Peds 13 Neurological and Sensory Disorders

The nurse is preparing an educational poster on reflexes present in a newborn. In what order should the nurse identify that the reflexes disappear? Moro reflex Babinski sign Placing reflex Rooting reflex

rooting, placing, moro, babinski

The nurse is admitting a toddler with suspected meningitis. In what order should the nurse perform these tasks? Start antibiotics. Obtain the lumbar puncture. Begin IV fluids as ordered. Start an IV.

start IV, obtain lumbar puncture, begin IV fluids, start antibiotics

A school-age child requires a lumbar puncture. In what order should the nurse provide care to this client? Assess the puncture site for bleeding. Support in a lateral side-lying position. Apply a dry dressing to the puncture site. Maintain strict bed rest for 4 to 24 hours.

support, apply, maintain, assess

The nurse suspects that a preadolescent client is experiencing migraine headaches. Which finding caused the nurse to make this clinical determination? Select all that apply. Begins to vomit Reports dizziness Asks for the lights to be turned off Turns the volume up on the television Asks for something to stop the "head pounding"

1,2,3,5

A preschool-age child requires an MRI of the brain and spinal cord. Which action should the nurse take when caring for this client? Select all that apply. Remove earrings from both ears. Provide age-appropriate sedation. Restrict oral fluids after the study. Monitor level of responsiveness after the study. Report crying after the study to the health care provider.

1,2,4

The nurse is providing education to a school-age client and her family on how to avoid headache triggers when possible, along with a list of some common headache triggers. What should the nurse include in that list? Select all that apply. Sleep deprivation Inadequate fluid intake Eating too many sugary sweets Stress Skipping meals, most commonly breakfast

1,2,4,5

The nurse is reviewing the plan of care for an adolescent child with cerebral palsy. Which treatment modalities would the nurse expect? Select all that apply . Speech therapy Physical therapy Respiratory therapy Occupational therapy Educational therapy

1,2,4,5

The nurse is assessing an infant for hydrocephalus. What signs and symptoms should the nurse identify to support this potential diagnosis? Select all that apply. Rapid increase in head circumference or an unusually large head size Bulging fontanel with crying Vomiting A high-pitched, shrill cry Sunsetting eyes

1,3,4,5

The nurse is preparing a school-age child for magnetic resonance imaging (MRI). What considerations should the nurse identify as important when preparing a pediatric client for an MRI? Select all that apply. The child is often given age-appropriate sedation for the MRI. Children should be encouraged to eat and drink prior to going into the MRI due to the long length of time they may be in the test. Nursing care is aimed at alleviating anxiety and complications. Any metallic piercings or jewelry must be removed from the child prior to the procedure. Intake and output must be monitored.

1,3,4,5

The nurse is asked to prepare a teaching tool about acquired hydrocephalus in pediatric clients. Which type should the nurse include? Select all that apply. Ex-vacuo Incomplete Communicating Normal pressure Non-communicating

1,3,5

An infant is born with an open spinal cord defect. Which action should the nurse take when caring for this client? Select all that apply. Position the client prone. Position the client supine. Keep the defect open to air. Place the client on an open diaper. Cover the defect with a moist, sterile dressing.

1,4,5

Which choice describes spina bifida cystica, also known as myelomeningocele? A section of the spinal cord and the nerves that come from the cord are exposed and visible on the outside of the body. It causes partial or complete paralysis below the spinal opening. The membrane that surrounds the spinal cord is enlarged, creating a cyst-like sac. The sac that is present usually on the lower back contains meninges, which are the membranes covering the spinal cord. A section of the spinal vertebrae is malformed, but the spinal cord and nerves are normal. The defect is not visible, though newborns may display dimpling, hair, or hemangioma in the lumbar sacral area. Tissue attachments limit the movement of the spinal cord within the spinal column.

A section of the spinal cord and the nerves that come from the cord are exposed and visible on the outside of the body. It causes partial or complete paralysis below the spinal opening.

