Wong S Pediatric Nursing c28 PDF

c28 9/2/15, 11:44 AM
Chapter 28: The Child with Cerebral Dysfunction
MULTIPLE CHOICE
1. The nurse has documented that a childs level of consciousness is

obtunded. Which describes this level of consciousness?
a. Slow response to vigorous and repeated
stimulation
b. Impaired decision making
c. Arousable with stimulation
d. Confusion regarding time and place
ANS: C
Obtunded describes a level of consciousness in which the child is arousable with
stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only
to vigorous and repeated stimulation. Confusion is impaired decision making.
Disorientation is confusion regarding time and place.
PTS: 1 DIF: Cognitive Level: Understand REF: 929

TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse has received report on four children. Which child should the
nurse assess first?
a. A school-age child in a coma with stable
vital signs
b. A preschool child with a head injury and
decreasing level of consciousness
c. An adolescent admitted after a motor
vehicle accident is oriented to person and
place
d. A toddler in a persistent vegetative state
with a low-grade fever
ANS: B
The nurse should assess the child with a head injury and decreasing level of
consciousness first (LOC). Assessment of LOC remains the earliest indicator of
improvement or deterioration in neurologic status. The next child the nurse should assess
is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in
a coma with stable vital signs and the adolescent admitted to the hospital who is oriented
to his surroundings would be of least worry to the nurse.
PTS: 1 DIF: Cognitive Level: Apply REF: 928

TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
Page 1 of 22
c28 9/2/15, 11:44 AM
3. The nurse is performing a Glasgow Coma Scale on a school-age child with

a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to
person, time, and place. Which is the score the nurse should record?
a. 8
b. 11
c. 13
d. 15
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal
response, and motor response. Numeric values of 1 through 5 are assigned to the levels of
response in each category. The sum of these numeric values provides an objective
measure of the patients level of consciousness (LOC). A person with an unaltered LOC
would score the highest, 15. The child who opens eyes spontaneously, obeys commands,
and is oriented is scored at a 15.

MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is closely monitoring a child who is unconscious after a fall and
notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret
this as:
a. eye trauma.
b. neurosurgical emergency.
c. severe brainstem damage.
d. indication of brain death.
ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The
nurse should immediately report this finding. Although a dilated pupil may be associated
with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or
bilateral fixed pupils for more than 5 minutes are indicative of brainstem damage. The
unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain.
One fixed and dilated pupil is not suggestive of brain death.
PTS: 1 DIF: Cognitive Level: Analyze REF: 942

5. The nurse is caring for a child with severe head trauma after a car
accident. Which is an ominous sign that often precedes death?
a. Papilledema
b. Delirium
c. Dolls head maneuver
d. Periodic and irregular breathing
Page 2 of 22
c28 9/2/15, 11:44 AM
ANS: D
Periodic or irregular breathing is an ominous sign of brainstem (especially medullary)
dysfunction that often precedes complete apnea. Papilledema is edema and inflammation
of optic nerve. It is commonly a sign of increased ICP. Delirium is a state of mental
confusion and excitement marked by disorientation for time and place. The dolls head
maneuver is a test for brainstem or oculomotor nerve dysfunction.

6. The nurse is taking care of a child who is alert but showing signs of
increased intracranial pressure. Which test is contraindicated in this case?
a. Oculovestibular response
b. Dolls head maneuver
c. Funduscopic examination for papilledema
d. Assessment of pyramidal tract lesions
ANS: A
The oculovestibular response (caloric test) involves the instillation of ice water into the
ear of a comatose child. The caloric test is painful and is never performed on an awake
child or one who has a ruptured tympanic membrane. Dolls head maneuver, funduscopic
examination for papilledema, and assessment of pyramidal tract lesions can be performed
on awake children.

7. The nurse is preparing a school-age child for computed tomography (CT

scan) to assess cerebral function. The nurse should include which statement in preparing
the child?
a. Pain medication will be given.
b. The scan will not hurt.
c. You will be able to move once the
equipment is in place.
d. Unfortunately, no one can remain in the
room with you during the test.
ANS: B
For CT scans, the child must be immobilized. It is important to emphasize to the child
that at no time is the procedure painful. Pain medication is not required; however,
sedation is sometimes necessary. Someone is able to remain with the child during the
procedure.

TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
Page 3 of 22
c28 9/2/15, 11:44 AM
8. Which neurologic diagnostic test gives a visualized horizontal and vertical

cross-section of the brain at any axis?
a. Nuclear brain scan
b. Echoencephalography
c. CT scan
d. Magnetic resonance imaging (MRI)
ANS: C
A CT scan provides a visualization of the horizontal and vertical cross-sections of the
brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the
blood-brain barrier is defective. Echoencephalography identifies shifts in midline
structures of the brain as a result of intracranial lesions. MRI permits visualization of
morphologic features of target structures and permits tissue discrimination that is
unavailable with any other techniques.

9. Which is the priority nursing intervention for an unconscious child after a

fall?
a. Establish adequate airway.
b. Perform neurologic assessment.
c. Monitor intracranial pressure.
d. Determine whether a neck injury is
present.
ANS: A
Respiratory effectiveness is the primary concern in the care of the unconscious child.
Establishment of an adequate airway is always the first priority. A neurologic assessment
and determination of whether a neck injury is present will be performed after breathing
and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if
indicated after airway, breathing, and circulation are maintained.

10. Which drug should the nurse expect to administer to a preschool child who
has increased intracranial pressure (ICP) resulting from cerebral edema?
a. Mannitol (Osmitrol)
b. Epinephrine hydrochloride (Adrenalin)
c. Atropine sulfate (Atropine)
d. Sodium bicarbonate (Sodium bicarbonate)
ANS: A
Page 4 of 22
c28 9/2/15, 11:44 AM
For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug
used most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate,
and sodium bicarbonate are not used to decrease ICP.

MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy
11. An appropriate nursing intervention when caring for an unconscious child

should be to:
a. change the childs position infrequently to
minimize the chance of increased ICP.
b. avoid using narcotics or sedatives to
provide comfort and pain relief.
c. monitor fluid intake and output carefully
to avoid fluid overload and cerebral
edema.
d. give tepid sponge baths to reduce fever
because antipyretics are contraindicated.
ANS: C
Often comatose patients cannot cope with the quantity of fluids that they normally
tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The childs
position should be changed frequently to avoid complications such as pneumonia and
skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and
discomfort, which can increase ICP. Antipyretics are the method of choice for fever
reduction.

12. The nurse is planning care for an 8-year-old child with a concussion.
Which is descriptive of a concussion?
a. Petechial hemorrhages cause amnesia.
b. Visible bruising and tearing of cerebral
tissue occur.
c. It is a transient and reversible neuronal
dysfunction.
d. A slight lesion develops remotely from the
site of trauma.
ANS: C
A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of
awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages
along the superficial aspects of the brain along the point of impact are a type of
contusion, but are not necessarily associated with amnesia. A contusion is visible bruising
Page 5 of 22
c28 9/2/15, 11:44 AM
and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of
trauma as a result of an acceleration-deceleration injury.
PTS: 1 DIF: Cognitive Level: Understand REF: 939-940

TOP: Integrated Process: Nursing Process: Planning
13. The nurse is teaching nursing students about childhood fractures. Which
describes a compound skull fracture?
a. Involves the basilar portion of the
occipital bone
b. Bone is exposed through the skin
c. Traumatic separations of the cranial
sutures
d. Bone is pushed inward, causing pressure
on the brain
ANS: B
A compound fracture has the bone exposed through the skin. A basilar fracture involves
the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. Diastatic
skull fractures are traumatic separations of the cranial sutures. A depressed fracture has
the bone pushed inward, causing pressure on the brain.

14. Which statement best describes a subdural hematoma?

a. Bleeding occurs between the dura and the
skull.
b. Bleeding occurs between the dura and the
cerebrum.
c. Bleeding is generally arterial, and brain
compression occurs rapidly.
d. The hematoma commonly occurs in the
parietotemporal region.
ANS: B
A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a
result of a rupture of cortical veins that bridge the subdural space. An epidural
hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain
concussion, and occurs most often in the parietotemporal region.
PTS: 1 DIF: Cognitive Level: Understand REF: 940-941

15. The nurse should recommend medical attention if a child with a slight
Page 6 of 22
c28 9/2/15, 11:44 AM
head injury experiences:

a. sleepiness.
b. vomiting, even once.
c. headache, even if slight.
d. confusion or abnormal behavior.
ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behavior,
loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of
blurred vision, or has an unsteady gait. Sleepiness alone does not require evaluation. If
the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting
more than three times requires medical attention. Severe or worsening headache or one
that interferes with sleep should be evaluated.
PTS: 1 DIF: Cognitive Level: Apply REF: 943-944

