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Test Bank for Pediatric Nursing An Introductory Text 11th Edition by Price Chapter 13: Neurologic and Sensory Disorders Testbank MULTIPLE CHOICE 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: TOP: Brain Growth KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 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 TOP: Intracranial Hemorrhage Implementation REF: p 244 OBJ: KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Basic Care and Comfort The nurse recognizes this posture in a child with a head injury as being indicative of injury to the: a Midbrain b Cerebral cortex c Brainstem d Skull ANS: A This is the decerebrate posture, which indicates injury to the midbrain DIF: Cognitive Level: Application REF: p 245 OBJ: TOP: Decerebrate Posturing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 b 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 TOP: Increasing Intracranial Pressure REF: p 246 OBJ: KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 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 c Could be a sign that there is an intracranial bleed d Is not uncommon during the first days after trauma ANS: D Mild temperature elevations in young children during the days following a trauma are not uncommon DIF: Cognitive Level: Application TOP: Elevated Temperature REF: p 247 OBJ: KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 d 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: TOP: Ventriculoperitoneal Shunt Implementation KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 A 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: TOP: One-way Pressure Valve Implementation KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 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 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 TOP: Hypostatic Pneumonia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort The nurse is aware that the most appropriate position for 1-day post-operative child with a ventriculoperitoneal (VP) shunt is: a High Fowler’s b Side-lying c Flat on the back d Upright ANS: C 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 TOP: Post-operative Ventriculoperitoneal Shunt KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort OBJ: N/A 10 The nurse clarifies that the difference between a myelomeningocele and a meningocele is that the cyst of a myelomeningocele contains: a Membranes and CSF b Membranes only c Membranes, CSF, and the spinal cord d CSF only ANS: C The myelomeningocele contains membranes, CSF, and the spinal cord This neural tube lesion can be the size of a walnut or as large as the baby’s head DIF: Cognitive Level: Comprehension TOP: Myelomeningocele Implementation REF: p 250 OBJ: 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 b Vitamin B c Niacin d Folic acid ANS: D There has been a steady decline of cases of neural tube defects because of daily use of folic acid DIF: Cognitive Level: Knowledge TOP: Folic Acid REF: p 250 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 c A bacterial infection d An aura ANS: D Most epileptic convulsive seizures are preceded by an aura DIF: Cognitive Level: Knowledge TOP: Aura REF: p 256 KEY: Nursing Process Step: N/A OBJ: 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 Absence seizures have no aura or post-ictal stage The person has a sudden cessation of motor activity lasting to 10 seconds and then returns to full activity DIF: Cognitive Level: Comprehension TOP: Absence Seizures REF: p 255 OBJ: 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: a minutes b minutes c minutes d minutes ANS: C Without oxygen, brain cells begin to die after to minutes DIF: Cognitive Level: Comprehension TOP: Near-Drowning MSC: NCLEX: N/A REF: p 259 OBJ: 11 KEY: Nursing Process Step: N/A 20 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: a Aspiration pneumonia b Brain damage c Hypothermia d Seizures ANS: C Because of the body makeup of a small child, the child is at risk for hypothermia after submersion DIF: Cognitive Level: Comprehension TOP: Near-Drowning Implementation REF: p 259 OBJ: 11 KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21 The nurse assesses an indication of hearing loss when a 3-month-old baby: a 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 months of age Pulling at the ears is more likely an indication of an ear infection DIF: Cognitive Level: Application TOP: Hearing Loss REF: p 260 OBJ: 12 KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 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 ANS: Opisthotonos Opisthotonos is a spasm in which the head and heels are bent backward and the body is bowed forward DIF: Cognitive Level: Knowledge TOP: Opisthotonos REF: p 244 OBJ: KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 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: TOP: Increasing Intracranial Pressure REF: p 244 OBJ: KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease Using the Pediatric Coma Scale, the nurse gives a score of _ to a 4-yearold child who opens his eyes when his name is called and says, “My arm hurts.” ANS: 11 Opening the eyes to speech is points, saying words is