Congenital Neuro/SpinalDisorders

30. A 3-month-old with spina bifida is admitted to the nurse's unit. Which of the following gross motor skills should the nurse assess at this age? 1. Head control. 2. Pincer grasp. 3. Sitting alone. 4. Rolling over

1. A 3-month-old has good head control.

37. The parent of a toddler newly diagnosed with CP asks the nurse what caused it. The nurse should answer which of the following? 1. Most cases are caused by unknown prenatal factors. 2. It is commonly caused by perinatal factors. 3. The exact cause is not known. 4. The exact cause is known in every instance.

1. At least 80% of cases of CP result from unknown prenatal factors.

22. The nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which of the following would be a priority nursing diagnosis before surgery? 1. Alteration in parent-infant bonding. 2. Altered growth and development. 3. Risk of infection. 4. Risk for weight loss.

3. A normal saline dressing is placed over the sac to prevent tearing, which would allow the cerebrospinal fluid to escape and microorganisms to enter and cause an infection.

31. A 15-year-old with spina bifida is seen in the clinic for a well-child checkup. The teen uses leg braces and crutches to ambulate. Which of the following nursing diagnoses takes priority? 1. Potential for infection. 2. Alteration in mobility. 3. Alteration in elimination. 4. Potential body image disturbance.

4. As an adolescent on crutches and wearing braces, the teen would have the issue of body image disturbance, which must be addressed. This is a priority.

21. A nurse is receiving an infant with myelomeningocele from an outside hospital. Which of the following priority items should be placed at the newborn's bedside? 1. A bottle of normal saline. 2. A rectal thermometer. 3. Extra blankets. 4. A blood pressure cuff.

1. Before the surgical closure of the sac, the infant is at risk for infection. A sterile dressing is placed over the sac to keep it moist and help prevent it from tearing.

43. A child is admitted to the pediatric unit with spastic CP. Which of the following would the nurse expect this child to demonstrate? Select all that apply. 1. Increased deep tendon reflexes. 2. Decreased muscle tone. 3. Scoliosis. 4. Contractures. 5. Scissoring. 6. Good control of posture. 7. Good fine motor skills.

1. Children with spastic CP have increased deep tendon reflexes. 3. Children with spastic CP have scoliosis. 4. Children with spastic CP have contractures of the Achilles tendons, knees, and adductor muscles. 5. Children with spastic CP have scissoring when walking.

74. The parents of an infant with hydrocephalus ask about future activities in which their child can participate in school and as an adolescent. The nurse should tell the parents which of the following? 1. A helmet should be worn during any activity that could lead to head injury. 2. Only non-contact sports should be pursued, such as swimming or tennis. 3. Because of the risk of shunt system infection, swimming is not a sports option. 4. The child should wear a life alert bracelet; then there is no need to be aware of the shunt system.

1. The risk of shunt breakage or obstruction is extremely low.

6. The nurse is preparing to give preoperative teaching to the parents of an infant with hydrocephalus. The nurse knows that the most common treatment for hydrocephalus includes the surgical placement of a shunt connecting which of the following? 1. The ventricle of the brain to the peritoneum. 2. The ventricle of the brain to the right atrium of the heart. 3. The ventricle of the brain to the lower esophagus. 4. The ventricle of the brain to the small intestine.

1. The ventriculoperitoneal is the most common shunt used to treat hydrocephalus.

89. The nurse is doing discharge teaching for a 3-month-old with a new shunt that was placed for hydrocephalus. Which of the following are signs and symptoms of hydrocephalus that the parents may see if the shunt malfunctions? Select all that apply. 1. Vomiting. 2. Irritability. 3. Poor feeding. 4. Headache. 5. Sunken fontanel. 6. Seizures. 7. Inability to wake up infant. 8. Hyperactivity.

12367

27. A newborn is diagnosed with a myelomeningocele at L2. Which of the following should be the priority nursing diagnosis for this infant at 12 hours of age? 1. Altered bowel elimination related to neurological deficits. 2. Potential for infection related to the physical defect. 3. Altered nutrition related to neurological deficit. 4. Disturbance in self-concept related to physical disability.

2. Because this infant has not had a repair, the sac is exposed. It could rupture, allowing organisms to enter the cerebrospinal fluid, so this is the priority.

29. Which of the following should the nurse tell the parent of an infant with spina bifida? 1. Bone growth will be more than that of babies who are not sick, because your baby will be less active. 2. Physical and occupational therapy will be helpful to stimulate the senses and improve cognitive skills. 3. Nutritional needs for your infant will be calculated based on activity level. 4. Fine motor skills will be delayed because of the disability.