16. A 10-year-old boy on a bicycle has been hit by a car in front of the school.
The school nurse immediately assesses airway, breathing, and circulation. The next
nursing action: should be to
a. place on side.
b. take blood pressure.
c. stabilize neck and spine.
d. check scalp and back for bleeding.
ANS: C
After determining that the child is breathing and has adequate circulation, the next action
is to stabilize the neck and spine to prevent any additional trauma. The childs position
should not be changed until the neck and spine are stabilized. Blood pressure is a later
assessment. Less urgent, but an important assessment, is inspection of the scalp for
bleeding.

17. An adolescent boy is brought to the emergency department after a

motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme
fluctuations in blood pressure. Pupils are dilated and fixed. The nurse should suspect
which type of head injury?
a. Brainstem
b. Skull fracture
c. Subdural hemorrhage
d. Epidural hemorrhage
ANS: A
Page 7 of 22
c28 9/2/15, 11:44 AM
Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping
respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse
pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury.
Skull fracture, subdural hemorrhage, and epidural hemorrhage are not consistent with
brainstem injuries.

18. A child is unconscious after a motor vehicle accident. The watery

discharge from the nose tests positive for glucose. The nurse should recognize that this
suggests:
a. diabetic coma.
b. brainstem injury.
c. upper respiratory tract infection.
d. leaking of cerebrospinal fluid (CSF).
ANS: D
Watery discharge from the nose that is positive for glucose suggests leaking of CSF from
a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid
is probably CSF from a skull fracture and does not signify whether the brainstem is
involved.

19. A toddler fell out of a second-story window. She had a brief loss of
consciousness and vomited four times. Since admission, she has been alert and oriented.
Her mother asks why a computed tomography (CT) scan is required when she seems
fine. Which explanation should the nurse give?
a. Your child may have a brain injury and
the CT can rule one out.
b. The CT needs to be done because of your
childs age.
c. Your child may start to have seizures and
a baseline CT should be done.
d. Your child probably has a skull fracture
and the CT can confirm this diagnosis.
ANS: A
The childs history of the fall, brief loss of consciousness, and vomiting four times
necessitates evaluation of a potential brain injury. The severity of a head injury may not
be apparent on clinical examination but will be detectable on a CT scan. The need for the
CT scan is related to the injury and symptoms, not the childs age. The CT scan is
necessary to determine whether a brain injury has occurred.
Page 8 of 22
c28 9/2/15, 11:44 AM

20. The nurse is assessing a child who was just admitted to the hospital for
observation after a head injury. Which is the most essential part of the nursing assessment
to detect early signs of a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
ANS: D
The most important nursing observation is assessment of the childs level of
consciousness. Alterations in consciousness appear earlier in the progression of an injury
than do alterations of vital signs or focal neurologic signs. Neurologic posturing is
indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of
progression when compared with level-of-consciousness changes.

21. A school-age child has sustained a head injury and multiple fractures after
being thrown from a horse. The childs level of consciousness is variable. The parents tell
the nurse that they think their child is in pain because of periodic crying and restlessness.
The most appropriate nursing action is to:
a. discuss with parents the childs previous
experiences with pain.
b. discuss with practitioner what analgesia
can be safely administered.
c. explain that analgesia is contraindicated
with a head injury.
d. explain that analgesia is unnecessary
when child is not fully awake and alert.
ANS: B
A key nursing role is to provide sedation and analgesia for the child. Consultation with
the appropriate practitioner is necessary to avoid conflict between the necessity to
monitor the childs neurologic status and the promotion of comfort and relief of anxiety.
Information on the childs previous experiences with pain should be obtained as part of
the assessment, but because of the severity of injury, analgesia should be provided as
soon as possible. Analgesia can be safely used in individuals who have sustained head
injuries and can decrease anxiety and resultant increased ICP.
Page 9 of 22
c28 9/2/15, 11:44 AM

22. A 5-year-old girl sustained a concussion when she fell out of a tree. In
preparation for discharge, the nurse is discussing home care with her mother. Which
statement made by the mother indicates a correct understanding of the teaching?
a. I should expect my child to have a few
episodes of vomiting.
b. If I notice sleep disturbances, I should
contact the physician immediately.
c. I should expect my child to have some
behavioral changes after the accident.
d. If I notice diplopia, I will have my child
rest for 1 hour.
ANS: C
The parents are advised of probable posttraumatic symptoms that may be expected. These
include behavioral changes and sleep disturbances. If the child has these clinical signs,
they should be immediately reported for evaluation. Sleep disturbances are to be
expected.