The school nurse is being consulted by a teacher with concerns about a student who is doing poorly in class. The student stares off into space regularly and is unable to recall information that was just discussed. What disorder should the nurse suspect? Myoclonic seizures Absence seizures Febrile seizures Tonic-clonic seizures

Absence seizures

The nurse is assessing a full-term newborn infant and notes the lack of a Moro reflex. What should this finding represent to the nurse? A birth defect A normal finding An impairment of the central nervous system A dysfunction of the neuromuscular junction

An impairment of the central nervous system

The nurse is with a family as the mother is receiving an ultrasound. The test reveals a defect in the fetus in which the unborn child is missing a large part of the brain and skull. Which defect would the nurse identify this as being? Anencephaly Encephalocele Chiari malformation Microcephaly

Anencephaly

The nurse is caring for a newborn after delivery and recognizes that the child was with born with a myelomeningocele. What action should the nurse take? Clean the area and leave it open to air. Clean the defect and cover with impregnated gauze. Cover the defect with a sterile dressing moistened with warm and sterile normal saline. Cover the defect with a simple dressing until the infant can go directly into surgery.

Cover the defect with a sterile dressing moistened with warm and sterile normal saline.

A 5-year-old client has been experiencing seizure activity for the last 20 minutes. What medication should the nurse prepare to administer to this client? Diazepam Clonazepam Ethosuximide Carbamazepine

Diazepam

The nurse is visiting the home of a school-age child who is recovering from shunt placement for hydrocephalus. Which assessment finding indicates that the shunt is draining too aggressively? Fever Lethargy Dizziness Severe headache

Dizziness

A 5-year-old client is being tested for muscular dystrophy. Which type of this disorder should the nurse expect the client to perform Gowers' sign? Becker muscular dystrophy Acquired muscular dystrophy Duchenne muscular dystrophy Facioscapulohumeral muscular dystrophy

Duchenne muscular dystrophy

The nurse is doing health promotion education with a group of young women. Because of the risk of neural tube defects, the nurse should stress the importance of taking which supplement daily while of childbearing age? Calcium Magnesium Folic acid Iron

Folic acid

A 1-month-old infant is demonstrating tremulous movements. Which action should the nurse take to determine if the client is experiencing a seizure? Place in a side-lying position Assess heart and breath sounds Count the number of respirations Gently grasp the tremulous extremity

Gently grasp the tremulous extremity

The nurse is assigned an adolescent client with newly diagnosed meningitis and is going in the client's room to hang the antibiotics. What personal protective equipment (PPE) should the nurse put on? Gown and gloves Gown, mask, and gloves Gown, goggles, mask, and gloves Gloves

Gown, mask, and gloves

The nurse in a pain clinic is seeing an adolescent about recurrent headaches. What is an initial step the nurse could suggest that would help manage the client's headache pain? Have the client keep a headache diary. Give samples of some new medications targeted for migraines. Administer a pain injection. Have the client avoid gluten.

Have the client keep a headache diary.

A school-age client who has been on bed rest for several days becomes dizzy when moving to a sitting position. What type of hypotension should the nurse document in this client's medical record? Cardiac Vasovagal Orthostatic Psychogenic

Orthostatic

A nurse in the emergency department (ED) is assessing a pre-school age client who had a febrile seizure at home. The parent is very concerned and asks the nurse if this is very serious. How should the nurse respond? "Yes, the child is likely to get brain damage when a fever gets too high." "Generally they are not. But it is best to treat a fever when it starts." "No, they don't cause any issues." "Yes, you should consider this a medical emergency any time something like this occurs."

"Generally they are not. But it is best to treat a fever when it starts."

The nurse is collecting data from the caregivers of a child admitted with seizures. Which of the following statements indicates the child most likely had an atonic seizure? "He fell down and his whole body started shaking." "His arms had rapid jerking movements." "He was just staring into space and was totally unaware." "He usually is very coordinated, but he couldn\"t even walk without falling."

