Chapter 18: Impact of Cognitive or Sensory Impairment on the Child and Family

The nurse is talking to the parent of a 13-month-old child. The mother states, "My child does not make noises like 'da' or 'na' like my sister's baby, who is only 9 months old." Which statement by the nurse would be most appropriate to make? a."I am going to request a referral to a hearing specialist." b."You should not compare your child to your sister's child." c."I think your child is fine, but we will check again in 3 months." d."You should ask other parents what noises their children made at this age."

ANS: A By 11 months of age a child should be making well-formed syllables such as "da" or "na" and should be referred to a specialist if not. "You should not compare your child to your sister's child," "I think your child is fine, but we will check again in 3 months," and "You should ask other parents what noises their children made at this age," are not appropriate statements to make to the parent.

Hearing is expressed in decibels (dB), or units of loudness. Which is the softest sound a normal ear can hear? a.0 dB b.10 dB c.40 to 50 dB d.100 dB

ANS: A By definition, 0 dB is the softest sound the normal ear can hear. Ten decibels is the sound of the heartbeat or the rustling of leaves. 40 to 50 dB is in the range of normal conversation. The noise of a train is approximately 100 dB.

Prevention of hearing impairment in children is a major goal for the nurse. This can be achieved through which intervention? a.Being involved in immunization clinics for children b.Assessing a newborn for hearing loss c.Answering parents' questions about hearing aids d.Participating in hearing screening in the community

ANS: A Childhood immunizations can eliminate the possibility of acquired sensorineural hearing loss from rubella, mumps, or measles encephalitis. Assessing a newborn for hearing loss, answering parents' questions about hearing aids, and participating in hearing screening in the community are interventions to screen for the presence of hearing loss or deal with an identified loss, not prevention.

A school nurse is performing hearing screening on school children. The nurse recognizes that the most common type of hearing loss resulting from interference of transmission of sound to the middle ear is characteristic of which type of hearing loss? a.Conductive b.Sensorineural c.Mixed conductive-sensorineural d.Central auditory imperceptive

ANS: A Conductive or middle-ear hearing loss is the most common type. It results from interference of transmission of sound to the middle ear, most often from recurrent otitis media. Sensorineural, mixed conductive-sensorineural, and central auditory imperceptive are less common types of hearing loss.

A nurse should suspect possible visual impairment in a child who displays which characteristic? a.Excessive rubbing of the eyes b.Rapid lateral movement of the eyes c.Delay in speech development d.Lack of interest in casual conversation with peers

ANS: A Excessive rubbing of the eyes is a clinical manifestation of visual impairment. Rapid lateral movement of the eyes, delay in speech development, and lack of interest in casual conversation with peers are not associated with visual impairment.

Which term refers to the ability to see objects clearly at close range but not at a distance? a.Myopia b.Amblyopia c.Cataract d.Glaucoma

ANS: A Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not at distance. Amblyopia, or lazy eye, is reduced visual acuity in one eye. A cataract is opacity of the lens of the eye. Glaucoma is a group of eye diseases characterized by increased intraocular pressure.

A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child? a.Maintain a structured routine and keep stimulation to a minimum. b.Place child in a room with a roommate of the same age. c.Maintain frequent touch and eye contact with the child. d.Take the child frequently to the playroom to play with other children.

ANS: A Providing a structured routine for the child to follow is a key in the management of ASD. Decreasing stimulation by using a private room, avoiding extraneous auditory and visual distractions, and encouraging the parents to bring in possessions the child is attached to may lessen the disruptiveness of hospitalization. Because physical contact often upsets these children, minimum holding and eye contact may be necessary to avoid behavioral outbursts. Children with ASD need to be introduced slowly to new situations, with visits with staff caregivers kept short whenever possible. The playroom would be too overwhelming with new people and situations and should not be a priority of care.

Which should be the major consideration when selecting toys for a child who is cognitively impaired? a.Safety b.Age appropriateness c.Ability to provide exercise d.Ability to teach useful skills

ANS: A Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are cognitively impaired. Age appropriateness, the ability to provide exercise, and the ability to teach useful skills should all be considered in the selection of toys, but safety is of paramount importance.