points, and localizing pain is points DIF: Cognitive Level: Analysis REF: p 247 OBJ: TOP: Pediatric Coma Scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease The child with hydrocephalus is found to have an obstruction in the subarachnoid space Based on this finding, the child has type of hydrocephalus ANS: Communicating Communicating hydrocephalus is caused by a defect in the absorption of CFS in the subarachnoid space DIF: Cognitive Level: Comprehension TOP: Communicating Hydrocephalus REF: p 247 OBJ: KEY: Nursing Process Step: N/A MSC: NCLEX: N/A The nurse caring for a child with meningitis would plan care to minimize disturbing the child unnecessarily as these children are extremely sensitive to stimuli that may initiate a ANS: Seizure Children with meningitis are sensitive to stimuli that may cause a seizure DIF: Cognitive Level: Comprehension TOP: Reduction of Stimuli REF: p 253 OBJ: KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 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: TOP: Spinal Fluid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 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 d Evolving myelination e Underdeveloped cranial bones ANS: A, C, E Open fontanels, an unfused cranium, and underdeveloped cranial bones allow for brain growth Myelination is not an aspect of the cranium DIF: Cognitive Level: Application TOP: Cranial Differences Implementation REF: p 244 OBJ: KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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.) a Forceful vomiting b High-pitched shrill cry c Strabismus d Inability to move normally e Equal pupils ANS: A, B, D Forceful vomiting, shrill cry, and inability to move normally would be clues to a possible hemorrhage All babies are strabismic, and equal pupils are not an indicator of hemorrhage DIF: Cognitive Level: Application TOP: Intracranial Hemorrhage REF: p 244 OBJ: KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 b 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 TOP: Seizures REF: p 244 OBJ: KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 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 c Strong muscle tone d Good appetite e Eyes protruding ANS: A, B Infants with hydrocephalus exhibit bulging fontanels, widened cranial sutures, a shiny scalp with dilated veins, and poor muscle tone Appetite is poor, and there is frequent vomiting The eyes are deviated downward (setting sun eyes) DIF: Cognitive Level: Application TOP: Hydrocephalic Signs REF: p 248 OBJ: KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 d Burp the baby often e Feed rapidly to prevent swallowing air ANS: A, B, C, D The hydrocephalic child is difficult to feed because of vomiting and the difficulty with the weight of the head The feeding time should be calm and slow The room should be darkened and quiet The baby should be burped often to reduce the threat of vomiting DIF: Cognitive Level: Comprehension TOP: Feeding the Hydrocephalic Child REF: p 249 OBJ: N/A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort In caring for an infant who has had a ventriculoperitoneal (VP) shunt, the nurse will include in the plan of care: (Select all that apply.) a Taking daily head measurements b Taking daily abdominal measurements c Positioning on the stomach if fontanels are bulging d Positioning on the opposite side from surgery e Changing the position every hours ANS: A, B, D The baby should have daily head and abdominal measurements to track whether the CSF is being drained from the head and absorbed in the abdomen The child should be positioned on the side opposite the surgery unless the fontanels are bulging In this event, the child is placed in a semi-Fowler’s position to facilitate drainage Position changes should occur every hours DIF: Cognitive Level: Comprehension TOP: Post-shunt Care REF: p 249 OBJ: N/A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort The nurse is aware that the child with a myelomeningocele may also have problems with: (Select all that apply.) a Lower limb paralysis b Mental retardation c Poor bladder control d Hydrocephalus e Poor bowel control ANS: A, C, D, E Mental retardation is not seen consistently in neural tube defects DIF: Cognitive Level: Comprehension TOP: Myelomeningocele REF: p 250 OBJ: KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse caring for a 1-month-old child with a myelomeningocele will take into consideration when positioning the baby to: (Select all that apply.) a Place the baby in prone position b Maintain hip abduction c Counteract hip subluxation d Maintain a neutral foot position e Maintain upper limb alignment ANS: A, B, C, D The positioning of an infant prior to the repair of a myelomeningocele would focus on protecting the sac and preventing postural deformities The baby should be placed in the prone position with a towel roll between the legs to maintain hip abduction and counteract hip subluxation, and another small roll to maintain a neutral foot position DIF: Cognitive Level: Application TOP: Positioning REF: p 251 OBJ: N/A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort Pediatric Nursing An Introductory Text 11th Edition Test Bank – Price