Chapter 52 The Child with a Neurologic Alteration

Chapter 52  The Child with a Neurologic Alteration

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?

a. Headache
b. Bulging fontanel
c. Tachypnea
d. Increase in head circumference

ANS: A
Headaches are a clinical manifestation of increased ICP in children. A change in the child’s
normal behavior pattern may be an important early sign of increased ICP. Bulging fontanel or
increased head circumference is seen in infants. A change in respiratory pattern is a late sign
of increased ICP. Cheyne–Stokes respiration may be evident. This refers to a pattern of
increasing rate and depth of respirations followed by a decreasing rate and depth with a pause
of variable length.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 1279 | Box 52.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity

2. Which information should the nurse give to a child who is to have magnetic resonance

imaging (MRI) of the brain?
a. “You won’t be able to move your head during the procedure.”
b. “You will have to drink a special fluid before the test.”
c. “You will have to lie flat after the test is finished.”
d. “You will have electrodes placed on your head with glue.”

ANS: A
To reduce fear and enhance cooperation during the MRI, the child should be made aware that
head movement will be restricted to obtain accurate information. The child does not need to
drink special liquids, lie on the back afterward, or have electrodes placed.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 1278 OBJ: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity

3. Which 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

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated
stimulation. 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 is
arousable with stimulation. Persistent vegetative state describes the permanent loss of function
of the cerebral cortex.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 1282 | Nursing Quality Alert Box
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. The Glasgow Coma Scale consists of an assessment of

a. pupil reactivity and motor response.
b. eye opening and verbal and motor responses.
c. level of consciousness and verbal response.
d. ICP and level of consciousness.

ANS: B
The Glasgow Coma Scale assesses eye opening, and 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 is not a part of the Glasgow Coma Scale. Intracranial pressure and
level of consciousness are not part of the Glasgow Coma Scale.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 1282 | Table 52.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity

5. Nursing care of the infant who has had a myelomeningocele repair should include

a. securely fastening the diaper.
b. measurement of pupil size.
c. measurement of head circumference.
d. administration of seizure medications.

ANS: C
Head circumference measurement is essential because hydrocephalus can develop in these
infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open
facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size
measurement is usually not necessary. Seizure medications are not routinely given to infants
who do not have seizures.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 1286 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity