244 OBJ: 3 TOP: Intracranial Hemorrhage Implementation KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Basic Care and Comfort... 248 OBJ: 6 TOP: Ventriculoperitoneal Shu
Trang 1Test Bank for Pediatric Nursing An Introductory Text 11th
Edition by Price Chapter 13: Neurologic and Sensory Disorders
Testbank
MULTIPLE CHOICE
1 The nurse is aware that during early childhood cerebral blood flow
and oxygen consumption:
a Are twice that of the adult
b Are scant due to rapid physical growth
c Fluctuate dependent on growth cycles
d Are impossible to measure
ANS: A
In the first several years of the child’s life, cerebral blood flow and oxygen
consumption are almost twice that of the adult Brain growth is measured by
head circumference
DIF: Cognitive Level: Comprehension REF: p 243 OBJ: 2
Trang 2TOP: Brain Growth KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2 The newborn nursery nurse takes special care in feeding a child with
a possible intracranial hemorrhage because these children:
a Will be likely to engorge themselves
b Need more nutrients than other babies
c Have a poor sucking reflex
d Need cuddling and nurturing
ANS: C
Babies with intracranial hemorrhage have a poor sucking reflex They do not need any more nutrients or affection than any other child They are not likely to eat too much because of their poor sucking reflex and the tendency to vomit
DIF: Cognitive Level: Application REF: p 244 OBJ: 3
TOP: Intracranial Hemorrhage
Implementation KEY: Nursing Process Step:
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Trang 3The nurse recognizes this posture in a child with a head injury as being indicative
This is the decerebrate posture, which indicates injury to the midbrain
DIF: Cognitive Level: Application REF: p 245 OBJ: 3
TOP: Decerebrate Posturing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4 A 12-year-old is admitted to the emergency department after a head injury His admission vital signs are: T: 98.2°, P: 68, BP: 96/56, and R: 16 Select the set of vital signs that would indicate to the nurse that there is increasing intracranial pressure (ICP):
a T: 98.2°, P: 66, BP: 100/60, R: 18
Trang 4b T: 98.4°, P: 68, BP: 112/72, R: 16
c T: 98.4°, P: 60, BP: 118/68, R: 14
d T: 99°, P: 66, BP: 98/54, R: 14
ANS: C
The pulse and respirations are dropping, the systolic blood pressure is rising,
and the pulse pressure is getting wider These are all indicators of increasing ICP
DIF: Cognitive Level: Analysis REF: p 246 OBJ: 3
TOP: Increasing Intracranial Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
5 The mother of a 3-year-old who received a mild concussion during a fall from his tricycle the previous day tells the home health nurse that she is worried about his temperature elevation of 100° The nurse’s best response will be based on the knowledge that the temperature elevation:
a Is an indication of an infection
b Suggests that there is increasing intracranial pressure
Trang 5c Could be a sign that there is an intracranial bleed
d Is not uncommon during the first 2 days after trauma
ANS: D
Mild temperature elevations in young children during the 2 days following a
trauma are not uncommon
DIF: Cognitive Level: Application REF: p 247 OBJ: 2
TOP: Elevated Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6 When the mother of a child who has just received a ventriculoperitoneal (VP) shunt for the relief of hydrocephalus asks the nurse what happens to all the fluid that is pumped into the peritoneal space, the nurse bases the
response on the knowledge that the fluid is:
a Absorbed into the circulating volume and excreted
b Taken up by the fat cells in the abdomen
c Ultimately stored in the liver
Trang 6d Stored in the lymphatic system
ANS: A
The fluid from the ventricles is absorbed into the circulating volume and excreted
DIF: Cognitive Level: Comprehension REF: p 248 OBJ: 6
TOP: Ventriculoperitoneal Shunt KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7 The nurse explains that once a ventriculoperitoneal (VP) shunt is in place the CSF is prevented from back-flowing by:
a Placement of a one-way pressure valve
b A system of locks along the shunt tubing
c Organ movement in peritoneal space
d Gravity
ANS: A
Trang 7A one-way pressure valve that responds to a preset intraventricular pressure allows the fluid to be removed under its own pressure, but does not allow back-flow
DIF: Cognitive Level: Comprehension REF: p 248 OBJ: 6
TOP: One-way Pressure Valve KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8 The nurse includes in the plan of care for a 5-month-old hydrocephalic baby an intervention to prevent hypostatic pneumonia, which would be:
