- Which term is used to describe the level of consciousness when a child can be aroused with stimulation? a. Stupor
b. Confusion
c. Obtundation d. Disorientation
ANS: C
Obtundation describes the level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is indicated by impaired decision making. Disorientation is confusion regarding time and place.
- What term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?
a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative state
ANS: B
When the child remains in a deep sleep, responsive only to vigorous and repeated stimulation, he or she is in a stupor. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.
- Which does the Glasgow Coma Scale assess?
a. Pupil reactivity and motor response
b. Eye-opening, verbal, and motor responses
c. Level of consciousness and verbal response
d. Intracranial pressure and level of consciousness
ANS: B
The Glasgow Coma Scale assesses eye-opening, verbal, and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and intracranial pressure are not measured by the Glasgow Coma Scale.
- The nurse is closely monitoring a child who is unconscious after a fall and notices that he suddenly has a fixed and dilated pupil. How should the nurse interpret this finding?
a. Eye trauma
b. Neurosurgical emergency
c. Severe brainstem damage
d. Indication of brain death
ANS: B
Pupils that suddenly appear fixed and dilated indicate 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 neurological insult. Pinpoint pupils or bilateral pupils that remain fixed 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.
- The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which is the basis of the nurse’s response?
a. Pain medication will be administered prior to the scan.
b. CT scans do not cause pain.
c. Movement is allowed once the equipment is in place.
d. No one is able to remain in the room with the child during the test.
ANS: B
For CT scans, the child will not be allowed to move and 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.
- Which neurological diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?
a. Nuclear brain scan
b. Echoencephalography
c. Computed tomography (CT) scan
d. Magnetic resonance imaging (MRI)
ANS: C
A CT scan provides 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. An MRI provides visualizations of morphological features of target structures and tissue discrimination that is unavailable with any other technique.
- What is the priority nursing intervention when a child is unconscious after a fall?
a. Establish adequate airway.
b. Perform neurological assessment.
c. Monitor intercranial pressure.
d. Determine whether a neck injury is present.
ANS: A
Respiratory effectiveness is the primary concern when caring for the unconscious child. Establishing an adequate airway is always the first priority. A neurological assessment and examination for neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.
- Which drug is used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema?
a. Mannitol
b. Epinephrine hydrochloride
c. Atropine sulphate
d. Sodium bicarbonate
ANS: A
For increased ICP, mannitol, an osmotic diuretic administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulphate, and sodium bicarbonate are not used to decrease ICP.
- Which of the following describes a concussion?
a. Petechial hemorrhages that cause amnesia and cognitive delay
b. Visible bruising and tearing of cerebral tissue occurs
c. An alteration in neurological or cognitive function with or without loss of
consciousness
d. A slight lesion that develops remote from the site of trauma with immediate loss
of consciousness
ANS: C
A mild traumatic brain injury, or concussion, is an alteration in neurological or cognitive function with or without loss of consciousness, which occurs immediately after a head injury. Petechial hemorrhages along the superficial aspects of the brain at the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. A contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.
- What type of fracture involves fragmented bone that is pushed inward and causes pressure on the brain? a. Basilar
b. Compound
c. Open
d. Depressed
ANS: D
A depressed fracture means the bone is pushed inward, causing pressure on the brain. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture means the bone is exposed through the skin. An open fracture causes communication between the skull and the scalp or surfaces of the upper respiratory tract.
- Which statement best describes a subdural hematoma?
a. Bleeding occurs between the dura and the skull.
b. Bleeding occurs between the dura and the arachnoid membrane.
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 arachnoid membrane, usually 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.
- When providing discharge teaching to the mother of a child with a slight head injury, which symptom should the nurse tell the parent to seek medical attention for immediately?
a. Sleepiness
b. Vomiting, even once
c. Headache, even if slight
d. Confusion or abnormal behaviour
ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behaviour; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or 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 also requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.
- 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 his blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect?
a. Brainstem injury
b. Skull fracture
c. Subdural hemorrhage
d. Epidural hemorrhage
ANS: A
Signs of brainstem injury include deep, rapid, intermittent, and gasping respirations. Wide fluctuations in or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are also consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these symptoms.
- A toddler fell out of a second-story window. She briefly lost 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.” What knowledge should the nurse base her response on?
a. She may have a brain injury.
b. She needs this because of her age.
c. She may start having seizures.
d. She probably has a skull fracture.
ANS: A
The child’s history of the fall, brief loss of consciousness, and vomiting four times necessitates evaluation for a potential brain injury. The severity of a head injury may not be apparent in 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 child’s age, and is necessary to determine whether a brain injury has occurred.
- The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of the nursing assessment to detect early signs of a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurological signs
d. Level of consciousness
ANS: D
The most important nursing observation is assessment of the child’s level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurological signs. Neurological posturing indicates neurological damage. Vital signs and focal neurological signs are later signs of progression when compared to level-of-consciousness changes.
