NSG-317 Module 8 Cerebral and Neuromuscular Quiz

The nurse is caring for an infant who has recently undergone surgery to correct myelomeningocele. What should be the nurse's basic focus during postoperative care? Select all that apply. a) Monitor vital signs, nourishment, signs of infection, and manage pain. b) Care for the operative site and monitor signs of cerebrospinal fluid leakage. c) Educate the parents on hydrocephalus and developing cognitive skills. d) Practice stretches and exercises to minimize muscle contractures and deformity. e) Educate parents on positioning, feeding, skin care, and exercise.

a) Monitor vital signs, nourishment, signs of infection, and manage pain. b) Care for the operative site and monitor signs of cerebrospinal fluid leakage. e) Educate parents on positioning, feeding, skin care, and exercise. Rationale Postoperative care for a child who has undergone a surgery to correct myelomeningocele includes monitoring vital signs, nourishment, signs of infection, and managing pain. It is also important to take adequate steps in caring for the operative site and monitoring signs of cerebrospinal fluid leakage. The nurse also needs to educate the parents on positioning, feeding, skin care, and range-of-motion exercises after the child returns home. Parents are not taught about hydrocephalus or cognitive skill development. Similarly, they are not taught about stretches and exercises to minimize the muscle contractures and deformity. p. 1466

A child with cerebral palsy has postural instability and difficulty during meals. The nurse teaches the parent the preferred way to facilitate eating. The most important areas the nurse should advise the parent to be careful about are what? Select all that apply. a) Position of the child after feeding b) Jaw control during feeding c) Bowel activity during feeding d) Respiratory action during feeding e) Chewing and swallowing during feeding

a) Position of the child after feeding b) Jaw control during feeding e) Chewing and swallowing during feeding Rationale The nurse must advise the parent to keep the child in a semi-upright position after feeding. It is also important to encourage the parent to use jaw control while feeding by carefully assessing the child's ability to manage oral feeding. To do this, the parent must assess the child's chewing and swallowing capability. It is not necessary to assess bowel activity or monitor respiratory action during feeding. p. 1460

The nurse is performing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. What is the most appropriate nursing assessment in this case? a) Reactivity of pupils b) Doll's head maneuver c) Oculovestibular response d) Funduscopic examination to identify papilledema

a) Reactivity of pupils Rationale Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. Doll's head maneuver should not be performed if there is a cervical spine injury. Oculovestibular response is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness. p. 1356

A 6-year-old girl born with a myelomeningocele has a neurogenic bladder disorder. Her parents have been performing clean intermittent catheterization. What is the nurse's most appropriate action? a) Teach the child to do self-catheterization. b) Teach the child appropriate bladder control. c) Continue having parents do catheterization. d) Encourage the family to consider urinary diversion.

a) Teach the child to do self-catheterization. Rationale At 6 years old, this child should be able to perform the intermittent catheterization herself. This will give her more control and mastery over her disability. Bladder control cannot be taught to a child with a neurogenic bladder. This would be a good time to have the child begin caring for herself. A urinary diversion is not necessary. p. 1464

The primary health care provider asks the nurse to watch for signs of developing hydrocephalus in a toddler with spina bifida. The nurse should look for what signs? a) Temperature instability, irritability, and lethargy, and elevated intracranial pressure b) Intactness of the membranous cyst, anal reflex inactivity, and motor or sensory impairment c) Behavioral instability, and inactivity in spinal cord reflex and limb movement with stimuli d) Cognitive impairment, pain, and tension or bulging in any part of the body

a) Temperature instability, irritability, and lethargy, and elevated intracranial pressure Rationale Early signs of hydrocephalus include signs of infection, such as temperature instability (axillary), irritability, and lethargy, and elevated intracranial pressure. Children with spina bifida are placed in an incubator so their temperature can be maintained without clothing. Signs of intactness of the membranous cyst, anal reflex inactivity, and motor or sensory impairment leading to immobility are not signs of developing hydrocephalus. Similarly, behavioral instability, impaired limb movement in conjunction with stimuli, and spinal cord reflex inactivity also are not signs of developing hydrocephalus. In addition to this, cognitive impairment, pain, and tension or bulging in any part of the body are also looked for, but these are not signs of developing hydrocephalus. p.1465

What pattern on an electroencephalogram (EEG) indicates the presence of absence seizure in a child? a) High-voltage spike discharges b) A three-per-second spike and wave pattern c) Absence of electrical activity in an area d) Abnormal patterns in the discharge intervals

b) A three-per-second spike and wave pattern Rationale An EEG is used to evaluate a seizure disorder. Various seizure types produce characteristic EEG patterns. A three-per-second spike and wave pattern on EEG indicates an absence seizure. High-voltage spike discharges indicate tonic-clonic seizures. Absence of electrical activity in an area indicates a large lesion such as an abscess or subdural collection of fluid. Abnormal patterns in the discharge intervals indicate tonic-clonic seizures. p. 1381

The nurse is caring for an infant who sustained a head injury during a fall. The infant presents with signs of increased intracranial pressure (ICP). What is an appropriate nursing action in this context? a) Weighing the infant daily before feeding b) Elevating the infant's head higher than the hips c) Checking the infant's reflexes every 15 minutes d) Providing stimulation to check the level of consciousness

b) Elevating the infant's head higher than the hips Rationale Elevation of the head helps decrease intracranial pressure by promoting venous return through gravity. The child is usually placed with the head of the bed elevated slightly and the child's head in midline position. Weighing daily is done routinely for many ill infants because it is an accurate measure of hydration status, but this is not specific to increased ICP. Checking reflexes frequently may be disturbing to the infant and impair the ability to rest. Frequent stimulation may further irritate an already traumatized central nervous system. p.1355