2. Children with decreased activity due to illness or trauma are helped by physical and occupational therapy. The varied activities stimulate the senses.

37. 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. "We measure all babies' heads to ensure that their growth is on track." 2. "Babies with myelomeningocele are at risk for hydrocephalus, which can show up with an increase in head circumference." 3. "Because your baby has an opening on the spinal cord, your infant is at risk for meningitis, which can show up with an increase in head circumference." 4. "Many infants with myelomeningocele have microcephaly, which can show up with a decrease in head circumference."

2. Children with myelomeningocele are at increased risk for hydrocephalus, which can be manifested with an increase in head circumference.

8. The nurse is working in the PICU caring for an infant who has just returned from having a ventriculoperitoneal shunt placed. Which position initially will be most beneficial for this child? 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 is the position usually used initially, with the angle gradually increasing as the child tolerates.

26. Which of the following should the nurse do first when caring for an infant who just had a repair of a myelomeningocele? 1. Weigh diapers for 24-hour urine output. 2. Measure head circumference. 3. Offer clear fluids. 4. Assess for infection.

2. Hydrocephalus occurs in about 90% of infants with myelomeningocele, so measuring the head circumference daily and watching for an increase are important. Accumulation of cerebrospinal fluid can occur after closure of the sac.

28. A 2-month-old has had a myelomeningocele repair and has been brought in by a parent for the well-child checkup and shots. Over the last week, the baby has had a high-pitched cry and has been irritable. Height, weight, and head circumference have been at the 50th percentile. Today height is at the 50th percentile, weight is at the 70th percentile, and head circumference is at the 90th percentile. The nurse should do which of the following? 1. Tell the parent this is normal for an infant with a repaired myelomeningocele. 2. Tell the parent this might mean the baby has increased intracranial pressure. 3. Suspect the baby's intracranial pressure is low because of a leak. 4. Refer the baby to the neurologist for follow-up care.

2. The increase in head size is one of the first signs of increased intracranial pressure; other signs include highpitched cry and irritability.

42. A 6-month-old infant male has just been diagnosed with craniosynostosis. He is being evaluated for reconstructive surgery. The infant's father asks the nurse for more information about the surgery. Select the nurse's best response. 1. "The surgery is done for cosmetic reasons and is without many complications." 2. "The surgery is important to allow the brain to grow properly. Although most children do well, serious complications can occur, so your child will be closely observed in the intensive care unit." 3. "The surgery is important to allow the brain to grow properly. Most surgeons wait until the child is 3 years old to minimize potential complications." 4. "The surgery is mainly done for cosmetic reasons, and most surgeons wait until the child is 3 years old as the head has finished growing at that time."

2. The surgery is done to reconstruct the skull to allow the brain to grow properly. Because there are potential complications associated with this surgery, such as increased ICP, the child is usually closely observed in the PICU.

44. A 3-year-old child with CP is admitted for dehydration following an episode of diarrhea. The nurse's assessment follows: awake, pale, thin child lying in bed, multiple contractures, drooling, coughing spells noted when parent feeds. T 97.8°F (36.5°C), P 75, R 25, weight 7.2 kg, no diarrheal stool for 48 hours. Which of the following nursing diagnoses is most important? 1. Potential for skin breakdown: lying in one position. 2. Alteration in nutrition: less than body requirements. 3. Potential for impaired social support: mother sole caretaker. 4. Alteration in elimination: diarrhea.

2. This is the priority nursing diagnosis for this severely underweight child. Weight is average for a 4-month-old. The coughing episodes while feeding may indicate aspiration. The parent needs help to learn how to feed so less coughing occurs.

38. The most common complication associated with myelomeningocele is: 1. Learning disability. 2. Urinary tract infection. 3. Hydrocephalus. 4. Decubitus ulcers and skin breakdown.

2. 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.

5. The nurse is caring for a 6-month-old infant with a diagnosis of hydrocephalus. Which of the following signs best indicates increased ICP in this child? 1. Sunken anterior fontanel. 2. Complaints of blurred vision. 3. High-pitched cry. 4. Increased appetite.

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

34. A newborn with a repaired myelomeningocele is assessed for hydrocephalus. What would the nurse expect if the infant has hydrocephalus? 1. Low-pitched cry and depressed fontanel. 2. Low-pitched cry and bulging fontanel. 3. Bulging fontanel and downwardly rotated eyes. 4. Depressed fontanel and upwardly rotated eyes.

