shunt placement because it would increase ICP. The head elevated to 90 degrees will allow the ventricle of the brain to drain too quickly.

The nurse is reviewing a list of clients to be seen in the clinic. Which client should the nurse identify as being at high risk for Reye syndrome? A) A 9-month-old infant with varicella-zoster not responding to treatment with famciclovir B) A 5-year-old client scheduled for a follow-up visit for the treatment of epiglottitis C) A 3-year-old client whose parents have been treating a fever with aspirin D) A 4-year-old client with a fever of 101.3℉ (38.5℃) not responding to the treatment for tonsillitis

C) A 3-year-old client whose parents have been treating a fever with aspirin

Which child would likely have experienced a delay in the diagnosis of a brain tumor? 1. A 3-month-old, because signs and symptoms would not have been readily apparent. 2. A 5-month-old, because signs and symptoms would not have been readily suspected. 3. School-age child, because signs and symptoms could have been misinterpreted. 4. Adolescent, because signs and symptoms could have been ignored and denied.

1. A 3-month-old, because signs and symptoms would not have been readily apparent. Rationale: In infants, signs and symptoms may not be readily apparent because the open fontanel allows for expansion.

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: 1. Absence seizure. 2. Akinetic seizure. 3. Non-epileptic seizure. 4. Simple spasm seizure.

1. Absence seizure. Rationale: Absence seizures occur frequently and last less than 30 seconds. The child experiences a brief loss of consciousness during which she may have a change in activity. These children rarely fall, but they may drop an object. The condition is often confused with daydreaming.

A child diagnosed with meningitis is having a generalized tonic-clonic seizure. Which should the nurse do first? 1. Administer blow-by oxygen and call for additional help. 2. Reassure the parents that seizures are common in children with meningitis. 3. Call a code and ask the parents to leave the room. 4. Assess the child's temperature and blood pressure.

1. Administer blow-by oxygen and call for additional help. Rationale: The child experiencing a seizure usually requires more oxygen because the seizure increases the body's metabolic rate and demand for oxygen. The seizure may also affect the child's airway, causing the child to be hypoxic. It is always appropriate to give the child blow-by oxygen immediately. The nurse should remain with the child and call for additional help.

Which should be included in the plan of care for a child who has a neuroblastoma with metastasis to the bone marrow and pancytopenia? 1. Administer red blood cells. 2. Limit school attendance to less than 4 hours daily. 3. Administer warfarin (Coumadin). 4. Encourage a diet high in fresh fruits and vegetables.

1. Administer red blood cells.

The nurse is caring for an unconscious 6-year-old who has had a severe closed-head injury and notes the following changes: Heart rate has dropped from 120 to 55, blood pressure has increased from 110/44 to 195/62, and respirations are becoming more irregular. Which should the nurse do first after calling the physician? 1. Call for additional help and prepare to administer mannitol (Osmitrol). 2. Continue to monitor the patient's vital signs and prepare to administer a bolus of isotonic fluids. 3. Call for additional help and prepare to administer an antihypertensive. 4. Continue to monitor the patient and administer supplemental oxygen.

1. Call for additional help and prepare to administer mannitol (Osmitrol). Rationale: Cushing triad is characterized by a decrease in heart rate, an increase in blood pressure, and changes in respirations. The triad is associated with severely increased ICP. Mannitol is an osmotic diuretic that helps decrease the increased ICP.

A 2-month-old infant is brought to the emergency department after experiencing a seizure. The infant appears lethargic with very irregular respirations and periods of apnea. The parents report the baby is no longer interested in feeding and, before the seizure, rolled off the couch. What additional testing should the nurse immediately prepare for? 1. Computed tomography (CT) scan of the head and dilation of the eyes. 2. Computed tomography (CT) scan of the head and electroencephalogram (EEG). 3. X-rays of the head. 4. X-rays of all long bones.

1. Computed tomography (CT) scan of the head and dilation of the eyes. Rationale: A computed tomography (CT) scan of the head will reveal trauma. Dilating the eyes is performed to check for retinal hemorrhages that are seen in an infant who has experienced shaken baby syndrome (SBS).

The nurse tells a family of a child with cerebral palsy (CP) that since the 1960s the incidence of CP has: 1. Increased. 2. Decreased. 3. Remained the same. 4. Has decreased because of early misdiagnosis.

1. Increased.

The parents of a 12-month-old with cerebral palsy (CP) ask the nurse if they should teach their child sign language because he has not begun to vocalize. The nurse bases the response on the knowledge that sign language: 1. Maybe a very beneficial way to help children with CP communicate. 2. May cause confusion and further delay vocalization. 3. Is difficult to learn for most children with CP. 4. Is beneficial to learn, but it would be best to wait until the child is older.

1. Maybe a very beneficial way to help children with CP communicate. Rationale: Sign language may help the child with CP communicate and ultimately decrease frustration. Children with CP may have diffi culty verbalizing because of weak tongue and jaw muscles. They may be able to have suffi cient motor skills to communicate with their hands.

Which has the potential to alter a child's level of consciousness? Select all that apply. 1. Metabolic disorders. 2. Trauma. 3. Hypoxic episode. 4. Dehydration. 5. Endocrine disorders.

1. Metabolic disorders. 2. Trauma. 3. Hypoxic episode. 4. Dehydration. 5. Endocrine disorders.

The nurse is caring for a child with a skull fracture who is unconscious and has severely increased intracranial pressure (ICP). The nurse notes the child's temperature to be 104°F (40°C). Which should the nurse do first? 1. Place a cooling blanket on the child. 2. Administer acetaminophen (Tylenol) via nasogastric tube. 3. Administer acetaminophen (Tylenol) rectally. 4. Place ice packs in the child's axillary areas.