23. A 3-year-old child is hospitalized after a submersion injury. The childs

mother complains to the nurse, Being at the hospital seems unnecessary when he is
perfectly fine. The nurses best reply should be:
a. He still needs a little extra oxygen.
b. Im sure he is fine, but the doctor wants
to make sure.
c. The reason for this is that complications
could still occur.
d. It is important to observe for possible
central nervous system problems.
ANS: C
All children who have a submersion injury should be admitted to the hospital for
observation. Although many children do not appear to have suffered adverse effects from
the event, complications such as respiratory compromise and cerebral edema may occur
24 hours after the incident. The mother would not think the child is fine if oxygen were
still required. The nurse should clarify that different complications can occur up to 24
hours later and that observations are necessary.

Page 10 of 22
c28 9/2/15, 11:44 AM
24. The most common clinical manifestation(s) of brain tumors in children is/
are:
a. irritability.
b. seizures.
c. headaches and vomiting.
d. fever and poor fine motor control.
ANS: C
Headaches, especially on awakening, and vomiting that is not related to feeding are the
most common clinical manifestation(s) of brain tumors in children. Irritability, seizures,
and fever and poor fine motor control are clinical manifestations of brain tumors, but
headaches and vomiting are the most common.

25. A 5-year-old boy is being prepared for surgery to remove a brain tumor.
Nursing actions should be based on which statement?
a. Removal of tumor will stop the various
symptoms.
b. Usually the postoperative dressing covers
the entire scalp.
c. He is not old enough to be concerned
about his head being shaved.
d. He is not old enough to understand the
significance of the brain.
ANS: B
The child should be told what he will look and feel like after surgery. This includes the
size of the dressing. The nurse can demonstrate on a doll the expected size and shape of
the dressing. Some of the symptoms may be alleviated by the removal of the tumor, but
postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated.
Children should be prepared for the loss of their hair, and it should be removed in a
sensitive, positive manner if the child is awake. Children at this age have poorly defined
body boundaries and little knowledge of internal organs. Intrusive experiences are
frightening, especially those that disrupt the integrity of the skin.

MSC: Area of Client Needs: Health Promotion and Maintenance
26. The nurse is teaching nursing students about childhood nervous system
tumors. Which best describes a neuroblastoma?
a. Diagnosis is usually made after metastasis
occurs.
b. Early diagnosis is usually possible
because of the obvious clinical
manifestations.
c. It is the most common brain tumor in Page 11 of 22
young children.
c28 9/2/15, 11:44 AM
a. Diagnosis is usually made after metastasis

occurs.
b. Early diagnosis is usually possible
because of the obvious clinical
manifestations.
c. It is the most common brain tumor in
young children.
d. It is the most common benign tumor in
young children.
ANS: A
Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases,
diagnosis is made after metastasis occurs, with the first signs caused by involvement in
the nonprimary site. In only 30% of cases is diagnosis made before metastasis.
Neuroblastomas are the most common malignant extracranial solid tumors in children.
The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic
chain. They are not benign but metastasize.

27. The mother of a 1-month-old infant tells the nurse she worries that her
baby will get meningitis like her oldest son did when he was an infant. The nurse should
base her response on which statement?
a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to
meningitis is found.
c. Vaccination to prevent all types of
meningitis is now available.
d. Vaccination to prevent Haemophilus
influenzae type B meningitis has
decreased the frequency of this disease in
children.
ANS: D
H. influenzae type B meningitis has been virtually eradicated in areas of the world where
the vaccine is administered routinely. Bacterial meningitis remains a serious illness in
children. It is significant because of the residual damage caused by undiagnosed and
untreated or inadequately treated cases. The leading causes of neonatal meningitis are the
group B streptococci and Escherichia coli organisms. Meningitis is an extension of a
variety of bacterial infections. No genetic predisposition exists. Vaccinations are not
available for all of the potential causative organisms.