"He usually is very coordinated, but he couldn\"t even walk without falling."

The nurse is caring for a school-age client who was recently diagnosed with Guillain-Barré syndrome. The parent asks, "What happens with this disease?" How should the nurse respond? "It involves ascending paralysis; weakness occurs in the lower limbs and spreads upward." "It involves your muscles; they become spastic and difficult to control. " "It involves the blood; you get an overproduction of immature white blood cells." "It involves your nerve endings; you lose feeling and sensation in your extremities."

"It involves ascending paralysis; weakness occurs in the lower limbs and spreads upward."

The nurse is providing education to a parent whose toddler is diagnosed with Duchenne muscular dystrophy. Which statement by the parent indicates the teaching was understood? "I am glad that my child's disability will not progress beyond where it is now." "It is acquired related to a maternal infection." "This disorder is characterized by muscle spasticity and mental deficits." "Life expectancy is in the twenties and death is usually caused by respiratory or cardiac failure."

"Life expectancy is in the twenties and death is usually caused by respiratory or cardiac failure."

A mother is talking to the nurse and is concerned that her infant will get meningitis and die like her cousin's child did many years ago. The mother asks the nurse, "What is the best way I can protect my child?" How should the nurse respond? "There is no way to prevent it, unfortunately, but you must be quick to respond to any symptoms." "You should avoid taking your baby anywhere." "Many strains are vaccine-preventable, so getting all your vaccinations is a good start." "Keep your baby away from anyone who is sick."

"Many strains are vaccine-preventable, so getting all your vaccinations is a good start."

A nurse is providing education to a pregnant woman who is believed to have been exposed to the Zika virus. The woman asks, "What is the biggest complication babies born with this syndrome often experience?" How should the nurse respond? "Most babies born with this syndrome suffer with paralysis." "Most babies born with this syndrome suffer with hydrocephalus." "Most babies born with this syndrome suffer with microcephaly." "Most babies born with this syndrome suffer with Down syndrome."

"Most babies born with this syndrome suffer with microcephaly."

The nurse is providing education to a family who recently delivered a child with a myelomeningocele and the parents ask, "What issues can this cause?" How should the nurse respond? "This can cause paralysis of the legs, flaccid muscles, and problems with control of the bowel and bladder." "This can cause progressive muscle deterioration and mild mental delays." "This can cause spastic muscles, which can prompt difficulty with ambulation and cognitive deficits." "This can cause problems with mental abilities, a lack of coordination, and uncoordinated, jerky body movements."

"This can cause paralysis of the legs, flaccid muscles, and problems with control of the bowel and bladder."

The parent reports that a 3-year-old child receiving Lamotrigine for partial seizures has developed a rash. Which response should the nurse make to the parent? "Stop the medication immediately." "This means the dose needs to be doubled." "Take the client to the nearest medical facility." "This is something that occurs within the first 6 weeks of treatment."

"This is something that occurs within the first 6 weeks of treatment."

A school-age child is diagnosed with meningitis. What should the nurse expect to assess in this client? Select all that apply. Stiff neck Photosensitivity Severe headache Lower extremity weakness Elevated body temperature

1,2,3,5

A school-age child is reported as having a seizure at school. Which finding should indicate to the nurse that the client is experiencing focal seizures? Select all that apply. Spasms Muscle rigidity Head turning Loss of muscle tone Jerking of the extremities

1,2,3,5

An 8-month-old client is diagnosed with microcephaly. What should the nurse expect to assess in this client? Select all that apply. Seizures Hyperactivity Dysmorphic facial features Paralysis on one side of the body Circumference more than two standard deviations below normal

1,2,3,5

The nurse is caring for an adolescent with a head injury and suspects increased intracranial pressure (ICP). What findings support that belief? Select all that apply. Headache Vomiting that can increase to projectile Papilledema and blurred or double vision Petechial hemorrhages Sunsetting eyes