1. Place a cooling blanket on the child. Rationale: A cooling blanket will help cool the child quickly and at a controlled temperature. Acetaminophen (Tylenol) should be administered after the cooling blanket has been applied. Tylenol is an effective medication, but a cooling blanket will begin to be effective before the medication is absorbed. Ice packs will cause the child to shiver, which will increase oxygen consumption and possibly increase ICP. Shivering can also cause the child to experience a rebound increase in temperature.

The parents of a child with cerebral palsy (CP) are learning how to feed their child and avoid aspiration. The nurse would question which of the following when reviewing the teaching plan? 1. Place the food on the tip of the tongue. 2. Place the child in an upright position during feedings. 3. Feed the child soft and blended foods. 4. Feed the child slowly.

1. Place the food on the tip of the tongue. Rationale: The food should be placed far back in the mouth to avoid tongue thrust.

Which is the nurse's best response to the parents of a neonate with a meningocele who ask what can they expect? 1. "After initial surgery to close the defect, most children experience no neurological dysfunction." 2. "Surgery to close the sac will be postponed until the infant has grown and has enough skin to form a graft." 3. "After the initial surgery to close the defect, the child will likely have motor and sensory deficits." 4. "After the initial surgery to close the defect, the child will likely have future problems with urinary and bowel continence."

1. "After initial surgery to close the defect, most children experience no neurological dysfunction." Rationale: Because a meningocele does not contain any nerve endings, most children experience no neurological problems after surgical correction.

A preschooler has been having periods during which he suddenly falls and appears to be weak for a short time after the event. The preschool teacher asks what she should do. Select the nurse's best response. 1. "Have the parents follow up with his health-care provider because this is likely an atonic seizure." 2. "Find out if there have been any new stressors in his life because it could be attention-seeking behavior." 3. "Have the parents follow up with his health-care provider because this is likely an absence seizure." 4. "The preschool years are a time of rapid growth, and many children appear clumsy. It would be best to watch him and see if it continues."

1. "Have the parents follow up with his health-care provider because this is likely an atonic seizure." Rationale: An atonic seizure is characterized by a loss of muscular tone, whereby the child may fall to the ground.

A child with cerebral palsy (CP) has been fitted for braces and is beginning physical therapy to assist with ambulation. The parents ask why he needs the braces when he was crawling without any assistive devices. Select the nurse's best response. 1. "The CP has progressed, and he now needs more assistance to ambulate." 2. "As your child grows, different muscle groups may need more assistance." 3. "Most children with CP need braces to help with ambulation." 4. "We have found that when children with CP use braces, they are less likely to fall."

2. "As your child grows, different muscle groups may need more assistance." Rationale: CP can manifest in different ways as the child grows. It does not progress, but its clinical manifestations may change.

Which child is at increased risk for cerebral palsy (CP)? 1. An infant born at 34 weeks with an Apgar score of 6 at 5 minutes. 2. A 17-day-old infant with group B Streptococcus meningitis. 3. A 24-month-old child who has experienced a febrile seizure. 4. A 5-year-old with a closed-head injury after falling off a bike.

2. A 17-day-old infant with group B Streptococcus meningitis. Rationale: Any infection of the CNS increase the infant's risk of CP

Which child requires continued follow-up because of behaviors suspicious of cerebral palsy (CP)? 1. A 1-month-old who demonstrates the startle reflex when a loud noise is heard. 2. A 6-month-old who always reaches for toys with the right hand. 3. A 14-month-old who has not begun to walk. 4. A 2-year-old who has not yet achieved bladder control during waking hours.

2. A 6-month-old who always reaches for toys with the right hand. Rationale: The clinical characteristic of hemiplegia can be manifested by the early preference of one hand. This may be an early sign of CP.

Which medication should the nurse anticipate administering first to a child in status epilepticus? 1. Establish an intravenous line and administer intravenous lorazepam (Ativan). 2. Administer rectal diazepam (Valium). 3. Administer an oral glucose gel to the side of the child's mouth. 4. Administer oral diazepam (Valium).

2. Administer rectal diazepam (Valium). Rationale: Rectal diazepam (Valium) is first administered in an attempt to stop the seizure long enough to establish an IV, and then IV medication is administered.

The nurse is caring for a 3-year-old with an altered state of consciousness. The nurse determines that the child is oriented by asking the child to: 1. Name the president of the United States. 2. Identify her parents and state her own name. 3. State her full name and phone number. 4. Identify the current month but not the date.

2. Identify her parents and state her own name.

Which is the best action for the nurse to take during a child's seizure? 1. Administer the child's rescue dose of oral diazepam (Valium). 2. Loosen the child's clothing, and call for help. 3. Place a tongue blade in the child's mouth to prevent aspiration. 4. Carry the child to the infirmary to call 911 and start an intravenous line.

2. Loosen the child's clothing, and call for help. Rationale: The nurse should remain with the child and observe the seizure. The child should be protected from his environment, and clothing should be loosened.

The nurse is caring for a 1-year-old who has just been diagnosed with viral encephalitis. The parents ask if their child will be admitted to the hospital. Select the nurse's best response. 1. "Your child will likely be sent home because encephalitis is usually caused by a virus and not bacteria." 2. "Your child will likely be admitted to the pediatric floor for intravenous antibiotics and observation." 3. "Your child will likely be admitted to the PICU for close monitoring and observation." 4. "Your child will likely be sent home because she is only 1 year old. We see fewer complications and a shorter disease process in the younger child."