A nurse is caring for a hearing-impaired child who lip reads. The nurse should plan which intervention to facilitate lipreading? a.Speak at an even rate. b.Exaggerate pronunciation of words. c.Avoid using facial expressions. d.Repeat in exactly the same way if the child does not understand.

ANS: A The child should be helped to learn and understand how to read lips by speaking at an even rate. It interferes with the child's comprehension of the spoken word to exaggerate pronunciation of words, to avoid using facial expressions, and to repeat in exactly the same way if the child does not understand.

When should children with cognitive impairment be referred for stimulation and educational programs? a.As young as possible b.As soon as they have the ability to communicate in some way c.At age 3 years, when schools are required to provide services d.At age 5 or 6 years, when schools are required to provide services

ANS: A The child's education should begin as soon as possible. Considerable evidence exists that early intervention programs for children with disabilities are valuable for cognitively impaired children. The early intervention may facilitate the child's development of communication skills. States are encouraged to provide early intervention programs from birth under Public Law 101-476, the Individuals with Disabilities Education Act.

Which assessment findings indicate to the nurse a child has Down syndrome? (Select all that apply.) a.High arched narrow palate b.Protruding tongue c.Long, slender fingers d.Transverse palmar crease e.Hypertonic muscle tone

ANS: A, B, D The assessment findings of Down syndrome include high arched narrow palate, protruding tongue, and transverse palmar creases. The fingers are stubby and the muscle tone is hypotonic, not hypertonic.

A nurse is instructing a nursing assistant on techniques to facilitate lipreading with a hearing-impaired child who lip reads. Which techniques should the nurse include? (Select all that apply.) a.Speak at eye level. b.Stand at a distance from the child. c.Speak words in a loud tone. d.Use facial expressions while speaking. e.Keep sentences short.

ANS: A, D, E To facilitate lipreading for a hearing-impaired child who can lip read, the speaker should be at eye level, facing the child directly or at a 45-degree angle. Facial expressions should be used to assist in conveying messages, and the sentences should be kept short. The speaker should stand close to the child, not at a distance, and using a loud tone while speaking will not facilitate lipreading.

Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which areas with onset before age 3 years? (Select all that apply.) a.Language as used in social communication b.Parallel play c.Gross motor development d.Growth below the 5th percentile for height and weight e.Symbolic or imaginative play f.Social interaction

ANS: A, E, F These are three of the areas in which autistic children may show delayed or abnormal functioning: language as used in social communication, symbolic or imaginative play, and social interaction. Parallel play is typical play of toddlers and is usually not affected. Gross motor development and growth below the 5th percentile for height and weight are usually not characteristic of autism.

When a child with mild cognitive impairment reaches the end of adolescence, which characteristic should be expected? a.Achieves a mental age of 5 to 6 years b.Achieves a mental age of 8 to 12 years c.Unable to progress in functional reading or arithmetic d.Acquires practical skills and useful reading and arithmetic to an eighth-grade level

ANS: B By the end of adolescence, the child with mild cognitive impairment can acquire practical skills and useful reading and arithmetic to a third- to sixth-grade level. A mental age of 8 to 12 years is obtainable, and the child can be guided toward social conformity. The achievement of a mental age of 5 to 6 years and being unable to progress in functional reading or arithmetic are characteristics of children with moderate cognitive impairment. Acquiring practical skills and useful reading and arithmetic to an eighth-grade level is not descriptive of cognitive impairment.

Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs, such as Cub Scouts, that he might join. The nurse's recommendation should be based on which statement? a.Programs like Cub Scouts are inappropriate for children who are cognitively impaired. b.Children with Down syndrome have the same need for socialization as other children. c.Children with Down syndrome socialize better with children who have similar disabilities. d.Parents of children with Down syndrome encourage programs, such as scouting, because they deny that their children have disabilities.