1,2,3,5

A school-age child is reported as experiencing sleepwalking at home. Which behavior should the nurse anticipate this client demonstrating? Select all that apply. Wakes up screaming in fear Appears awake with the eyes open Conversation does not makes sense Found sleeping on the floor near the window Appears confused and disoriented when awakened

Appears awake with the eyes open Conversation does not makes sense Found sleeping on the floor near the window Appears confused and disoriented when awakened

The nurse is caring for an adolescent client with myasthenia gravis. What issues should the nurse be vigilant and monitor for due to the complications it causes? Blood clots Heart failure Aspiration Hemorrhage

Aspiration

The nurse notes that a client with cerebral palsy has difficulty with balance and illegible writing. For which type of cerebral palsy should the nurse plan care for this client? Ataxic Mixed Spastic Athetoid

Ataxic

The nurse is preparing an education program on the Zika virus for a community health fair. Which information should the nurse include? Sleep in a room that is not air-conditioned. Apply insect repellant to the skin of all children. Avoid travelling to areas with outbreaks if pregnant. Spray porches and lawn areas with water at nightfall.

Avoid travelling to areas with outbreaks if pregnant.

The nurse, caring for a school-age client recovering from a ventriculoperitoneal (VP) shunt implant, completes an assessment and immediately notifies the healthcare provider. Which assessment finding caused the nurse to be concerned? Poor appetite Blood pressure 110/70 mm Hg Pain level 4 on a scale from 1 to 10 Blood tinged spot on the pillowcase encircled by a lighter ring

Blood tinged spot on the pillowcase encircled by a lighter ring

A preschool-age child is diagnosed with type 1 neurofibromatosis. What should the nurse expect to assess in this client? Rash Café au lait spots Edematous lower extremities Tiny red veins that appear in the corners of the eyes

Café au lait spots

The parent of a 3-month-old client is concerned because the child's eyes are deviating downward. What additional assessment should the nurse complete with this client? Oral intake Urine output Status of reflexes Integrity of the fontanelles

Integrity of the fontanelles

A school-age client is experiencing bilateral lower extremity weakness that is spreading to the hands and arms. Which diagnostic test should the nurse expect to prepare this client? MRI of the spine Lumbar puncture CT scan of the head Electroencephalogram

Lumbar puncture

The nurse is giving medications to an adolescent with cerebral palsy (CP). What symptom(s) do a majority of the CP medications target? Decreased cardiac output Muscle spasm and spasticity Respiratory compromise Muscle atrophy

Muscle spasm and spasticity

The nurse is performing a home assessment on a preschool-age child. The nurse notices that when in a squatting position, the child has to use his hands and arms to "walk up" his own body, pushing as he goes, in order to stand. What condition should the nurse investigate further? Cerebral palsy Muscular dystrophy Myasthenia gravis Guillain-Barré

Muscular dystrophy

The nurse in the clinic is assessing a school-age child brought in by his parent with reports of prolonged muscle weakness and fatigue. The nurse notes ptosis of the eyelids and an inability to smile. What condition should the nurse investigate further? Cerebral palsy Muscular dystrophy Myasthenia gravis Guillain-Barré

Myasthenia gravis

The nurse in the emergency department (ED) is assessing a school-age child with a new ventriculoperitoneal (VP) shunt. The child is being seen for lethargy, irritability, vomiting, severe headache, and a fever of 102.4°. What initial action should the nurse expect would be taken? An admission to the hospital for IV fluids and monitoring Give mannitol for increased intracranial pressure. Obtain a CT scan of the brain with X-rays of the chest and abdomen. A surgical intervention for hydrocephalus

Obtain a CT scan of the brain with X-rays of the chest and abdomen.