3. "Your child will likely be admitted to the PICU for close monitoring and observation."

Which signs best indicate increased intracranial pressure (ICP) in an infant? Select all that apply. 1. Sunken anterior fontanel. 2. Complaints of blurred vision. 3. High-pitched cry. 4. Increased appetite. 5. Sleeping more than usual.

3. High-pitched cry. 5. Sleeping more than usual.

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 to as: 1. Coma. 2. Delirium. 3. Obtunded. 4. Confusion.

3. Obtunded. Rationale: "Obtunded" describes a state of consciousness in which the child has a limited response to the environment and can be aroused by verbal or tactile stimulation.

Select the best room assignment for a newly admitted child with bacterial meningitis. 1. Semiprivate room with a roommate who also has bacterial meningitis. 2. Semiprivate room with a roommate who has bacterial meningitis but has received intravenous antibiotics for more than 24 hours. 3. Private room that is dark and quiet with minimal stimulation. 4. Private room that is bright and colorful and has developmentally appropriate activities available.

3. Private room that is dark and quiet with minimal stimulation. Rationale: A quiet private room with minimal stimulation is ideal because the child with meningitis should be in a quiet environment to avoid cerebral irritation.

The nurse is caring for a child with cerebral palsy (CP) whose weight is in the fifth percentile and who has been hospitalized for aspiration pneumonia. His parents are anxious and state that they do not want a G-tube placed. Which would be the nurse's best response? 1. "A G-tube will help your son gain weight and reduce his risk for future hospitalizations due to pneumonia." 2. "G-tubes are very easy to care for and will make feeding time easier for your family." 3. "Are you concerned that you will not be able to care for his G-tube?" 4. "Tell me your thoughts about G-tubes."

4. "Tell me your thoughts about G-tubes."

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 best response. 1. "Give her some acetaminophen (Tylenol), and see if her symptoms improve. If they do not improve, bring her to the health-care provider's office." 2. "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." 3. "You are probably worried that she is having a problem with her shunt. This is very unlikely because it has been working well for 9 years." 4. "You should immediately take her to the emergency department because these may be symptoms of a shunt malfunction."

4. "You should immediately take her to the emergency department because these may be symptoms of a shunt malfunction."

The parents of a 12-month-old with a neurogenic bladder ask the nurse if their child will always have to be catheterized. Select the nurse's best response. 1. "Your child will never feel when her bladder is full, so she will always have to be catheterized. Because she is female, she will always need assistance." 2. "As your child ages, she will likely be able to sense when her bladder is full and will be able to empty it on her own." 3. "Although your child will not be able to feel when her bladder is full, she can learn to urinate every 4 to 6 hours and therefore not require catheterizations." 4. "Your child will never be able to completely empty her bladder spontaneously, but there are other options to traditional catheterization. An opening can be made surgically through the abdomen, allowing a catheter to be placed into the opening."

4. "Your child will never be able to completely empty her bladder spontaneously, but there are other options to traditional catheterization. An opening can be made surgically through the abdomen, allowing a catheter to be placed into the opening."

The nurse is caring for an adolescent who remains unconscious 24 hours after sustaining a closed-head injury in a motor vehicle accident (MVA). She responds to deep, painful stimulation with decorticate posturing and has an intracranial monitor that shows periodic increased ICP. All other vital signs remain stable. Select the most appropriate nursing action. 1. Encourage the teen's peers to visit and talk to her about school and other pertinent events. 2. Encourage the teen's parents to hold her hand and speak loudly to her in an attempt to help her regain consciousness. 3. Attempt to keep a normal day/night pattern by keeping the teen in a bright, lively environment during the day and dark quiet environment at night. 4. Attempt to keep the environment dark and quiet and encourage minimal stimulation.

4. Attempt to keep the environment dark and quiet and encourage minimal stimulation. Rationale: A dark, quiet environment and minimal stimulation will decrease oxygen consumption and ICP.

A child is being admitted with the diagnosis of meningitis. Select the procedure the nurse should do first: 1. Administration of intravenous antibiotics. 2. Administration of maintenance intravenous fluids. 3. Placement of a Foley catheter. 4. Send the spinal fluid and blood samples to the laboratory for cultures.

4. Send the spinal fluid and blood samples to the laboratory for cultures.

The nurse is admitting a young child to the hospital with possible bacterial meningitis. The major priority of nursing care is to: A) initiate isolation precautions as soon as the diagnosis is confirmed. B) administer antibiotic therapy as soon as it is ordered. C) initiate isolation precautions as soon as the causative agent is identified. D) administer sedatives/analgesics on a preventive schedule to manage pain.

B) administer antibiotic therapy as soon as it is ordered. Rationale: Administration of antibiotic therapy as soon as it is ordered is the priority action. Antibiotics are begun as soon as possible to prevent death and avoid resultant disabilities.

A child with spina bifida has a latex allergy from exposure to numerous bladder catheterizations and surgeries. A priority nursing intervention is to: 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) provide a latex-free environment. Rationale: Providing a latex-free environment is the most important nursing intervention. From birth on, the limitation of exposure to latex is essential in an attempt to minimize sensitization.

A young child is having a seizure that has lasted 35 minutes with loss of consciousness. The nurse recognizes that this is: A) an absence seizure. B) status epilepticus. C) a generalized seizure. D) a simple partial seizure.

B) status epilepticus. Rationale: Status epilepticus is a generalized seizure that lasts more than 30 minutes.