ANS: B Children of all ages need peer relationships. Children with Down syndrome should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics. Programs such as Cub Scouts can help children with cognitive impairment develop socialization skills. Although all children should have an opportunity to form a close relationship with someone of the same developmental level, it is appropriate for children with disabilities to develop relationships with children who do not have disabilities. The parents are acting as advocates for their child.

Which is an implanted ear prosthesis for children with sensorineural hearing loss? a.Hearing aid b.Cochlear implant c.Auditory implant d.Amplification device

ANS: B Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have severe or profound hearing loss of sensorineural origin. Hearing aids and amplification devices are external devices for enhancing hearing. Auditory implants do not exist.

Parents of a child with Down syndrome ask the nurse about techniques for introducing solid food to their 8-month-old child's diet. The nurse should give the parents which priority instruction? a.It is too early to add solids; the parents should wait for 2 to 3 months. b.A small but long, straight-handled spoon should be used to push the food toward the back and side of the mouth. c.If the child thrusts the food out, the feeding should be stopped. d.Solids should be offered only three times a day.

ANS: B Down syndrome children have a protruding tongue which can interfere with feeding, especially of solid foods. Parents need to know that the tongue thrust is not an indication of refusal to feed but a physiologic response. Parents are advised to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be re-fed. Six months is the time to introduce solid foods to a child, so waiting 2 to 3 months is inappropriate. Small frequent feedings should be initiated to prevent the child from tiring. Three times a day is too infrequent.

A school nurse is performing hearing screening on school children. The nurse recognizes that distortion of sound and problems in discrimination are characteristic of which type of hearing loss? a.Conductive b.Sensorineural c.Mixed conductive-sensorineural d.Central auditory imperceptive

ANS: B Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to the inner ear structures or the auditory nerve. It results in the distortion of sounds and problems in discrimination. Conductive hearing loss involves mainly interference with loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination of both sensorineural and conductive loss. Central auditory imperceptive hearing loss includes all hearing losses that do not demonstrate defects in the conduction or sensory structures.

The nurse should suspect a hearing impairment in an infant who demonstrates which behavior? a.Absence of the Moro reflex b.Absence of babbling by age 7 months c.Lack of eye contact when being spoken to d.Lack of gesturing to indicate wants after age 15 months

ANS: B The absence of babbling or inflections in voice by age 7 months is an indication of hearing difficulties. The absence of the Moro reflex and eye contact when being spoken to does not indicate a hearing impairment. The child with hearing impairment uses gestures rather than vocalizations to express desires at this age.

What are appropriate interventions to facilitate socialization of the cognitively impaired child? a.Provide age-appropriate toys and play activities. b.Provide peer experiences, such as scouting, when older. c.Avoid exposure to strangers who may not understand cognitive development. d.Emphasize mastery of physical skills because they are delayed more often than verbal skills.

ANS: B The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics. It is important to provide age-appropriate toys and play activities, but peer interactions will facilitate social development. Parents should expose the child to strangers so that the child can practice social skills. Verbal skills are delayed more than physical skills.

The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes which intervention? a.Apply a regular eye patch. b.Apply a Fox shield to affected eye and any type of patch to the other eye. c.Apply ice until the physician is seen. d.Irrigate eye copiously with a sterile saline solution.

ANS: B The nurse's role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye and a regular eye patch to the other eye to prevent bilateral movement. It may cause more damage to the eye to apply a regular eye patch, apply ice until the physician is seen, or irrigate the eye copiously with a sterile saline solution.

A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. Of what are these findings most suggestive? a.Microcephaly b.Down syndrome c.Cerebral palsy d.Fragile X syndrome

ANS: B These are characteristics associated with Down syndrome. The infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth. No characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, and/or protruding ears; long, narrow face with prominent jaw; hypotonia; and high arched palate.

When assessing the eyes of a neonate, the nurse observes opacity of the lens. This represents which impairment? a.Blindness b.Glaucoma c.Cataracts d.Retinoblastoma

ANS: C A cataract is opacity of the lens of the eye. The child may have visual impairment secondary to the cataract, but the opacity is a cataract. Glaucoma is increased intraocular pressure. Retinoblastoma is a tumor of the eye.

Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage? a.Trisomy b.Monosomy c.Translocation d.Nondisjunction

ANS: C A translocation occurs when a part of a chromosome breaks off and attaches to another chromosome. When this occurs in the germ cells, the translocation can be transmitted to the next generation. Trisomy is the condition in which three of a specific chromosome are found rather than the usual two. Monosomy is the condition in which one of a specific chromosome is noted rather than the usual two. The term is not used for males when the normal complement of sex chromosomes (one X and one Y) is present. Nondisjunction is the failure of a chromosome to separate during cell division. Of the resultant daughter cells, one will be trisomic and one will be monosomic.

The nurse is discussing sexuality with the parents of an adolescent girl with moderate cognitive impairment. Which should the nurse consider when dealing with this issue? a.Sterilization is recommended for any adolescent with cognitive impairment. b.Sexual drive and interest are limited in individuals with cognitive impairment. c.Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. d.Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.

ANS: C Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be laid out for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychological effects on the adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual information regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances.

When caring for a newborn with Down syndrome, what should the nurse be aware is the most common congenital anomaly associated with Down syndrome? a.Hypospadias b.Pyloric stenosis c.Congenital heart disease d.Congenital hip dysplasia

ANS: C Congenital heart malformations, primarily septal defects, are the most common congenital anomaly in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are not frequent congenital anomalies associated with Down syndrome.

A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive impairment (CI) who sustained a minor burn. Which strategy should the nurse use to prepare the child for this procedure? a.Verbally explain what will be done. b.Have the child watch a video on dressing changes. c.Demonstrate a dressing change on a doll. d.Explain the importance of keeping the burn area clean.

ANS: C Children with CI have a marked deficit in their ability to discriminate between two or more stimuli because of difficulty in recognizing the relevance of specific cues. However, these children can learn to discriminate if the cues are presented in an exaggerated, concrete form and if all extraneous stimuli are eliminated. Therefore, demonstration is preferable to verbal explanation, and learning should be directed toward mastering a skill rather than understanding the scientific principles underlying a procedure. Watching a video would require the use of both visual and auditory stimulation and might produce overload in the child with mild cognitive impairment. Explaining the importance of keeping the burn area clean would be too abstract for the child.

The child with Down syndrome should be evaluated for which condition before participating in some sports? a.Hyperflexibility b.Cutis marmorata c.Atlantoaxial instability d.Speckling of iris (Brushfield spots)

ANS: C Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Hyperflexibility, cutis marmorata, and speckling of iris (Brushfield spots) are characteristic of Down syndrome, but they do not affect the child's ability to participate in sports.

A child has just been diagnosed with fragile X syndrome. What is fragile X syndrome? a.A chromosomal defect affecting females only b.A chromosomal defect that follows the pattern of X-linked recessive disorders c.The second most common genetic cause of cognitive impairment d.The most common cause of noninherited cognitive impairment

ANS: C Fragile X syndrome is the second most common cause of cognitive impairment after Down syndrome. Fragile X primarily affects males, and follows the inheritance pattern of X-linked dominant with reduced penetrance. This is in distinct contrast to the classic X-linked recessive pattern in which all carrier females are normal, all affected males have symptoms of the disorder, and no males are carriers.

A young child has an intelligence quotient (IQ) of 45. The nurse should document this finding as: a.within the lower limits of the range of normal intelligence. b.mild cognitive impairment but educable. c.moderate cognitive impairment but trainable. d.severe cognitive impairment and completely dependent on others for care.

ANS: C Moderate cognitive impairment IQs range between 35 and 55. The lower limit of normal intelligence is approximately 70. Individuals with IQs of 50 to 70 are considered to have mild cognitive impairment but educable. An IQ of 20 to 40 results in severe cognitive impairment.

Which of the following terms refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina? a.Myopia b.Amblyopia c.Cataract d.Glaucoma

ANS: C Opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina is the definition of a cataract. Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not at a distance. Amblyopia, or lazy eye, is reduced visual acuity in one eye. Glaucoma is a group of eye diseases characterized by increased intraocular pressure.