28. The vector reservoir for agents causing viral encephalitis in the United
Page 12 of 22
c28 9/2/15, 11:44 AM
States is:
a. tarantula spiders.
b. mosquitoes.
c. carnivorous wild animals.
d. domestic and wild animals.
ANS: B
Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by
mosquitoes. The vector reservoir for most agents pathogenic for humans and detected in
the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear
during the hot summer months. Tarantula spiders, carnivorous wild animals, and
domestic and wild animals are not reservoirs for the agents that cause viral encephalitis.

29. Which is beneficial in reducing the risk of Reye syndrome?

a. Immunization against the disease
b. Medical attention for all head injuries
c. Prompt treatment of bacterial meningitis
d. Avoidance of aspirin to treat fever
associated with influenza
ANS: D
Although the etiology of Reye syndrome is obscure, most cases follow a common viral
illness, either varicella or influenza. A potential association exists between aspirin therapy
and the development of Reye syndrome, so use of aspirin is avoided. No immunization
currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or
bacterial meningitis.

30. When taking the history of a child hospitalized with Reye syndrome, the
nurse should not be surprised that a week ago the child had recovered from:
a. measles.
b. varicella.
c. meningitis.
d. hepatitis.
ANS: B
Most cases of Reye syndrome follow a common viral illness such as varicella or
influenza. Measles, meningitis, and hepatitis are not associated with Reye syndrome.

Page 13 of 22
c28 9/2/15, 11:44 AM
31. When caring for the child with Reye syndrome, the priority nursing
intervention should be to:
a. monitor intake and output.
b. prevent skin breakdown.
c. observe for petechiae.
d. do range-of-motion exercises.
ANS: A
Accurate and frequent monitoring of intake and output is essential for adjusting fluid
volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown,
observing for petechiae, and doing range-of-motion exercises are important interventions
in the care of a critically ill or comatose child. Careful monitoring of intake and output is
a priority.

32. A young childs parents call the nurse after their child was bitten by a
raccoon in the woods. The nurses recommendation should be based on which statement?
a. Child should be hospitalized for close
observation.
b. No treatment is necessary if thorough
wound cleaning is done.
c. Antirabies prophylaxis must be initiated.
d. Antirabies prophylaxis must be initiated if
clinical manifestations appear.
ANS: C
Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and
passive immunization with human rabies immune globulin (HRIG) as soon as possible.
Hospitalization is not necessary. The wound cleansing, passive immunization, and
immune globulin administration can be done as an outpatient. The child needs to receive
both HRIG and rabies vaccine.

33. A child is brought to the emergency department after experiencing a

seizure at school. There is no previous history of seizures. The father tells the nurse that
he cannot believe the child has epilepsy. The nurses best response is:
a. Epilepsy is easily treated.
b. Very few children have actual epilepsy.
c. The seizure may or may not mean that
your child has epilepsy.
d. Your child has had only one convulsion;
it probably wont happen again.
Page 14 of 22
c28 9/2/15, 11:44 AM
a. Epilepsy is easily treated.

b. Very few children have actual epilepsy.
c. The seizure may or may not mean that
your child has epilepsy.
d. Your child has had only one convulsion;
it probably wont happen again.
ANS: C
Seizures are the indispensable characteristic of epilepsy; however, not every seizure is
epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures.
The treatment of epilepsy involves a thorough assessment to determine the type of
seizure the child is having and the cause, followed by individualized therapy to allow the
child to have as normal a life as possible. The nurse should not make generalized
comments regarding the incidence of epilepsy until further assessment is made.

34. Which type of seizure involves both hemispheres of the brain?

a. Focal
b. Partial
c. Generalized
d. Acquired
ANS: C
Clinical observations of generalized seizures indicate that the initial involvement is from
both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the
frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are
caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed
region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain
injury from a variety of factors; it does not specify the type of seizure.
PTS: 1 DIF: Cognitive Level: Remember REF: 957

35. Which is the initial clinical manifestation of generalized seizures?

a. Being confused
b. Feeling frightened
c. Losing consciousness
d. Seeing flashing lights
ANS: C
Loss of consciousness is a frequent occurrence in generalized seizures and is the initial
clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are
clinical manifestations of a complex partial seizure.