A woman 6 weeks pregnant tells the nurse that she is worried the baby might have spina bifida because of a family history. The nurse's response should be based on: A) There is no genetic basis for the defect. B) Prenatal detection is not possible yet. C) Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. D) The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally.

D) The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally. Rationale: Fetal ultrasonography and elevated concentrations of alpha-fetoprotein in amniotic fluid may indicate the presence of neural tube defects.

A nurse is caring for a newborn diagnosed with hydrocephalus related to a neural tube defect. Which surgical procedure should the nurse prepare the client for? A) Pial synangiosis B) Gastroschisis repair C) Patent foramen transcatheter repair D) Ventriculoperitoneal shunt

D) Ventriculoperitoneal shunt

A neural tube defect that is not visible externally in the lumbosacral area is called: A) a meningocele. B) a myelomeningocele. C) spina bifida cystica. D) spina bifida occulta.

D) spina bifida occulta. Rationale: Spina bifida occulta is completely enclosed. Often this defect will not be noticed.

The nurse explains increased intracranial pressure (ICP) to the nursing student. Complete the following sentence by choosing from the list of options. Increased intracranial pressure (ICP) results from an increase in the volume of any of the three contents within the skull, which include the ____________ (*brain tissue / dura cortex / papillary muscles*), ___________ (*blood / pleura / lymph nodes*), and ___________ (*cerebrospinal fluid / hydrostatic fluid / salivary secretions*).

Increased intracranial pressure (ICP) results from an increase in the volume of any of the three contents within the skull, which include the *brain tissue, blood, and cerebrospinal fluid*.

The nurse is caring for an infant with a myelomeningocele. The parents ask the nurse why the nurse keeps measuring the baby's head circumference. Select the nurse's best response: 1. "Babies' heads are measured to ensure growth is on track." 2. "Babies with a myelomeningocele are at risk for hydrocephalus, which shows up as an increase in head size." 3. "Because your baby has an opening on the spinal cord, your infant is at risk for meningitis, which can show up as an increase in head size." 4. "Many infants with myelomeningocele have microcephaly, which can show up as a decrease in head size."

2. "Babies with a myelomeningocele are at risk for hydrocephalus, which shows up as an increase in head size."

The parents of a child with altered consciousness ask if they can stay during the morning assessment. Select the nurse's best response. 1. "Your child is more likely to answer questions and cooperate with any procedures if you are not present." 2. "Most children feel more at ease when parents are present, so you are more than welcome to stay at the bedside." 3. "It is our policy to ask parents to leave during the first assessment of the shift." 4. "Many children fear that their parents will be disappointed if they do not do well with procedures, so we recommend that no parents be present at this time."

2. "Most children feel more at ease when parents are present, so you are more than welcome to stay at the bedside."

The nurse is providing discharge teaching to the parents of a toddler who experienced a febrile seizure. The nurse knows clarification is needed when the mother says: 1. "My child will likely have another seizure." 2. "My child's 7-year-old brother is also at high risk for a febrile seizure." 3. "I'll give my child acetaminophen (Tylenol) when ill to prevent the fever from rising too high too rapidly." 4. "Most children with febrile seizures do not require seizure medicine."

2. "My child's 7-year-old brother is also at high risk for a febrile seizure." Rationale: Most children over the age of 5 years do not have febrile seizures.

The nurse is aware that cloudy cerebrospinal fluid (CSF) most likely indicates: 1. Viral meningitis. 2. Bacterial meningitis. 3. No infection, because CSF is usually cloudy. 4. Sepsis.

2. Bacterial meningitis.

Which activity should an adolescent just diagnosed with epilepsy avoid? 1. Swimming, even with a friend. 2. Being in a car at night. 3. Participating in any strenuous activities. 4. Returning to school right away.

2. Being in a car at night. Rationale: The rhythmic reflection of other car lights can trigger a seizure in some children.

A child involved in a motor vehicle accident (MVA) is currently on a backboard with a cervical collar in place. The child is diagnosed with a cervical fracture. Which would the nurse expect to find in the child's plan of care? 1. Remove the cervical collar, keep the backboard in place, and administer highdose methylprednisolone (Medrol). 2. Continue with all forms of spinal stabilization and administer high-dose methylprednisolone (Medrol) and ranitidine (Zantac). 3. Remove the backboard and cervical collar and prepare for halo traction placement. 4. Remove the cervical collar and backboard, place the child on spinal precautions, and administer high-dose methylprednisolone (Medrol) and ranitidine (Zantac).

2. Continue with all forms of spinal stabilization and administer high-dose methylprednisolone (Medrol) and ranitidine (Zantac).

The parent of an infant diagnosed with a neuroblastoma asks the nurse what the prognosis is. The nurse's best response is: 1. Excellent, because a neuroblastoma is always cured. 2. Excellent, because infants with a neuroblastoma have the best prognosis. 3. Poor, because infants with a neuroblastoma rarely survive. 4. Variable, depending on the site of origin.

2. Excellent, because infants with a neuroblastoma have the best prognosis.

An infant is born with a sac protruding through the spine, containing cerebrospinal fluid (CSF), a portion of the meninges, and nerve roots. This condition is referred to as: 1. Meningocele. 2. Myelomeningocele. 3. Spina bifida occulta. 4. Anencephaly.

2. Myelomeningocele. Rationale: A myelomeningocele is a sac that contains a portion of the meninges, the CSF, and the nerve roots.