A father calls the emergency department nurse saying that his daughter's eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. The nurse also should recommend which action before the child is transported? a.Keep eyes closed. b.Apply cold compresses. c.Irrigate eyes copiously with tap water for 20 minutes. d.Prepare a normal saline solution (salt and water) and irrigate eyes for 20 minutes.

ANS: C The first action is to flush the eyes with clean tap water. This will rinse the detergent from the eyes. Keeping eyes closed and applying cold compresses may allow the detergent to do further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the detergent to cause continued injury to the eyes.

The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. Which is the most appropriate nursing action? a.Ignore the sound. b.Ask him to reverse the hearing aids in his ears. c.Suggest he reinsert the hearing aid. d.Suggest he raise the volume of the hearing aid.

ANS: C The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making certain no hair is caught between the ear mold and the ear canal. It would be annoying to others to ignore the sound or to suggest he raise the volume of the hearing aid. The hearing aids are molded specifically for each ear.

Which of the following is the most common clinical manifestation of retinoblastoma? a.Glaucoma b.Amblyopia c.Cat's eye reflex d.Sunken eye socket

ANS: C When the eye is examined, the light will reflect off the tumor, giving the eye a whitish appearance. This is called a cat's eye reflex. A late sign of retinoblastoma is a red, painful eye with glaucoma. Amblyopia, or lazy eye, is reduced visual acuity in one eye. The eye socket is not sunken.

A nurse is preparing a teaching session for parents on prevention of childhood hearing loss. What is the most common cause of hearing impairment in children? a.Auditory nerve damage b.Congenital ear defects c.Congenital rubella d.Chronic otitis media

ANS: D Chronic otitis media is the most common cause of hearing impairment in children. It is essential that appropriate measures be instituted to treat existing infections and prevent recurrences. Auditory nerve damage, congenital ear defects, and congenital rubella are rarer causes of hearing impairment.

Trisomy 13, trisomy 18, and trisomy 21 have which in common? a.Viability is rare. b.They are considered deletion syndromes. c.Diagnosis is difficult, time-consuming, and expensive. d.Diagnosis can be made early, based on physical characteristics.

ANS: D Each of these disorders, trisomy 13, 18, and 21, has unique physical characteristics. A presumptive diagnosis can often be made soon after birth and later confirmed by chromosomal analysis. Children with trisomy 13 and 18 usually have short life expectancies. Trisomy 21 has a variable life expectancy, with 80% of individuals living to age 30 years. Trisomy 13, trisomy 18, and trisomy 21 are not deletion syndromes.

What is one of the major physical characteristics of the child with Down syndrome? a.Excessive height b.Spots on the palms c.Inflexibility of the joints d.Hypotonic musculature

ANS: D Hypotonic musculature is one of the major characteristics. Children with Down syndrome have short stature and a transverse palmar crease. Hyperflexibility is a characteristic of Down syndrome.

Many of the physical characteristics of Down syndrome present nursing problems. Care of the child should include which intervention? a.Delay feeding solid foods until the tongue thrust has stopped. b.Modify diet as necessary to minimize the diarrhea that often occurs. c.Provide calories appropriate to child's age. d.Use a cool-mist vaporizer to keep mucous membranes moist.

ANS: D The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep the mucous membranes moist and liquefy secretions. The child has a protruding tongue, which makes feeding difficult. The parents must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is predisposed to constipation. Calories should be appropriate to the child's weight and growth needs, not age.

An adolescent gets hit in the eye during a fight. The school nurse, using a flashlight, notes the presence of gross hyphema (hemorrhage into anterior chamber). What is the priority nursing action? a.Apply a Fox shield b.Instruct the adolescent to apply ice for 24 hours c.Have the adolescent rest with eye closed and ice applied d.Notify parents that the adolescent needs to see an ophthalmologist

ANS: D The parents should be notified that the adolescent needs to see an ophthalmologist as soon as possible. Applying a Fox shield, instructing the adolescent to apply ice for 24 hours, and having the adolescent rest with eye closed and ice applied may cause further damage. Referral to an ophthalmologist is indicated.