3. An alteration in the circulation of the cerebrospinal fluid causes hydrocephalus. The anterior fontanel bulges because of an increase in cerebrospinal fluid, and an increase in intracranial pressure causes a high-pitched cry in infants and downward deviation of the eyes, also called sunset eyes. With sunset eyes the sclera can be seen above the iris

34. A newborn with a repaired myelomeningocele is assessed for hydrocephalus. What would the nurse expect if the infant has hydrocephalus? 1. Low-pitched cry and depressed fontanel. 2. Low-pitched cry and bulging fontanel. 3. Bulging fontanel and downwardly rotated eyes. 4. Depressed fontanel and upwardly rotated eyes.

3. An alteration in the circulation of the cerebrospinal fluid causes hydrocephalus. The anterior fontanel bulges because of an increase in cerebrospinal fluid, and an increase in intracranial pressure causes a high-pitched cry in infants and downward deviation of the eyes, also called sunset eyes. With sunset eyes the sclera can be seen above the iris.

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

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

41. A child with spastic CP had an intrathecal dose of baclofen in the early afternoon. What is the expected result 31/2 hours post dose that suggests the child would benefit from a baclofen pump? 1. The ability to self-feed. 2. The ability to walk with little assistance. 3. If the spasticity were decreased. 4. If the spasticity were increased.

3. If baclofen were going to work for this patient, one could tell because spasticity would be decreased.

45. The parent of an infant with CP asks the nurse if the infant will be Intellectually disabled. Which of the following is the nurse's best response? 1. "Children with CP have some amount of intellectual disability." 2. "Approximately 20% of children with CP have normal intelligence." 3. "Many children with CP have normal intelligence." 4. "Intellectual disability is expected if motor and sensory deficits are severe."

3. Many children with CP have normal intelligence

72. Which of the following is immediate postoperative care for an infant diagnosed with hydrocephalus who had a shunt placed? 1. Wet-to-dry dressing changes at both the shunt insertion site and the abdominal incision site. 2. Inform the parents they will have to measure the child's head at least once a day. 3. Position the infant's head off the shunt site for the first 2 postoperative days. 4. Complete vital signs and neurological checks every 4 hours.

3. Position the head on the side opposite the surgical site to prevent pressure on the shunt and valve. This provides better visibility to watch for signs of bleeding or infection.

25. The nurse is caring for a newborn with a myelomeningocele who will have a surgical repair tomorrow. The nurse should do which of the following? 1. Offer formula every 3 hours. 2. Turn the infant back to front every 2 hours. 3. Place a wet dressing on the sac. 4. Provide pain medication every 4 hours.

3. Priority care for an infant with a myelomeningocele is to protect the sac. A wet dressing keeps it moist with less chance of tearing

40. The parent of a young child with CP brings the child to the clinic for a checkup. Which of the parent's following statements indicates an understanding of the child's long-term needs? 1. "My child will need all my attention for the next 10 years." 2. "Once in school, my child will catch up and be like the other children." 3. "My child will grow up and need to learn to do things independently." 4. "I'm the one who knows the most about my child and can do the most for my child."

3. This statement indicates that the parent understands the long-term needs of the child.

What is the most common cause of cerebral palsy (CP)? a. Central nervous system (CNS) diseases b. Birth asphyxia c. Cerebral trauma d. Neonatal encephalopathy

Powerpoint said it's Birth Asphyxia....

33. Following surgical repair and closure of a myelomeningocele shortly after birth, which of the following is true of an infant? 1. The infant will not need any long-term management and should be considered cured. 2. The infant will no longer be at risk of urinary tract infections or movement problems. 3. The infant will have continual drainage of cerebrospinal fluid, needing frequent dressing changes. 4. The infant will need lifelong management of urinary, orthopedic, and neurological problems.

4. Although immediate surgical repair decreases infection, morbidity, and mortality rates, these children will require lifelong management of neurological, orthopedic, and elimination problems.

39. The parent of an infant asks the nurse what to watch for to determine if the infant has CP. The nurse should reply which of the following? 1. If the infant cannot sit up without support before 8 months. 2. If the infant demonstrates tongue thrust before 4 months. 3. If the infant has poor head control after 2 months. 4. If the infant has clenched fists after 3 months.