The nurse is assessing motor skills of a preschool-age child. What method would best accomplish this goal? Ask the parent what the child is able to do. Offer age-appropriate toys to see if the child manipulates the toy appropriately. Ask the child questions to determine the level of capability. Give the child a physical exam.

Offer age-appropriate toys to see if the child manipulates the toy appropriately.

A hospitalized preadolescent client is having difficulty waking up in the morning. Which observation should the nurse identify as contributing to this client's issue with sleep? Reading a book before bed Playing computer games until after midnight Eating a light snack with milk before bedtime Talking with the parents before turning out the light

Playing computer games until after midnight

A preschool-age client begins to experience a tonic-clonic seizure. What action should the nurse take first? Apply oxygen. Support the head. Position the client on the side. Place a padded tongue blade in the mouth.

Position the client on the side.

A preadolescent client experiences severe migraine headaches. Which medication should the nurse expect to be prescribed to treat this client's health problem? Valproate Propranolol Sumatriptan Nortriptyline

Sumatriptan

The parent of a school-age child who is recovering from a concussion that took place several weeks ago reports the child fell off a bicycle and hit the head again. What direction should the nurse provide to the parent? Place on bed rest. Monitor for orientation. Take to the nearest medical facility. Provide an over-the-counter analgesic.

Take to the nearest medical facility.

The nurse is providing anticipatory guidance to a family with a toddler who is getting ready to sleep in his own bed. What information should the nurse share with the parents to help establish healthy sleep patterns? Select all that apply. Put the child to bed at the same time each night through the week, with more freedom on the weekends. The child should only sleep in bed. The bedroom should be dark, quiet, and cool. Establish a bedtime routine. Perform vigorous activity before bed to burn off extra energy.

The child should only sleep in bed. The bedroom should be dark, quiet, and cool. Establish a bedtime routine.

The nurse is doing post-procedure education with a school-age child after a lumbar puncture. What factor is important for the nurse to emphasize? The child will be NPO for 6 hours post-procedure. The child will need to lay flat for 4 to 24 hours. The child will need hourly vital signs for the first 6 hours post-procedure. The child will need to be assessed for adequate urinary elimination within 4 hours post-procedure.

The child will need to lay flat for 4 to 24 hours.

Which choice describes meningocele? A section of the spinal cord and the nerves that come from the cord are exposed and visible on the outside of the body. It causes partial or complete paralysis below the spinal opening. The membrane that surrounds the spinal cord is enlarged, creating a cyst-like sac. The sac that is present usually on the lower back contains meninges, which are the membranes covering the spinal cord. A section of the spinal vertebrae is malformed, but the spinal cord and nerves are normal. The defect is not visible, though newborns may display dimpling, hair, or hemangioma in the lumbar sacral area. Tissue attachments limit the movement of the spinal cord within the spinal column.

The membrane that surrounds the spinal cord is enlarged, creating a cyst-like sac. The sac that is present usually on the lower back contains meninges, which are the membranes covering the spinal cord.

The nurse notes that a preschool-age client makes sudden repetitive shoulder movements. The nurse should assess this client for which health problem? Tic Chorea Tremor Dystonia

Tic

An 18-month-old client is scheduled for an electroencephalogram (EEG). What should the nurse do to facilitate this diagnostic test? Wash the client's hair before the test. Provide a sedative 30 minutes prior to the test. Withhold food and fluids for 2 hours before the test. Transport the client to the testing site during naptime.

Transport the client to the testing site during naptime.

A preadolescent client with a history of Chiari malformation type II arrives for a sports physical. What information is essential for the nurse to collect before beginning the physical assessment? Type of sport Head circumference Grade level in school Current height and weight

Type of sport

A toddler is scheduled for a routine wellness examination. What should the nurse do before beginning the assessment? Encourage the parent to hold the child. Ask the child to state his or her name and age. Allow the child to manipulate the stethoscope. Watch the child play with an age-appropriate toy.

Watch the child play with an age-appropriate toy.