Page 15 of 22
c28 9/2/15, 11:44 AM
36. Which of the following types of seizures may be difficult to detect?

a. Absence
b. Generalized
c. Simple partial
d. Complex partial
ANS: A
Absence seizures may go unrecognized because little change occurs in the childs
behavior during the seizure. Generalized, simple partial, and complex partial seizures all
have clinical manifestations that are observable.

37. An important nursing intervention when caring for a child who is

experiencing a seizure would be to:
a. describe and record the seizure activity
observed.
b. restrain the child when seizure occurs to
prevent bodily harm.
c. place a tongue blade between the teeth if
they become clenched.
d. suction the child during a seizure to
prevent aspiration.
ANS: A
When a child is having a seizure, the priority nursing care is observation of the child and
seizure. The nurse then describes and records the seizure activity. The child should not be
restrained, and nothing should be placed in the childs mouth. This may cause injury. To
prevent aspiration, if possible, the child should be placed on the side, facilitating
drainage.

38. A 10-year-old child, without a history of previous seizures, experiences a

tonic-clonic seizure at school. Breathing is not impaired, but some postictal confusion
occurs. The most appropriate initial action by the school nurse is to:
a. stay with child and have someone call
emergency medical service (EMS).
b. notify parent and regular practitioner.
c. notify parent that child should go home.
d. stay with child, offering calm reassurance.
Page 16 of 22
c28 9/2/15, 11:44 AM
ANS: A
The EMS should be called to transport the child because this is the childs first seizure.
Because this is the first seizure, evaluation should be performed as soon as possible. The
nurse should stay with the child while someone else notifies the EMS.

39. A child has been seizure-free for 2 years. A father asks the nurse how
much longer the child will need to take the antiseizure medications. The nurse includes
which intervention in the response?
a. Medications can be discontinued at this
time.
b. The child will need to take the drugs for 5
years after the last seizure.
c. A step-wise approach will be used to
reduce the dosage gradually.
d. Seizure disorders are a lifelong problem.
Medications cannot be discontinued.
ANS: C
A predesigned protocol is used to wean a child gradually off antiseizure medications,
usually when the child is seizure-free for 2 years and has a normal electroencephalogram
(EEG). Medications must be gradually reduced to minimize the recurrence of seizures.
Seizure medications can be safely discontinued. The risk of recurrence is greatest within
the first year.

40. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin

(Dilantin) may experience a deficiency of:
a. calcium.
b. vitamin C.
c. fat-soluble vitamins.
d. vitamin D and folic acid.
ANS: D
Deficiencies of vitamin D and folic acid have been reported in children taking
phenobarbital and phenytoin. Calcium, vitamin C, and fat-soluble vitamin deficiencies
are not associated with phenobarbital or phenytoin.

Page 17 of 22
c28 9/2/15, 11:44 AM
41. Which clinical manifestations would suggest hydrocephalus in a neonate?

a. Bulging fontanel and dilated scalp veins
b. Closed fontanel and high-pitched cry
c. Constant low-pitched cry and restlessness
d. Depressed fontanel and decreased blood
pressure
ANS: A
Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of
hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched
cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical
manifestations of hydrocephalus, but all should be referred for evaluation.

42. The nurse is monitoring a 7-year-old child post-surgical resection of an

infratentorial brain tumor. Which vital sign findings indicate Cushings triad?
a. Increased temperature, tachycardia,
tachypnea
b. Decreased temperature, bradycardia,
bradypnea
c. Bradycardia, hypertension, irregular
respirations
d. Bradycardia, hypotension, tachypnea
ANS: C
Cushings triad is a hallmark sign of increased intracranial pressure (ICP). The triad
includes bradycardia, hypertension, and irregular respirations. Increased or decreased
temperature is not a sign of Cushings triad.

43. Which position should the nurse place a 10-year-old child after a large
tumor was removed through a supratentorial craniotomy?
a. On the inoperative side with the bed flat
b. On the inoperative side with the head of
bed elevated 20 to 30 degrees
c. On the operative side with the bed flat and
pillows behind the head
d. On the operative side with the head of bed
elevated 45 degrees
Page 18 of 22
c28 9/2/15, 11:44 AM
ANS: B
If a large tumor was removed, the child is not placed on the operative side because the
brain may suddenly shift to that cavity, causing trauma to the blood vessels, linings, and
the brain itself. The child with an infratentorial procedure is usually positioned on either
side with the bed flat. When a supratentorial craniotomy is performed, the head of bed is
elevated 20 to 30 degrees with the child on either side or on the back. In a supratentorial
craniotomy, the head elevation facilitates CSF drainage and decreases excessive blood
flow to the brain to prevent hemorrhage. Pillows should be placed against the childs
back, not head, to maintain the desired position.