4. Clenched fists after 3 months of age may be a sign of CP

Early signs and symptoms of hydrocephalus in infants include which of the following? 1. Confusion, headache, diplopia. 2. Rapid head growth, poor feeding, confusion. 3. Papilledema, irritability, headache. 4. Full fontanels, poor feeding, rapid head growth.

4. Previously undiagnosed, one of the first signs of hydrocephalus is a bulging fontanel, followed by irritability, poor feeding, and overall rapid head growth.

36. The nurse knows that teaching of parents of a child newly diagnosed with CP is successful when the parents state that CP is which of the following? 1. Inability to speak and drooling. 2. Poor dentition due to poor hygiene. 3. Involuntary movements of upper extremities only. 4. An increase in muscle tone and deep tendon reflexes.

4. The primary disorder is of muscle tone, but there may be other neurological disorders such as seizures, vision disturbances, and impaired intelligence. Spastic CP is the most common type and is characterized by a generalized increase in muscle tone, increased deep tendon reflexes, and rigidity of the limbs on both flexion and extension.

35. The nurse is developing a plan of care for a child recently diagnosed with CP. Which of the following should be the nurse's priority goal? 1. Ensure the ingestion of sufficient calories for growth. 2. Decrease intracranial pressure. 3. Teach appropriate parenting strategies for a special-needs child. 4. Ensure that the child reaches full potential.

4. The priority for all children is to develop to their full potential.

7. The nurse receives a phone call from the parents of a 9-year-old female who is complaining of a headache and blurry vision. The child has been healthy but has a history of hydrocephalus and received a ventriculoperitoneal shunt at the age of 1 month. The parents also state that she is not acting like herself, is irritable, and sleeps more than she used to. They ask the nurse what they should do. Select the nurse's best response. 1. "Give her some acetaminophen, and see if her symptoms improve. If they do not improve, bring her to the pediatrician'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 as it has been working well for 9 years." 4. "You should immediately bring her to the emergency room as these may be symptoms of a shunt malfunction.

4. These are symptoms of a shunt malfunction and should be evaluated immediately.

71. A newborn with suspected hydrocephalus is transferred to the intensive care unit for further evaluation and treatment. The baby's nurse knows which of the following? 1. To use sedation as needed to keep the baby from crying or being fussy. 2. To keep the crib in a flat and neutral position. 3. To expect the infant to sleep more than a baby without hydrocephalus. 4. To not use any scalp veins for intravenous infusions.

4. These may interfere with surgery and shunt placement.

73. In preparing the patient and family for hospital discharge, which of the following signs and symptoms of shunt malfunction and infection should the nurse include in the teaching plan? Select all that apply. 1. Emesis, lethargy. 2. A change in neurological behavior. 3. Fever, irritability. 4. Diarrhea or constipation. 5. Redness along the shunt system.

73. 1, 2, 3, 5. 1. Emesis and lethargy can be signs of increased intracranial pressure and may indicate an infectious process. 2. A change in behavior can be a sign of increased intracranial pressure and can be a sign of shunt malfunction. 3. Fever and irritability can be an indication of a possible shunt infection. 5. Redness along the shunt system can be an indication of a possible infectious process.

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

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

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

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

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

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

7. What might the nurse explain as a common treatment for amblyopia? a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractory muscles to rest c. Using glasses that will slightly blur the image for the good eye d. Using corticosteroids to treat inflammation of the optic nerve

ANS: A Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.

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

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

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

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

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

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

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

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

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

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

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

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

The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). What statement should the nurse include in the training? a. Children with dyskinetic CP have a wide-based gait and repetitive movements. b. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus. c. Children with hemiplegia CP have mouth muscles and one lower limb affected. d. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria.

ANS: B CP has a variety of clinical classifications. Spastic pyramidal CP includes manifestations such as a positive Babinski sign and ankle clonus; ataxic CP has a wide-based gait and repetitive movements; hemiplegia CP is characterized by motor dysfunction on one side of the body with upper extremity more affected than lower limbs; and dyskinetic CP involves the pharyngeal and oral muscles, causing drooling and dysarthria.

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

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

A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. What is the most appropriate nursing action related to feeding this child? a. Bottle or tube feed him a specialized formula until he gains sufficient weight. b. Stabilize his jaw with caregiver's hand (either from a front or side position) to facilitate swallowing. c. Place him in a well-supported, semireclining position. d. Place him in a sitting position with his neck hyperextended to make use of gravity flow.

ANS: B Jaw control is compromised in many children with CP. More normal control is achieved if the feeder stabilizes the oral mechanisms from the front or side of the face. Bottle or tube feeding will not improve feeding without jaw support. The semireclining position and hyperextended neck position increase the chances of aspiration.

Gingivitis is a common problem in children with cerebral palsy (CP). What preventive measure should be included in the plan of care? a. High-carbohydrate diet b. Meticulous dental hygiene c. Minimum use of fluoride d. Avoidance of medications that contribute to gingivitis

ANS: B Meticulous oral hygiene is essential. Many children with CP have congenital enamel defects, high-carbohydrate diets, poor nutritional intake, and difficulty closing their mouths. These, coupled with the child's spasticity or clonic movements, make oral hygiene difficult. Children with CP have high carbohydrate intake and retention, which contribute to dental caries. Use of fluoride should be encouraged through fluoridated water or supplements and toothpaste. Certain medications such as phenytoin do contribute to gingival hyperplasia. If that is the drug of choice, then meticulous oral hygiene must be used.

The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes which teaching? a. Patterning b. Positions to reduce spasticity c. Stretching exercises after meals d. Topical analgesics for muscle spasms

ANS: B Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy of Pediatrics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not effective for the muscle spasms of spastic CP.

What type of cerebral palsy (CP) is the most common type? a. Ataxic b. Spastic c. Dyskinetic d. Mixed type

ANS: B Spastic CP is the most common clinical type. Early manifestations are usually generalized hypotonia, or decreased tone that lasts for a few weeks or may extend for months or as long as 1 year. It is replaced by increased stretch reflexes, increased muscle tone, and weakness. Ataxic, dyskinetic, and mixed type are less common forms of CP.

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

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

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

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

6. What assessment made by the school nurse would lead to the suspicion of strabismus? a. Reddened sclera in one eye b. Child covers one eye to read the chalkboard c. Child complains of a headache d. Copious tears while watching TV

ANS: B Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder.

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

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

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

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

The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurse's response should be based on which knowledge? a. Affected children have some degree of cognitive impairment. b. Around 20% of affected children have normal intelligence. c. About 45% of affected children have normal intelligence. d. Cognitive impairment is expected if motor and sensory deficits are severe.

ANS: C Children with CP have a wide range of intelligence, and 40% to 50% are within normal limits. A large percentage of children with CP do not have mental impairment. Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise.

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

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

Spastic cerebral palsy (CP) is characterized by which clinical manifestations? a. Athetosis, dystonic movements b. Tremors, lack of active movement c. Hypertonicity; poor control of posture, balance, and coordinated motion d. Wide-based gait; poor performance of rapid, repetitive movements

ANS: C Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic CP. Athetosis and dystonic movements are part of the classification of dyskinetic or athetoid CP. Tremors and lack of active movement may indicate other neurologic disorders. A wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic CP.

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

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

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

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

What condition is defined as reduced visual acuity in one eye despite appropriate optical correction? a. Myopia b. Hyperopia c. Amblyopia d. Astigmatism

ANS: C Amblyopia, or lazy eye, is reduced visual acuity in one eye. Amblyopia is usually caused by one eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be avoided with the treatment of the primary visual defect such as strabismus. Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not a distance. Hyperopia, or farsightedness, is the ability to see objects at a distance but not at close range. Astigmatism is unequal curvatures in refractive apparatus.

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

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

An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurse's response should be based on which knowledge? a. Most activities such as Girl Scouts cannot be adapted for children with CP. b. After-school activities usually result in extreme fatigue for children with CP. c. Trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP. d. Recreational activities often provide children with CP with opportunities for socialization and recreation.

ANS: D After-school and recreational activities serve to stimulate children's interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are adapted for children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation.

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

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

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

ANS: D The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious.

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

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

A child with strabismus is undergoing treatment for impaired vision of the left eye. The nurse covers the child's right eye with an occlusion patch. Why does the nurse do so?

C (While caring for a child with strabismus, the nurse should cover the unaffected eye with an occlusive patch because it helps stimulate vision and movement in the weaker eye. The main reason for applying an ocular patch is to improve vision in the left eye, not to protect the right eye from dust. Applying an ocular patch on the right eye does not reduce intraocular pressure in the left eye; antiglaucoma medications can be used to reduce intraocular pressure. Applying an occlusion patch will not prevent the child from rubbing his or her eyes. The nurse should explain to the child that rubbing the eyes may cause further damage.)

24. The parent of a 6-year-old with a repaired myelomeningocele is in the clinic for her child's regular examination. The child has frequent constipation and has been crying at night because of

or lower extremity functioning.