ACCURATE QUESTIONS AND
ANSWERS (VERIFIED ANSWERS) |
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1. 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 - ANSWER ✓ D. Subtle and barely
discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip
smacking, tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to
maintain a generalized seizure.
The newborn's central nervous system is not sufficiently developed to
maintain a tonic-clonic (generalized) seizure.
, The newborn's central nervous system is not sufficiently developed to
maintain a well-organized seizure.
2. 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 - ANSWER ✓ A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP
in infants. The characteristic cry occurs secondary to the pressure being placed
on the meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased
ICP would be seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present
with diarrhea, it is more indicative of a gastrointestinal disturbance.
3. 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 - ANSWER ✓ A.
Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils
should be assessed for no reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine
injury.
Assessing for an oculovestibular response is a painful test that should not be
done for a child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of
unconsciousness.
4. 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 - ANSWER ✓ A. neurologic health
, The Moro, tonic neck, and withdrawal reflexes are usually present in infants
under 3 to 4 months of age. Therefore, the presence of these reflexes indicates
neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not
indicate severe brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex
and is not related to the presence of the Moro, tonic neck, or withdrawal
reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain
and is not related to the presence of the Moro, tonic neck, or withdrawal
reflexes.
5. The temperature of an unconscious adolescent is 105º F (40.5º 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. - ANSWER ✓ C. apply a hypothermia blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is
extremely important to institute temperature-lowering interventions such as
hypothermia blankets and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the
priority.