MSC: Area of Client Needs: Physiological Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. The treatment of brain tumors in children consists of which therapies?

(Select all that apply.)
a. Surgery
b. Bone marrow transplantation
c. Chemotherapy
d. Stem cell transplantation
e. Radiation
f. Myelography
ANS: A, C, E
Treatment for brain tumors in children may consist of surgery, chemotherapy, and
radiotherapy alone or in combination. Bone marrow and stem cell transplantation
therapies are used for leukemia, lymphoma, and other solid tumors where myeloablative
therapies are used. Myelography is a radiographic examination after an intrathecal
injection of contrast medium. It is not a treatment.

2. Which are clinical manifestations of increased intracranial pressure (ICP)

in infants? (Select all that apply.)
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia and blurred vision
d. Irritability
e. Distended scalp veins
f. Increased blood pressure
ANS: D, E
Page 19 of 22
c28 9/2/15, 11:44 AM
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased
ICP in infants. Diplopia and blurred vision is indicative of ICP in children. A high-
pitched cry and a tense or bulging fontanel are characteristics of increased ICP. Increased
blood pressure, common in adults, is rarely seen in children.

3. An infant with hydrocephalus is hospitalized for surgical placement of a

ventriculoperitoneal shunt. Which interventions should be included in the childs
postoperative care? (Select all that apply.)
a. Observe closely for signs of infection.
b. Pump the shunt reservoir to maintain
patency.
c. Administer sedation to decrease
irritability.
d. Maintain Trendelenburg position to
decrease pressure on the shunt.
e. Maintain an accurate record of intake and
output.
f. Monitor for abdominal distention.
ANS: A, E, F
Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of
infection is a priority nursing intervention. Intake and output should be measured
carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus.
Pumping of the shunt may cause obstruction or other problems and should not be
performed unless indicated by the neurosurgeon. Pain management rather than sedation
should be the goal of therapy. The child is kept flat to avoid too rapid a reduction of
intracranial fluid.

4. The nurse is evaluating the laboratory results on cerebral spinal fluid

(CSF) from a 3-year-old child with bacterial meningitis. Which findings confirm bacterial
meningitis? (Select all that apply.)
a. Elevated white blood cell (WBC) count
b. Decreased glucose
c. Normal protein
d. Elevated red blood cell (RBC) count
ANS: A, B
The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count,
Page 20 of 22
c28 9/2/15, 11:44 AM
decreased glucose, and increased protein content. There should not be RBCs evident in
the CSF fluid.

TOP: Integrated Process: Nursing Process: Evaluation
5. The nurse is caring for a neonate with suspected meningitis. Which

clinical manifestations should the nurse prepare to assess if meningitis is confirmed?
a. Headache
b. Photophobia
c. Bulging anterior fontanel
d. Weak cry
e. Poor muscle tone
ANS: C, D, E
Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak
cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.

6. The nurse is monitoring an infant for signs of increased intracranial

pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?
a. Tachycardia
b. Alteration in pupil size and reactivity
c. Increased motor response
d. Extension or flexion posturing
e. Cheyne-Stokes respirations
ANS: B, D, E
Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and
reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes
respirations.

ESSAY
1. A 6-year-old child is having a generalized seizure in the classroom at

school. Place in order the interventions the school nurse should implement starting with
the highest-priority intervention sequencing to the lowest-priority intervention. Provide
Page 21 of 22
c28 9/2/15, 11:44 AM
answer using lowercase letters separated by commas (e.g., a, b, c, d, e).

a. Take vital signs.
b. Ease child to the floor.
c. Allow child to rest.
d. Turn child to the side.
e. Integrate child back into the school environment.
ANS:
b, d, a, c, e
The nurse should ease the child to the floor immediately during a generalized seizure.
During (and sometimes after) the generalized seizure, the swallowing reflex is lost,
salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for
aspiration and airway occlusion. Placing the child on the side facilitates drainage and
helps maintain a patent airway. Vital signs should be taken next and the child should be
allowed to rest. When feasible, the child is integrated into the environment as soon as
possible.

