2.9 Neuro/Sensory Motor- Child

Assessment

100

When assessing a patient with a head injury, what is an early sign of ICP?

A: vomiting

B: Headache

C: Change in LOC

D: Sluggish pupil response

C: Change in Orientation 

200

When assessing a neurologic patient, the nurse uses the Glasgow coma scale obtains information related to:

A: LOC

B: Cerebral Edema presence

C: Presence of corneal reflexes

D: Integrated functions of cerebral cortex

A: LOC 

300

Which of the following terms describes a condition where pt. sleeps deeply and does not arouse unless stimulated to awake?

A: Alert

B: Confused

C: Lethargy

D: Obtunded

D: Obtunded 

400

When assessing orientation, which of the following questions would be most appropriate to ascertain pt's orientation to time?

A: What time is it now?

B: What day of the week is it today?

C: What time was the doctor here today?

D: What time did your children come to visit?

B: What day of the week is it today?

500

Which of the following is a clinical manifestation of increased ICP in an infant?

A: slurred speech.

B: Headache

C: Double vision

D: Bulging Fontanel

D: Bulging Fontanel.

Pediatric Disorders

100

A newborn has a sac in the lumbosacral area containing CSF, meninges, nerve roots, and the spinal cord. This condition is referred to as:

A: Myelomeningocele

B: Meningocele

C: Arnold Chiari malformation

D: Spina bifida occulta

A: Myelomeningocele

200

An appropriate nursing action during a tonic-clonic seizure is:

A: Restraining flailing extremities

B: Placing padding between the teeth.

C: Observing the type of movements and duration of seizure.

D: Placing child in supine or prone position 

C: Observing the type of movements and duration of the seizure.

300

An expected finding in an analysis of CSF in a child with bacterial meningitis is:

A: Cloudy appearance

B: Clear appearance

A: cloudy appearance 

Viral is clear. 

400

What is the most definitive diagnosis for Reyes Syndrome?

A: Lumbar puncture

B: Liver biopsy

C: Glucose

D: WBC

B:Liver biopsy

Rationale: In Reyes syndrome the viral agent leads to liver damage and increased ammonia levels. The ammonia levels cause cerebral edema. 

500

What is the most significant neurological assessment for a child <2 years old when assessing for increased ICP?

A: Poor feeding.

B: Mood swings

C: Slurred speech.

D: Head circumference. 

D: Head circumference. 

All of the answers are associated with increased ICP in infants and/or children, but head circumference is the most significant. 

Nursing Process

100

As inter cranial pressure rises compression of the 3rd cranial nerve causes pupil:

A: constriction.

B: inequality

C: Dilation

D: Diplopia 

C: Dilation

as ICP rises pupils dilate and become sluggish or absent constriction. Fixed and dilated pupils usually indicates brain death. 

200

When assessing a patient with increased ICP, the nurses notices flexion of the arms internal rotation of legs and plantar flexion of the feet. This position is called:

A: Decerebrate posturing.

B: Decorticate posturing. 

B: Decorticate posturing. 

Think: Corpse where arms are placed across the chest in the casket. (I know strange way to remember, but it may help)

300

In decerebrate posturing the patients arms are extended, hands are flexed and wrists are pronated. The patient was previously noted to have decorticate posturing. This change indicates:

A: improved neurologic status

B: declining neurologic status

C: unchanged neurologic status

D: 

B: declining neurologic status

Rationale: progression from decorticate to decerebrate to flaccid paralysis indicates decline in patients neurologic status. 

400

A patient with increased ICP requires what positioning in order to reduce increased ICP?

A: Prone

B: Supine

C: Left lateral sims

D: Fowlers

D: Fowlers with HOB 30-45 degrees.

Rationale: this facilitates venous drainage and therefore reduces ICP. 

500

Which is the most important thing to teach a patient who is on Phenytoin (dilantin)?

A: use a soft toothbrush.

B: drug causes gingival hyperplasia.

C: use a soft toothbrush.

D: do not stop abruptly. 

D: Do not stop abruptly.

All of the provided answers are correct regarding phenytoin. However, teaching not to stop the drug abruptly the most important r/t increased risk of causing seizure. 

Misc.

100

Which of the following is the most appropriate nursing intervention when assisting a provider with a lumbar puncture.

A: Ensuring informed consent signed.

B: Place child in side lying knee chest position.

C: Monitoring cardiorespiratory status during procedure.

D: Label specimens properly and delivery to lab asap.

C:  Monitoring cardiorespiratory status during the procedure.

All of the provided answers are important regarding lumbar puncture. However, cardiorespiratory status is the most important (ABC priority).

200

A 14 year old presents with c/o HA, anorexia, photophobia, nuccal rigidity, and altered LOC. The nurse suspects the patient may have:

A: Reyes syndrome

B: Cerebral Palsy

C: Meningitis

D: Spina Bifida

C: Meningitis

300

A nurse is admitting a patient to the pediatric unit with a diagnosis of suspected meningitis. What type of isolation should the nurse place the patient in?

A: Airborne.

B: Droplet

C: Contact

D: Reverse Isolation

B: Droplet.

Droplet precautions are required for bacterial meningitis. If bacterial or viral cannot be initially determined the nurse should assume bacterial and implement droplet precautions until it is ruled out. 

400

A nurse is teaching a parent of a 5 year old what medication to administer for a fever. What medications should the parent avoid? (select all that apply)

A: acetaminophen.

B: Aspirin

C: Alka Seltzer

D: Salicylate

E: Ibuprofen

B: aspirin

C: Alka seltzer

D: Salicylate

All of the above products contain aspirin. (salicylate is another name for aspirin).

500

Spina Bifida results from a genetic predisposition to the disease and what potential mineral deficiency?

A: Folic acid

B: Vitamin C

C: Selenium

D: Magnesium

A: Folic acid 

Misc 2

100

What assessment findings may be present in a newborn born with spina bifida?

A: Clubfoot

B: paralysis

C: Hip dysplasia

D: Intact neurological status

E: Hydrocephalus. 

A, B,C,E

You could see paralysis, hip dysplasia, hydrocephalus, and clubfoot in a patient with spina bifida. The extent of the problems determines the extent of the spina bifida. Occulta has less deficits than spina bifida cystic. 

200

Nursing interventions for an infant born with a myelomeningocele include: (select all that apply)

A: prone positioning.

B: supine positioning

C: monitor respiratory status.

D: place dressing over the myelomeningocele.

E: monitor for hydrocephalus. 

A: prone

C: respiratory status

D: cover myelomeningocele

E: monitor for hydrocephalus.

You do not want to put infant supine r/t increased pressure on the myelomeningocele. 

300

A child with a VP shunt in place becomes lethargic, confused, develops slurred speech and complains of a headache. What does the nurse suspect is occurring? What should the nurse do? 

There is a good possibility that the VP shunt is occluded and no longer working properly to drain the excess CSF from the ventricles of the brain. The nurse should notify the provider of the change in neurologic status stat. 

400

All patients diagnosed with cerebral palsy will present the same.

True  or False?

False.

Manifestations of s/s will vary widely from patient to patient depending on the extent of the CP. Some may have mild deficits and some may be very severe and debilitating. 

500

A nurse is observing a group of 7 year olds on the playground. The nurse notices a student playing alone, responds only with vocal tones and becomes very distraught when their routine is changed. What disorder would the nurse suspect?

A: Autism

B: Amblyopia

C: Hearing loss

D: Blindness

A: Austism spectrum disorder (ASD).