A child recently diagnosed with epilepsy is being evaluated for anticonvulsant medication therapy. The child will likely be placed on which type of regimen? 1. Two to three oral anticonvulsant medications so that dosing can be low and side effects minimized. 2. One oral anticonvulsant medication to observe effectiveness and minimize side effects. 3. One rectal gel to be administered in the event of a seizure. 4. A combination of oral and intravenous anticonvulsant medications to ensure compliance.

2. One oral anticonvulsant medication to observe effectiveness and minimize side effects.

A parent of a newborn diagnosed with myelomeningocele asks what is/are common long-term complication(s)? The nurse's best response is which of the following? Select all that apply. 1. Learning disabilities. 2. Urinary tract infections. 3. Hydrocephalus. 4. Decubitus ulcers and skin breakdown. 5. Nutrition issues. 6. Attention deficit disorders

2. Urinary tract infections. 3. Hydrocephalus. Rationale: Urinary tract infections are the most common complication of myelomeningocele. Nearly all children with myelomeningocele have a neurogenic bladder that leads to incomplete emptying of the bladder and subsequent urinary tract infections. Frequent catheterization also increases the risk of urinary tract infection. About 90% to 95% of children with myelomeningocele experience hydrocephalus.

A child has been diagnosed with a midline brain tumor. In addition to showing signs of increased intracranial pressure (ICP), she has been voiding large amounts of very dilute urine. Which medication does the nurse expect to administer? 1. Mannitol (Osmitrol). 2. Vasopressin. 3. Furosemide (Lasix). 4. Dopamine (Intropin).

2. Vasopressin. Rationale: The child is experiencing diabetes insipidus, a common occurrence in children with midline brain tumors. Vasopressin is a hormone that is used to help the body retain water.

A child fell off his bike and sustained a closed-head injury. The child is currently awake and alert, but his mother states that he "passed out" for approximately 2 minutes. The mother appears highly anxious and is very tearful. The child was not wearing a helmet. Which is a priority for the triage nurse to say at this time? 1. "Was anyone else injured in the accident?" 2. "Tell me more about the accident." 3. "Did he vomit, have a seizure, or display any other behavior that was unusual when he woke up?" 4. "Why was he not wearing a helmet?"

3. "Did he vomit, have a seizure, or display any other behavior that was unusual when he woke up?"

The nurse prepares baclofen for a child with cerebral palsy (CP) who just had her hamstrings surgically released. The child's parents ask what the medication is for. Select the nurse's best response. 1. "It is a medication that will help decrease the pain from her surgery." 2. "It is a medication that will prevent her from having seizures." 3. "It is a medication that will help control her spasms." 4. "It is a medication that will help with bladder control."

3. "It is a medication that will help control her spasms." Rationale: Baclofen is given to help control spasms associated with CP

A child in the PICU with a head injury is comatose and unresponsive. The parent asks if he needs pain medication. Select the nurse's best response. 1. "Pain medication is not necessary because he is unresponsive and cannot feel pain." 2. "Pain medication may interfere with his ability to respond and may mask any signs of improvement." 3. "Pain medication is necessary to make him comfortable." 4. "Pain medication is necessary for comfort, but we use it cautiously because it increases the demand for oxygen."

3. "Pain medication is necessary to make him comfortable."

The nurse is caring for a child receiving radiation therapy for a brain tumor. The parents ask if their child will likely have any learning disabilities. Select the nurse's best answer. 1. "All children who receive radiation have some amount of learning disability. As long as they receive extra tutoring, they usually do well in school." 2. "Because your child is so young, she will likely do well and have no problems in the future." 3. "Response varies with each child, but younger children who receive radiation tend to have some amount of learning disability later in life." 4. "Response varies with each child, but younger children who receive radiation tend to have fewer problems later in life than older children."

3. "Response varies with each child, but younger children who receive radiation tend to have some amount of learning disability later in life."

The parent of a child with neuroblastoma asks the nurse what the typical signs and symptoms are at first. Select the nurse's best answer. 1. "Most children complain of abdominal fullness and difficulty urinating." 2. "Many children in the early stages of a neuroblastoma have joint pain and walk with a limp." 3. "The signs and symptoms vary depending on where the tumor is located, but typical symptoms include weight loss, abdominal distention, and fatigue." 4. "The signs and symptoms are fairly consistent regardless of the location of the tumor. They include fatigue, hunger, weight gain, and abdominal fullness."

3. "The signs and symptoms vary depending on where the tumor is located, but typical symptoms include weight loss, abdominal distention, and fatigue."

The nurse is caring for a 2-month-old infant who is at risk for cerebral palsy (CP) due to extreme low birth weight and prematurity. His parents ask why a speech therapist is involved in his care. Select the nurse's best response. 1. "Your baby is likely to have speech problems because of his early birth. Involving the speech therapist now will ensure vocalization at a developmentally appropriate age." 2. "The speech therapist will help with tongue and jaw movements to assist with babbling." 3. "The speech therapist will help with tongue and jaw movements to assist with feeding." 4. "Many members of the health-care team are involved in your child ' s care so that we will know if there are any unmet needs."

3. "The speech therapist will help with tongue and jaw movements to assist with feeding." Rationale: The infant who is at risk for CP may have weakened and uncoordinated tongue and jaw movements.

The parents of a child with meningitis and multiple seizures ask if the child will likely develop cerebral palsy (CP). Select the nurse's best response. 1. "When your child is stable, she'll undergo computed tomography (CT) and magnetic resolution imaging (MRI). The physicians will be able to let you know if she has CP." 2. "Most children do not develop CP at this late age." 3. "Your child will be closely monitored after discharge, and a developmental specialist will be able to make the diagnosis." 4. "Most children who have had complications following meningitis develop some amount of CP."