a Monitor oxygen per nasal cannula
b Keep the baby hydrated by offering water between
feedings
c Change the baby’s position every 2 hours
d Position the baby in an upright position
ANS: C
Frequent position changes are helpful in preventing hypostatic pneumonia
and pressure sores
DIF: Cognitive Level: Comprehension REF: p 249 OBJ: N/A
Trang 8TOP: Hypostatic Pneumonia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9 The nurse is aware that the most appropriate position for 1-day
post-operative child with a ventriculoperitoneal (VP) shunt is:
The most appropriate position for a 1-day post-operative child with a VP shunt is
on the back to prevent a too-rapid reduction of fluid from the head Rapid fluid loss from the ventricles may lead to seizures or cortical bleeding
DIF: Cognitive Level: Application REF: p 249 OBJ: N/A
TOP: Post-operative Ventriculoperitoneal Shunt
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Trang 910 The nurse clarifies that the difference between a myelomeningocele and
a meningocele is that the cyst of a myelomeningocele contains:
Implementation KEY: Nursing Process Step:
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11 Studies have shown that the incidence of neural tube defects has been greatly reduced by the use of:
a Vitamin A
Trang 10DIF: Cognitive Level: Knowledge REF: p 250
TOP: Folic Acid KEY: Nursing Process Step: N/A
OBJ: N/A MSC: NCLEX: N/A
12 The nurse takes special caution in positioning the infant with a
myelomeningocele in order to:
a Protect the sac
b Support the back
c Facilitate feeding
Trang 11d Prevent vomiting
ANS: A
The primary preoperative focus in the nursing care of a child with
a myelomeningocele is to protect the sac
DIF: Cognitive Level: Comprehension REF: p 251 OBJ: 7 TOP: Positioning KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13 The nurse caring for a child with suspected meningitis assesses a cardinal indicator of meningococcal infection, which is:
Trang 12The petechiae over the trunk is an indicator of meningococcal infection
DIF: Cognitive Level: Comprehension REF: p 252
TOP: Petechiae KEY: Nursing Process Step: Assessment
a Received at least 24 hours of antibiotic therapy
b A normal temperature for 24 hours
c Spinal fluid that is clear
d Been free of upper respiratory symptoms
ANS: A
Isolation is maintained until the child has had 24 hours of antibiotic therapy
DIF: Cognitive Level: Comprehension REF: p 252 OBJ: 8
TOP: Isolation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
Trang 1315 The nurse clarifies to the frightened mother of a child who has had a
febrile seizure that these seizures usually occur when the temperature:
DIF: Cognitive Level: Comprehension REF: p 254 OBJ: N/A
TOP: Febrile Seizures KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16 The nurse is aware that most convulsive seizures begin with a:
Trang 14DIF: Cognitive Level: Application REF: p 255 OBJ: 9
TOP: Seizures KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17 Most epileptic generalized seizures are preceded by:
a A period of physical activity
b A high temperature
Trang 15c A bacterial infection
d An aura
ANS: D
Most epileptic convulsive seizures are preceded by an aura
DIF: Cognitive Level: Knowledge REF: p 256 OBJ: 1
TOP: Aura KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
18 The nurse is aware that in an absence seizure the patient will:
a Have an aura
b Be fully aware during the seizure
c Have a sudden cessation of motor activity
d Have a lengthy post-ictal period
ANS: C
Trang 16Absence seizures have no aura or post-ictal stage The person has a sudden cessation
of motor activity lasting 5 to 10 seconds and then returns to full activity
DIF: Cognitive Level: Comprehension REF: p 255 OBJ: 9
TOP: Absence Seizures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19 The maximum time a near-drowning victim can be without oxygen
with resultant brain damage is:
Without oxygen, brain cells begin to die after 4 to 6 minutes
DIF: Cognitive Level: Comprehension REF: p 259 OBJ: 11
TOP: Near-Drowning KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Trang 1720 The nurse explains that because of high body surface area to mass and small amount of subcutaneous fat, a child after submersion is at risk for:
Because of the body makeup of a small child, the child is at risk for
hypothermia after submersion
DIF: Cognitive Level: Comprehension REF: p 259 OBJ: 11
TOP: Near-Drowning KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