- A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child’s level of consciousness is variable. The parents tell the nurse they think their child is in pain because of periodic crying and restlessness. What is the most appropriate action for the nurse to take?
a. Discuss with the parents the child’s previous experiences with pain.
b. Discuss with the practitioner what analgesia can be safely administered.
c. Explain that analgesia is contraindicated with a head injury.
d. Explain that analgesia is unnecessary when a 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 child’s neurological status and to promote comfort and relieve anxiety. Gathering information about the child’s 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 used safely in individuals who have sustained head injuries and can decrease anxiety and the resultant increased intracranial pressure.
- A 3-year-old child is hospitalized after a submersion injury. The child’s mother complains to the nurse, “This seems unnecessary when he is perfectly fine.” What is the basis for the nurses’ response?
a. Supplemental oxygen is required after submersion injuries.
b. Hospitalization is probably not required.
c. Complications can occur after a submersion injury.
d. Observation is required for possible central nervous system problems.
ANS: C
All children who have a submersion injury experience should be admitted to the hospital for observation. The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary. Although many children do not appear to suffer adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur 24 hours after the incident. The child may or may not require additional oxygen.
- Which statement best describes a neuroblastoma?
a. The 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 tumour in young children.
d. It is the most common benign tumour in young children.
ANS: A
Neuroblastoma is a silent tumour with few symptoms until metastasis occurs. Neuroblastomas are the most common malignant extracranial solid tumours in children. The majority of tumours develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize.
- The mother of a 2-month-old infant tells the nurse that she worries her baby will get meningitis like her oldest son did when he was an infant. What knowledge should the nurse base her response on?
a. Meningitis rarely occurs during infancy.
b. Often there is a genetic predisposition to meningitis.
c. Vaccination to prevent all types of meningitis is now available.
d. Administration of Hib vaccine has decreased the frequency of bacterial
meningitis.
ANS: D
H. influenzae type B meningitis has virtually been 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.
- What agents are implicated for causing viral encephalitis?
a. Tarantula spiders
b. Mosquitoes and ticks
c. Carnivorous wild animals
d. Domestic and wild animals
ANS: B
Most agents for viral encephalitis have arthropod vectors, such as mosquitoes and ticks. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis.
- What may be beneficial in reducing the risk of Reye’s syndrome?
a. Immunization against the disease
b. Medical attention for all head injuries
c. Prompt treatment of bacterial meningitis
d. Avoidance of aspirin for children with varicella or influenza
ANS: D
Although the etiology of Reye’s syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin (ASA) therapy and the development of Reye’s syndrome, thus the use of aspirin is avoided. No immunization currently exists for Reye’s syndrome. Reye’s syndrome is not correlated with head injuries or bacterial meningitis.
- When taking the history of a child hospitalized with Reye’s syndrome, which would the nurse anticipate that the child experienced in the recent past?
a. Measles
b. Varicella c. Meningitis d. Hepatitis
ANS: B
Most cases of Reye’s syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye’s syndrome.
- What is the priority nursing intervention when caring for a child with Reye’s syndrome?
a. Monitor intake and output.
b. Prevent skin breakdown.
c. Observe for petechiae.
d. Do range-of-motion (ROM) 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 ROM exercises are important interventions in the care of a critically ill or comatose child.
- 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. What is the basis of the nurses’ response?
a. Epilepsy is an easily treatable disease.
b. Very few children have actual epilepsy.
c. The seizure may or may not be an indication of epilepsy.
d. Reassure the father that his child probably does not have epilepsy.
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 of events, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not base the response on generalizations that very few children have actual epilepsy or provide reassurance that it is not epilepsy until further assessment is made.
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Chapter 32: developmental influences30
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chapter 33: Communication, History, Physical, and Developmental Assessment34
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Chapter 35: infant and family32
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chapter 36: Toddler and family26
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chapter 37: pre-schooler26
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Chapter 39:The Adolescent and Family25
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Chapter 40: Chronic Illness, Complex Conditions, and End-of-Life Care25
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chapter 45: Respiratory dysfunction35
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Chapter 46: Gastrointestinal Dysfunction36
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Chapter 47: Cardiovascular dysfunction36
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Chapter 48: Hematological or Immunological Dysfunction35
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Chapter 49: Genitourinary Dysfunction27
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Chapter 50: Cerebral dysfunction38
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Chapter 51: Endocrine dysfunction26
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Chapter 52: Integumentary dysfuction43
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Chapter 53: Musculoskeletal or Articular Dysfunction24
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Chapter 54: Neuromuscular or Muscular Dysfunction14
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Chapter 41: Cognitive and Sensory Impairment27