3. "Your child will be closely monitored after discharge, and a developmental specialist will be able to make the diagnosis."

The mother of an unconscious child has been calling her name repeatedly and gently shaking her shoulders in an attempt to wake her up. The nurse notes that the child is flexing her arms and wrists while bringing her arms closer to the midline of her body. The child's mother asks, "What is going on?" Select the nurse's best response. 1. "I think your daughter hears you, and she is attempting to reach out to you." 2. "Your child is responding to you; please continue trying to stimulate her." 3. "It appears that your child is having a seizure." 4. "Your child is demonstrating a reflex that indicates she is overwhelmed with the stimulation she is receiving."

4. "Your child is demonstrating a reflex that indicates she is overwhelmed with the stimulation she is receiving." Rationale: Posturing is a reflex that often indicates that the child is receiving too much stimulation.

The nurse is planning to assess a client admitted to the unit with Reye syndrome. Which physiological system(s) should the nurse anticipate including during a focused assessment? Select all that apply. A) Cardiovascular B) Gastrointestinal C) Neurological D) Integumentary E) Genitourinary

A) Cardiovascular B) Gastrointestinal C) Neurological D) Integumentary E) Genitourinary Rationale: The nurse should document pertinent, focused assessment findings specifically associated with Reye syndrome. The nurse can expect changes in the neurological, genitourinary, integumentary, gastrointestinal, and cardiovascular systems.

Brain damage in a child who sustained a closed-head injury can be caused by which factor? 1. Increased perfusion to the brain and increased metabolic needs of the brain. 2. Decreased perfusion to the brain and decreased metabolic needs of the brain. 3. Increased perfusion to the brain and decreased metabolic needs of the brain. 4. Decreased perfusion of the brain and increased metabolic needs of the brain.

4. Decreased perfusion of the brain and increased metabolic needs of the brain.

Which is included in the plan of care for a newborn who has a myelomeningocele? 1. Place the infant in the prone position with a sterile dry dressing over the defect. Slowly begin oral gastric feeds to prevent the development of necrotizing enterocolitis. 2. Place the infant in the prone position with a sterile dry dressing over the defect. Begin intravenous fluids to prevent dehydration. 3. Place the infant in the prone position with a sterile moist dressing over the defect. Slowly begin oral gastric feeds to prevent the development of necrotizing enterocolitis. 4. Place the child in the prone position with a sterile moist dressing over the defect. Begin intravenous fluids to prevent dehydration.

4. Place the child in the prone position with a sterile moist dressing over the defect. Begin intravenous fluids to prevent dehydration. Rationale: The child is placed in the prone position to avoid any pressure on the defect. A sterile moist dressing is placed over the defect to keep it as clean as possible. Intravenous fluids are begun to prevent dehydration.

The nurse is obtaining a health history from a parent of a male pediatric client. The parent states, "I have been giving my son Pepto Bismol for constipation during the treatment of chickenpox. He has been vomiting quite a bit, and I think something is wrong." Which finding(s) should the nurse associate with Reye syndrome? Select all that apply. A) Confusion B) Rash C) Arthralgia D) Dysuria E) Lethargy

A) Confusion E) Lethargy Rationale:

The parent of a child newly diagnosed with epilepsy asks the nurse, "Why does my child have this condition?" Which is/are the appropriate response(s) by the nurse? Select all that apply. A) "Inherited genetic factors can increase seizure activity." B) "Some seizures have an unknown cause." C) "A lymphocyte count of 1000/mm³ increases the chance of epileptic seizures." D) "Epilepsy is caused by an increase in bone marrow production." E) "Underlying conditions such as trauma or illness can cause seizures."

A) "Inherited genetic factors can increase seizure activity." B) "Some seizures have an unknown cause." E) "Underlying conditions such as trauma or illness can cause seizures." Rationale: The causes of seizures vary. Causes may include a family history, underlying illnesses, and unknown causes. Many clients suffer from idiopathic seizures which are seizures without a cause. A first-degree relative increases the likelihood that clients will develop seizures. Underlying illnesses, such as trauma or infections, can also precipitate seizures.

Which of the following is a clinical manifestation of increased intracranial pressure in infants? A) Irritability B) Photophobia C) Pulsating anterior fontanel D) Vomiting and diarrhea

A) Irritability

The nurse is planning care for a school-age child with bacterial meningitis. Which of the following should be included? A) Keep environmental stimuli at a minimum. B) Avoid giving pain medications that could dull sensorium. C) Have the child move his head side to side at least every 2 hours. D) Measure head circumference to assess developing complications.

A) Keep environmental stimuli at a minimum. Rationale: Children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nurse should keep the room as quiet as possible, with a minimum of external stimuli.

A child is brought into the emergency room with vomiting, confusion, and lethargy. The parent tells the nurse the child has been treated with aspirin for fever after contracting chickenpox. Based on the child's history and clinical presentation, the nurse should anticipate preparing the client for which diagnostic test(s)? Select all that apply. A) Lumbar puncture B) Serum ammonia C) Liver panel D) Prothrombin time (PT) E) Computed tomography (CT) scan of the head

A) Lumbar puncture B) Serum ammonia C) Liver panel D) Prothrombin time (PT) E) Computed tomography (CT) scan of the head Rationale: A client presenting with confusion, lethargy, and history of varicella-zoster virus (chickenpox) can develop conditions such as encephalopathy, meningitis, and encephalitis. Therefore, a lumbar puncture is performed to help diagnose these conditions. The client's serum ammonia level will be evaluated and is anticipated to be elevated in a client with Reye syndrome. The nurse should anticipate a liver panel to be obtained to evaluate the liver function. The liver panel includes the liver enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT). A client with Reye syndrome will have abnormally high liver enzymes. A prothrombin time is a test to see how long it takes the blood to coagulate or clot. A client with Reye syndrome is at risk for bleeding. A CT scan of the head is performed to evaluate the client for cerebral edema, which can cause the client's symptoms and is a finding associated with Reye syndrome.