21 The nurse assesses an indication of hearing loss when a 3-month-old baby:
Trang 18a Does not babble unintelligible sounds
b Does not cry when startled by an extremely loud
sound
c Does not turn the head toward a sound
d Frequently pulls at the ears
ANS: C
A 3-month-old baby with hearing will turn toward a sound Babbling does not begin until about 6 months of age Pulling at the ears is more likely an indication of
an ear infection
DIF: Cognitive Level: Application REF: p 260 OBJ: 12
TOP: Hearing Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
COMPLETION
1 A baby with an intracranial hemorrhage may suffer a spasm called _ in which the head and heels are bent backward and the body is bowed forward
Trang 19ANS:
Opisthotonos
Opisthotonos is a spasm in which the head and heels are bent backward and the body is bowed forward
DIF: Cognitive Level: Knowledge REF: p 244 OBJ: 1
TOP: Opisthotonos KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2 The nurse is aware that the earliest indicator of increasing
intracranial pressure (ICP) is the _
ANS:
Level of consciousness (LOC)
The level of consciousness is the earliest indicator of increasing ICP
DIF: Cognitive Level: REF: p 244 OBJ: 3
TOP: Increasing Intracranial Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
3 Using the Pediatric Coma Scale, the nurse gives a score of _ to a old child who opens his eyes when his name is called and says, “My arm hurts.”
Trang 204-year-ANS:
11
Opening the eyes to speech is 3 points, saying words is 4 points, and localizing pain is 4 points
DIF: Cognitive Level: Analysis REF: p 247 OBJ: 5
TOP: Pediatric Coma Scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
4 The child with hydrocephalus is found to have an obstruction in the
subarachnoid space Based on this finding, the child has type
DIF: Cognitive Level: Comprehension REF: p 247 OBJ: 6
TOP: Communicating Hydrocephalus KEY: Nursing Process Step: N/A
Trang 21ANS:
Seizure
Children with meningitis are sensitive to stimuli that may cause a seizure
DIF: Cognitive Level: Comprehension REF: p 253 OBJ: 8
TOP: Reduction of Stimuli KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk
6 The nurse understands that when the lab report shows a very low glucose count in spinal fluid of the child with meningitis, the invading pathogen is
ANS:
Bacterial
The low glucose count in the spinal fluid is due to the invading bacteria
consuming the glucose
DIF: Cognitive Level: Analysis REF: p 252 OBJ: 8
TOP: Spinal Fluid KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
Trang 221 The nurse explains that a baby’s cranial characteristics allow the brain
to grow and enlarge These include: (Select all that apply.)
a Open anterior fontanel
b Fused cranium around the brain
c Open posterior fontanel
DIF: Cognitive Level: Application REF: p 244 OBJ: 2
TOP: Cranial Differences
Implementation KEY: Nursing Process Step:
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2 The nurse is caring for a newborn who was born after a long labor Because
of the length of labor, the nurse is alert for signs of intracranial hemorrhage,
which would include: (Select all that apply.)
Trang 23DIF: Cognitive Level: Application REF: p 244 OBJ: 2
TOP: Intracranial Hemorrhage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3 If a seizure occurs in a newborn who suffered an intracranial hemorrhage, the
nurse should record: (Select all that apply.)
a Parts of the body and limbs that were involved
Trang 24b Witnesses to the seizure
c Whether movements were unilateral or bilateral
d Severity of the seizure
e Length of time of the seizure
ANS: A, C, D, E
The nursing assessments of a seizure should include the parts of the body that were involved, whether the seizure activity was on only one side or both sides, the severity of the seizure, and the length of the seizure
DIF: Cognitive Level: Application REF: p 244 OBJ: 3
TOP: Seizures KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4 The nurse assigned to a 4-month-old hydrocephalic child anticipates
that assessments of this child will reveal: (Select all that apply.)
a Bulging fontanels
b Widened cranial sutures
Trang 25c Strong muscle tone
is frequent vomiting The eyes are deviated downward (setting sun eyes)
DIF: Cognitive Level: Application REF: p 248 OBJ: 6
TOP: Hydrocephalic Signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5 In feeding the child with hydrocephalus, the nurse would include in the plan
of care to: (Select all that apply.)
a Feed the child in a calm, unhurried manner
b Dim the lights in the room to reduce stimulation
c Give firm support to the head and neck