YOU
Which of the following phrases describes a characteristic of most neonatal seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure
D. Subtle and barely discernible seizure
The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain
A. cannot occur if the child is comatose.
B. may occur if the child regains consciousness.
C. requires astute nursing assessment and management.
D. is best assessed by family members who are familiar with the child.
C. requires astute nursing assessment and management.
The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. The most appropriate nursing action is to
A. notify the practitioner immediately.
B. assess for level of consciousness (LOC).
C. observe closely for signs of increased intracranial pressure (ICP).
D. administer pain medication and assess for response.
A. notify the practitioner immediately.
A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. Based on the nurse’s knowledge of seizures, the nurse recognizes this as
A. absence seizure.
B. generalized seizure.
C. status epilepticus.
D. simple partial seizure.
C. status epilepticus.
A Glasgow Coma Scale (GCS) is being used to assess neurological status in a child who was in a car accident and sustained head trauma. Total score documented in the electronic health record is 12. Based on this finding, the nurse suspects that the child is
A. unresponsive.
B. aware of surroundings.
C. unable to respond verbally.
D. has substantial neurological deficits.
B. aware of surroundings.
What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea
A. Shrill, high-pitched cry
What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child?
A. Suction the child frequently.
B. Provide environmental stimulation.
C. Turn the head side to side every hour.
D. Avoid activities that cause pain or crying.
D. Avoid activities that cause pain or crying.
The postoperative care of a preschool child who has had a brain tumor removed should include
A. recording of colorless drainage as normal on the nurse’s notes.
B. close supervision of the child while he or she is regaining consciousness.
C. positioning the child on the right side in the Trendelenburg position.
D. no administration of analgesics.
B. close supervision of the child while he or she is regaining consciousness.
The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. The most important part of the discussion with the parents is that
A. parental protection is essential until the child reaches adulthood.
B. cognitive impairment is to be expected with hydrocephalus.
C. shunt malfunction or infection requires immediate treatment.
D. most usual childhood activities must be restricted.
C. shunt malfunction or infection requires immediate treatment.
In assessing neurological integrity of the eyes, if the medical record stated that the Doll’s reflex was present. The nurse would interpret this as
A. a neurological deficit is present.
B. the patient’s eye movement is paired going in the direction to which the head is moved.
C. no oscillations of eye movements are noted.
D. cranial nerve III is intact.
D. cranial nerve III is intact.
The nurse is doing 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 priority assessment for this child?
A. Reactivity of pupils
B. Doll’s head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema
A. Reactivity of pupils
The nurse is caring for a 2-year-old child who is unconscious but stable after a car accident. The child’s parents are staying at the bedside most of the time. What is an appropriate nursing intervention?
A. Suggest that the parents go home until the child is alert enough to know they are present.
B. Use ointment on the lips but do not attempt to cleanse the teeth until swallowing returns.
C. Encourage the parents to hold, talk to, and sing to the child as they usually would.
D. Position the child with proper body alignment and the head of the bed lowered 15 degrees.
C. Encourage the parents to hold, talk to, and sing to the child as they usually would.
The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is the priority of nursing care?
A. Initiate isolation precautions as soon as the diagnosis is confirmed.
B. Initiate isolation precautions as soon as the causative agent is identified.
C. Administer antibiotic therapy as soon as it is ordered.
D. Administer sedatives and analgesics on a preventive schedule to manage pain.
C. Administer antibiotic therapy as soon as it is ordered.
A child is admitted to the pediatric intensive care unit for a submersion injury. The child’s parents express guilt over the submersion injury to the nurse. The most appropriate response by the nurse is
A. You will need to watch your child more closely in the future.
B. Why did you let your child almost drown?
C. Your child will be fine, so don’t worry.
D. Tell me more about your feelings.
D. Tell me more about your feelings.
In providing a health promotion plan for new parents aimed at maintaining safety of children, which option should be stressed?
A. Toddlers should be allowed to experiment with all types of foods as long as they are cut into two inch “bite size pieces.”
B. Children should not be left alone in height chairs even if the chair is properly locked with the tray table secured.
C. Children’s anatomical proportions make them less likely to suffer traumatic brain injury.
D. As long as you provide firm directions and instructions, children typically will not get into trouble in their home environment.
B. Children should not be left alone in height chairs even if the chair is properly locked with the tray table secured.
The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest
A. neurologic health.
B. severe brain damage.
C. decorticate posturing.
D. decerebrate posturing.
A. neurologic health.
The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration–deceleration head injuries because the
A. anterior fontanel is not yet closed.
B. nervous tissue is not well developed.
C. scalp of head has extensive vascularity.
D. musculoskeletal support of head is insufficient.
D. musculoskeletal support of head is insufficient.
The nurse is planning care for a school-age child with bacterial meningitis. Which nursing intervention should be included?
A. Keep environmental stimuli to a minimum.
B. Avoid giving pain medications that could dull the sensorium.
C. Measure the head circumference to assess developing complications.
D. Have the child move the head side to side at least every 2 hours.
A. Keep environmental stimuli to a minimum.
The most appropriate nursing intervention when caring for a child experiencing a seizure is to
A. restrain the child when a seizure occurs to prevent bodily harm.
B. place a padded tongue between the teeth if they become clenched.
C. suction the child during the seizure to prevent aspiration.
D. describe and document the seizure activity observed.
D. describe and document the seizure activity observed.
The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration-deceleration head injuries because the
A. anterior fontanel is not yet closed.
B. nervous tissue is not well developed.
C. scalp of head has extensive vascularity.
D. musculoskeletal support of head is insufficient.
D. musculoskeletal support of head is insufficient.
The temperature of an unconscious adolescent is 105° F (40.5° C). The priority nursing intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
C. apply a hypothermia blanket.
D. administer aspirin stat.
C. apply a hypothermia blanket.
A 3-year-old child is status post shunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.)
A. Personality change
B. Bulging anterior fontanel
C. Vomiting
D. Dizziness
E. Fever
B. Bulging anterior fontanel
D. Dizziness
When assessing a child for bacterial meningitis, which diagnostic tests should be included? (Select all that apply.)
A. Romberg test
B. Kernig’s sign
C. Brudzinki sign
D. Tactile fremitus
E. Ortolani Maneuver
A. Romberg test
B. Kernig’s sign
A pediatric patient has fallen into a pool and paramedics have revived the child at the scene and brought him to the Emergency Room for follow up treatment. With regard to submersion injury, what priority assessments should be included in the plan of care? (Select all that apply.)
A. Maintain airway and ventilator support
B. Obtain arterial blood gases (ABGs)
C. Find out what the temperature of the pool water
D. Place the patient in reverse isolation
E. Medicate patient for anxiety
A. Maintain airway and ventilator support
B. Obtain arterial blood gases (ABGs)