The parents of a five-year-old child are speaking with the nurse after placement of a ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus. The mother of the child asks the nurse, "How do we keep things from going wrong with the drain?" Which instruction(s) should the nurse include? Select all that apply. A) Notify the physician if the child regresses in their potty training. B) A stiff neck is an expected finding for the week following the procedure C) Soak the incision in warm water and soap during bath time. D) The child will be unsteady on their feet several days after surgery E) A lack of appetite may indicate VP shunt malfunction

A) Notify the physician if the child regresses in their potty training. E) A lack of appetite may indicate VP shunt malfunction Rationale: If hydrocephalus persists, clients may need surgical placement of a permanent shunt, which drains the excess cerebrospinal fluid (CSF) from brain ventricles to somewhere else in the body where it can then be absorbed into the bloodstream. The most commonly used shunt is ventriculoperitoneal (VP) shunt, which drains the CSF into the peritoneal cavity in the abdomen. Following placement of a VP shunt, the nurse should educate the parents of the client of signs of increased intracranial pressure (ICP), such as *change in level of consciousness, nausea, vomiting, and seizures*. Clients with a shunt need to be followed up for complications such as shunt obstruction, disconnection, and infection. *Findings associated with shunt malfunction may include irritability; a high, shrill cry; gait unsteadiness; regression in bowel and bladder training; a lack of appetite; and a headache.*

The nurse is evaluating the laboratory results of an adolescent client with suspected Reye syndrome admitted to the Intensive Care Unit with seizures after taking aspirin for pain from influenza. Which laboratory result(s) helps to confirm a diagnosis of Reye syndrome? Select all that apply. A) Prothrombin time (PT) 15.5 seconds B) Aspartate aminotransferase (AST) 110 mU/mL C) Total bilirubin 1.0 mg/dL D) Alanine aminotransferase (ALT) 98 mU/mL E) Ammonia 175 µ/dL

A) Prothrombin time (PT) 15.5 seconds B) Aspartate aminotransferase (AST) 110 mU/mL C) Total bilirubin 1.0 mg/dL D) Alanine aminotransferase (ALT) 98 mU/mL E) Ammonia 175 µ/dL Rationale: Clients with Reye syndrome will have liver damage reflected by lab tests showing hyperammonemia (normal range 15 to 45 µ/dL), as well as abnormal liver function tests. These include increased liver enzymes like aspartate aminotransferase, or AST (normal range 7 to 40 mU/mL), and alanine aminotransferase, or ALT (normal range 5 to 35 mU/m). However, bilirubin levels (normal range 0.2 to 1.3 mg/dL) are usually normal. Another important thing to test is prothrombin time, or PT (normal range 11 to 12.5 seconds), which refers to the time it takes for the blood to coagulate and is usually also elevated in Reye syndrome.

The nurse has provided parental education about how to avoid Reye syndrome in children. Which statement made by the parent indicates further teaching is required? A) "I will avoid giving my child any medications containing aspirin." B) "When my child reaches adolescence, I will be able to use aspirin to bring down a fever." C) "If I am unsure about an over-the-counter medication containing aspirin, I will ask the pharmacist." D) "There are commonly used medications that may contain aspirin."

B) "When my child reaches adolescence, I will be able to use aspirin to bring down a fever." Rationale: Aspirin and all products containing aspirin should be avoided in clients under 18 years of age.

The nurse is teaching a parent about non-modifiable risk factors associated with the development of Reye syndrome. Which information should the nurse include in the teaching? A) Gender B) Age C) Family history D) Immunocompetency

B) Age Rationale: Age is a non-modifiable risk factor for the development of Reye syndrome. Clients younger than 18-years-old have an increased risk of Reye syndrome.

The nurse is caring for a client receiving treatment for Reye syndrome. Which finding should the nurse immediately communicate to the healthcare provider? A) Partial thrombin (PT) 11 seconds B) Blood glucose level 44 mg/dL C) Client voided 65 mL over the past hour D) A heart rate of 88 bpm

B) Blood glucose level 44 mg/dL Rationale: Hypoglycemia is a complication of Reye syndrome and requires immediate treatment. The normal range for a blood glucose is 60 to 100 mg/dL.

The nurse is developing an interdisciplinary care plan for an adolescent client with Reye syndrome experiencing a decreased level of consciousness. Which healthcare professional should the nurse include in the plan of care? A) Respiratory therapist B) Neurologist C) Social worker D) Infection control nurse

B) Neurologist

The nurse is discussing long-term care with the parents of a child with a ventriculoperitoneal shunt to correct hydrocephalus. Part of the teaching plan includes: A) Parental protection is essential until the child reaches adulthood. B) Shunt malfunction or infection requires immediate treatment. C) Mental retardation is to be expected with hydrocephalus. D) Most usual childhood activities must be restricted.

B) Shunt malfunction or infection requires immediate treatment. Rationale: Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately, if present.