Page 22 of 22

Wong S Pediatric Nursing c28 PDF

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Wong S Pediatric Nursing c28 PDF

Diunggah oleh

Hak Cipta:

Format Tersedia

c28 9/2/15, 11:44 AM

Chapter 28: The Child with Cerebral Dysfunction

1. The nurse has documented that a childs level of consciousness is

PTS: 1 DIF: Cognitive Level: Understand REF: 929

PTS: 1 DIF: Cognitive Level: Apply REF: 928

3. The nurse is performing a Glasgow Coma Scale on a school-age child with

PTS: 1 DIF: Cognitive Level: Understand REF: 929

PTS: 1 DIF: Cognitive Level: Analyze REF: 942

PTS: 1 DIF: Cognitive Level: Understand REF: 930

PTS: 1 DIF: Cognitive Level: Analyze REF: 931

7. The nurse is preparing a school-age child for computed tomography (CT

PTS: 1 DIF: Cognitive Level: Apply REF: 933

8. Which neurologic diagnostic test gives a visualized horizontal and vertical

PTS: 1 DIF: Cognitive Level: Understand REF: 933

9. Which is the priority nursing intervention for an unconscious child after a

PTS: 1 DIF: Cognitive Level: Apply REF: 935

PTS: 1 DIF: Cognitive Level: Apply REF: 936

11. An appropriate nursing intervention when caring for an unconscious child

PTS: 1 DIF: Cognitive Level: Apply REF: 937

PTS: 1 DIF: Cognitive Level: Understand REF: 939-940

PTS: 1 DIF: Cognitive Level: Understand REF: 940

14. Which statement best describes a subdural hematoma?

PTS: 1 DIF: Cognitive Level: Understand REF: 940-941

head injury experiences:

PTS: 1 DIF: Cognitive Level: Apply REF: 943-944

PTS: 1 DIF: Cognitive Level: Apply REF: 942

17. An adolescent boy is brought to the emergency department after a

PTS: 1 DIF: Cognitive Level: Understand REF: 930

18. A child is unconscious after a motor vehicle accident. The watery

PTS: 1 DIF: Cognitive Level: Apply REF: 942

PTS: 1 DIF: Cognitive Level: Apply REF: 933

PTS: 1 DIF: Cognitive Level: Analyze REF: 929

PTS: 1 DIF: Cognitive Level: Apply REF: 944

TOP: Integrated Process: Teaching/Learning

PTS: 1 DIF: Cognitive Level: Apply REF: 944

23. A 3-year-old child is hospitalized after a submersion injury. The childs

PTS: 1 DIF: Cognitive Level: Apply REF: 945

PTS: 1 DIF: Cognitive Level: Understand REF: 947

PTS: 1 DIF: Cognitive Level: Apply REF: 948

a. Diagnosis is usually made after metastasis

PTS: 1 DIF: Cognitive Level: Apply REF: 949

PTS: 1 DIF: Cognitive Level: Apply REF: 950

PTS: 1 DIF: Cognitive Level: Understand REF: 954

29. Which is beneficial in reducing the risk of Reye syndrome?

PTS: 1 DIF: Cognitive Level: Understand REF: 956

PTS: 1 DIF: Cognitive Level: Understand REF: 956

MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

PTS: 1 DIF: Cognitive Level: Apply REF: 956

PTS: 1 DIF: Cognitive Level: Apply REF: 955

33. A child is brought to the emergency department after experiencing a

a. Epilepsy is easily treated.

PTS: 1 DIF: Cognitive Level: Apply REF: 956

34. Which type of seizure involves both hemispheres of the brain?

PTS: 1 DIF: Cognitive Level: Remember REF: 957

35. Which is the initial clinical manifestation of generalized seizures?

PTS: 1 DIF: Cognitive Level: Understand REF: 958

MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

36. Which of the following types of seizures may be difficult to detect?

PTS: 1 DIF: Cognitive Level: Understand REF: 958

37. An important nursing intervention when caring for a child who is

PTS: 1 DIF: Cognitive Level: Apply REF: 962

38. A 10-year-old child, without a history of previous seizures, experiences a

PTS: 1 DIF: Cognitive Level: Apply REF: 965