Which signs and symptoms indicate an increase in intracranial pressure (ICP) in a child? Select all that apply. a) Excessive thirst b) Increased sleeping c) Forceful vomiting d) Seizures

b) Increased sleeping c) Forceful vomiting d) Seizures Rationale Increased ICP in a child is indicated by increased sleeping or an altered level of consciousness such as lethargy, disorientation, and stupor. Forceful vomiting may be caused by abnormalities in the brainstem as a result of increased ICP. Seizures indicate an abnormal electrical discharge in the brain as a result of increased intracranial pressure. Excessive thirst is seen in children with diabetes insipidus, not in children with increased ICP. p. 1355

The nurse is caring for a 5-year-old child who had a craniotomy. The nurse is assessing the neurologic status of the child. The nurse has checked the level of consciousness, pupillary activity, and reflexes. What else does the nurse assess in the patient? a) Blood pressure b) Motor function c) Rectal temperature d) Head circumference

b) Motor function Rationale The nurse should observe for motor functions such as spontaneous activity, gait, and response to painful stimuli. This provides clues to the location and extent of cerebral dysfunction, if any. Assessment of motor function is an important component of a neurologic examination. Even subtle movements (e.g., the outward rotation of a hip) should be noted. Blood pressure is not a direct measure of neurologic status. Temperature is not a direct measure of neurologic status. Head circumference provides information as to skeletal development and brain growth, not neurologic data. A change in head circumference as a result of increased intracranial pressure is not expected in a 5-year-old whose cranial bones are fused. pp. 1357-1358

A 3-year-old male child has cerebral palsy and is currently hospitalized for orthopedic surgery. His mother says that 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 one hand (either from a front or side position) to facilitate swallowing. c) Place him in a well-supported, semireclining position to make use of gravity flow. d) Place him in a sitting position with his neck hyperextended to make use of gravity flow.

b) Stabilize his jaw with one hand (either from a front or side position) to facilitate swallowing. Rationale The neuromuscular compromise of the jaw interferes with the child's ability to eat. Because the jaw is compromised, more normal control can be achieved if the feeder provides stability. Manual jaw control assists with head control, correction of neck and trunk hyperextension, and jaw stabilization. Age 3 is too old for bottle-feeding. The child should be sitting up for meals. For swallowing, the neck should not be hyperextended. p. 1460

What does the nurse assess in a child who shows other symptoms of hydrocephalus such as sluggish pupils and dilation of scalp veins during crying? a) Evaluates the electroencephalogram (EEG) reports b) Assesses for signs of bacterial meningitis c) Measures the child's head circumference d) Assesses the child's motor functions

c) Measures the child's head circumference Rationale In hydrocephalus, the child's head circumference grows at an abnormal rate. The nurse measures the head circumference over 4 weeks and evaluates the measurements. Hydrocephalus is confirmed if the head circumference crosses at least one percentile line on the head measurement chart within 2 to 4 weeks. The nurse evaluates the child's EEG reports to assess seizure disorders. Bacterial meningitis is indicated if the child has fever and signs of meningeal irritation, including nausea, vomiting, irritability, back pain, and nuchal rigidity. The nurse evaluates motor functions in a child to assess the child's level of consciousness and not hydrocephalus. p. 1388

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is what? a) An absence seizure b) A generalized seizure c) Status epilepticus d) A simple partial seizure

c) Status epilepticus Rationale Status epilepticus is a generalized seizure that lasts more than 30 minutes. Absence seizures are brief losses of consciousness. Generalized seizures are the most common of seizures. They have a tonic phase of approximately 10 to 20 seconds. They involve both hemispheres of the brain. Simple partial seizures are characterized by varying sensations. p.1382

Cerebral palsy may result from a variety of causes. It is now known that what is the most common cause of cerebral palsy? a) Birth asphyxia b) Neonatal diseases c) Cerebral trauma d) Prenatal brain abnormalities

d) Prenatal brain abnormalities Rationale Cerebral palsy results from existing brain abnormalities during the prenatal period. Birth asphyxia, neonatal diseases, and cerebral trauma previously were thought to be factors. p.1455

What is a neural tube defect that is not visible externally in the lumbosacral area? a) Meningocele b) 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. Meningocele contains meninges and spinal fluid but no neural tissue. Unless there are associated cutaneous findings, it is often not identified until later. Myelomeningocele is a neural tube defect that contains meninges, spinal fluid, and nerves. Spina bifida cystica is a cystic formation with an external saclike protrusion. p. 1462

A 5-month-old infant is receiving treatment for hydrocephalus. A ventriculoperitoneal (VP) shunt has been inserted into the baby. What is an appropriate intervention by the nurse to ensure the patient's safety? a) Keep the infant in a prone position for a minimum of 12 hours. b) Apply sterile, saline-moistened dressings to the incision daily. c) Observe for signs and symptoms of cerebrospinal fluid leakage. d) Teach parents the signs of an increase in intracranial pressure.

d) Teach parents the signs of an increase in intracranial pressure. Rationale Parents must be taught how to identify signs of increased intracranial pressure because this would indicate that the shunt has malfunctioned, which is an urgent situation. The prone position places too much pressure on the shunt; the infant should be flat and turned onto the unaffected side. Dry, sterile dressings are applied postoperatively to prevent infection. Cerebrospinal fluid is not expected to drain from the incision. p. 1388