A nurse is performing discharge teaching for caregivers with a newborn diagnosed with spina bifida occulta. The nurse is teaching the caregivers about signs of seizure in their infant. Which signs should the nurse include in the discussion? Select all that apply. A) Fecal incontinence B) Tremor-like movements C) Excessive blinking D) Jerking of extremities E) Prolonged staring

B) Tremor-like movements C) Excessive blinking D) Jerking of extremities E) Prolonged staring Rationale: The nurse performing teaching to the caregivers of an infant with a neural tube defect should be sure to educate them about signs of seizure. The nurse should instruct the caregivers to watch for jerking or twitching movements, excessive blinking, or prolonged staring. Incontinence is not a reliable sign of seizure and is an expected finding in a newborn.

The nurse is preparing a plan of care for a 7-year-old client diagnosed with Reye syndrome. How should the nurse prioritize the nursing diagnoses? *Place in order from highest to lowest priority. All options must be used.* A) Deficient parental knowledge r/t use of antipyretics B) Risk for hemorrhage r/t liver dysfunction C) Deficient fluid volume r/t vomiting D) Risk for confusion r/t elevated ammonia levels

C) Deficient fluid volume r/t vomiting B) Risk for hemorrhage r/t liver dysfunction D) Risk for confusion r/t elevated ammonia levels A) Deficient parental knowledge r/t use of antipyretics

The pediatric intensive care unit (PICU) nurse is caring for a one-year-old client diagnosed with hydrocephalus who is 1 day post-ventriculoperitoneal (VP) shunt placement. The mother of the client comes out to the nurse's station and states, "My baby is staring off into space, and she won't make eye contact." Which intervention should the nurse perform first? A) Administer an intravenous sedative, such as fentanyl B) Inform the client's mother that this is an expected finding following shunt placement C) Immediately notify the healthcare provider D) Encourage the client's mother to offer the baby formula

C) Immediately notify the healthcare provider Rationale: Staring without eye contact is a possible clinical manifestation of an oncoming seizure or that intracranial pressure (ICP) is increasing. The nurse should immediately contact the healthcare provider to communicate this complication following VP shunt placement.

Which 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) Some degree of fecal continence can usually be achieved. Rationale: With diet modification and regular toilet habits to prevent constipation and impaction, some degree of fecal continence can be achieved.

A nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain: A) cannot occur if the child is comatose. B) may occur if the child regains consciousness. C) requires astute nursing assessment and management. D) is best assessed by family members who are familiar with the child.

C) requires astute nursing assessment and management. Rationale: Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must be focused on physiologic and behavioral manifestations.

The nurse in the community health clinic is speaking with the parents of a child who was recently diagnosed with a learning disability. The father of the child says to the nurse, "My child was born with hydrocephalus. Is this why he is having trouble in school now?" Which is the best response by the nurse? A) "Hydrocephalus can lead to decreased school performance since the size of the child's brain is much smaller than children without hydrocephalus." B) "Hydrocephalus does not affect cognitive abilities. Instead, it only affects physical strength and coordination, leading to conditions such as myasthenia gravis." C) "Hydrocephalus does not cause learning disabilities, and the two disorders are completely unrelated." D) "Babies born with hydrocephalus can develop difficulty paying attention and making memories as they age, which can affect school performance."

D) "Babies born with hydrocephalus can develop difficulty paying attention and making memories as they age, which can affect school performance." Rationale: Excess cerebrospinal fluid (CSF) puts pressure on the brain ventricles in clients diagnosed with hydrocephalus, causing brain injuries that lead to cognitive and physical disabilities. Clients diagnosed with hydrocephalus have a higher risk of developing long-term complications, such as permanent visual impairment, speech impairment, and learning difficulties affecting the client's attention, thinking, and memory formation. In children, this results in poor school performance.

The nurse is caring for a client diagnosed with Reye syndrome experiencing increased cranial pressure (ICP). Which intravenous solution should the nurse anticipate administering? A) Dextrose 5% in water (D5W) B) 0.45% sodium chloride C) 0.9% saline D) 3% hypertonic solution

D) 3% hypertonic solution Rationale: Clients with Reye syndrome experience cerebral edema. Hypertonic solutions are used to treat cerebral edema. They work by drawing the fluid out of edematous cerebral tissue due to its higher concentration gradient.

Which of the following is a nursing intervention to prevent increased intracranial pressure (ICP) in an unconscious child? A) Suction any secretions frequently. B) Provide environmental stimulation. C) Turn the head side to side every hour. D) Avoid activities that cause pain.

D) Avoid activities that cause pain. Rationale: Nursing interventions should focus on assessments and interventions that minimize pain. The activities in the other options can cause the intracranial pressure to increase.

The nurse is preparing to assess a 4-year-old client with Reye syndrome. Which clinical finding should the nurse expect? A) Pupils 3 mm B) Increased appetite C) +3 reflexes D) Headache pain 7/10

D) Headache pain 7/10 Rationale: A headache is an anticipated finding from the increase in intracranial pressure due to the toxicity of the elevated ammonia levels. Symptoms of Reye syndrome usually start after the onset of the viral illness treated with salicylates and include *severe and persistent vomiting and declining brain function associated with headache, lethargy, confusion, and impaired level of consciousness.*

Which nursing intervention is important when caring for an infant with myelomeningocele in the postoperative stage? A) Place the child on her side to decrease pressure on the spinal cord. B) Apply a heat lamp to facilitate drying and toughening of the sac. C) Keep skin clean and dry to prevent irritation from diarrheal stools. D) Measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus.

D) Measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus. Rationale: Hydrocephalus is frequently associated with myelomeningocele. Assessment of the fontanels and daily measurements of head circumference will aid in early detection.