Wongs Essentials of Pediatric Nursing 10th Edition | Chapter 27: The Child with Cerebral Dysfunction | Questions & Answers
The nurse has received report on four children. Which b. A preschool child with a head injury and decreasing level of consciousness
child should the nurse assess first? ANS: B
The nurse should assess the child with a head injury and decreasing level of
a. A school-age child in a coma with stable vital signs consciousness first (LOC).
b. A preschool child with a head injury and decreasing Assessment of LOC remains the earliest indicator of improvement or
level of consciousness deterioration in neurologic status.
c. An adolescent admitted after a motor vehicle The next child the nurse should assess is a toddler in a persistent vegetative
accident is oriented to person and state with a low-grade fever.
place The school-age child in a coma with stable vital signs and the adolescent
d. A toddler in a persistent vegetative state with a low- admitted to the hospital who is
grade fever oriented to his surroundings would be of least worry to the nurse.
DIF: Cognitive Level: Apply REF: p. 873
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management
of Care
The nurse is performing a Glasgow Coma Scale on a d. 15
school-age child with a head injury. The child opens ANS: D
eyes spontaneously, obeys commands, and is oriented The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye
to person, time, and place. Which is the score the nurse opening, verbal response, and
should record? motor response. Numeric values of 1 through 5 are assigned to the levels of
response in each category.
a. 8 The sum of these numeric values provides an objective measure of the patient's
b. 11 level of consciousness
c. 13 (LOC). A person with an unaltered LOC would score the highest, 15. The child
d. 15 who opens eyes
spontaneously, obeys commands, and is oriented is scored at a 15.
DIF: Cognitive Level: Understand REF: p. 873
TOP: Integrated Process: Nursing Process: Assessment
The nurse is closely monitoring a child who is b. Neurosurgical emergency
unconscious after a fall and notices that the child ANS: B
suddenly has a fixed and dilated pupil. How should the The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical
nurse interpret these findings? emergency. The nurse should
immediately report this finding. Although a dilated pupil may be associated
a. Eye trauma with eye trauma, this child
b. Neurosurgical emergency has experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils for
c. Severe brainstem damage more than 5 minutes are
d. Indication of brain death 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.
DIF: Cognitive Level: Analyze REF: p. 875
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
, Wongs Essentials of Pediatric Nursing 10th Edition | Chapter 27: The Child with Cerebral Dysfunction | Questions & Answers
The nurse is caring for a child with severe head trauma d. Periodic and irregular breathing
after a car accident. Which is an ANS: D
ominous sign that often precedes death? Periodic or irregular breathing is an ominous sign of brainstem (especially
medullary) dysfunction that
a. Papilledema often precedes complete apnea. Papilledema is edema and inflammation of
b. Delirium optic nerve. It is commonly a
c. Doll's head maneuver sign of increased intracranial pressure Delirium is a state of mental confusion
d. Periodic and irregular breathing and excitement marked by
disorientation for time and place. The doll's head maneuver is a test for
brainstem or oculomotor nerve
dysfunction.
DIF: Cognitive Level: Understand REF: p. 880
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is taking care of a child who is alert but a. Oculovestibular response
showing signs of increased intracranial pressure. Which ANS: A
test is contraindicated in this case? The oculovestibular response (caloric test) involves the instillation of ice water
into the ear of a comatose
a. Oculovestibular response child. The caloric test is painful and is never performed on a child who is awake
b. Doll's head maneuver or one who has a
c. Funduscopic examination for papilledema ruptured tympanic membrane. Doll's head maneuver, funduscopic examination
d. Assessment of pyramidal tract lesions for papilledema, and
assessment of pyramidal tract lesions can be performed on children who are
awake.
DIF: Cognitive Level: Analyze REF: p. 887
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is preparing a school-age child for computed b. "The scan will not hurt."
tomography (CT scan) to assess ANS: B
cerebral function. The nurse should include which For CT scans, the child must be immobilized. It is important to emphasize to the
statement in preparing the child? child that at no time is
the procedure painful. Pain medication is not required; however, sedation is
a. "Pain medication will be given." sometimes necessary.
b. "The scan will not hurt." Someone is able to remain with the child during the procedure.
c. "You will be able to move once the equipment is in DIF: Cognitive Level: Apply REF: p. 876
place." TOP: Integrated Process: Teaching/Learning
d. "Unfortunately, no one can remain in the room with MSC: Area of Client Needs: Health Promotion and Maintenance
you during the test."
Which neurologic diagnostic test gives a visualized c. CT scan
horizontal and vertical cross-section ANS: C
of the brain at any axis? A CT scan provides a visualization of the horizontal and vertical cross-sections
of the brain at any axis. A
a. Nuclear brain scan nuclear brain scan uses a radioisotope that accumulates where the blood-brain
b. Echoencephalography barrier is defective.
c. CT scan Echoencephalography identifies shifts in midline structures of the brain as a
d. Magnetic resonance imaging (MRI) result of intracranial lesions.
MRI permits visualization of morphologic features of target structures and
permits tissue discrimination
that is unavailable with any other techniques.
DIF: Cognitive Level: Understand REF: p. 877
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
The nurse has received report on four children. Which b. A preschool child with a head injury and decreasing level of consciousness
child should the nurse assess first? ANS: B
The nurse should assess the child with a head injury and decreasing level of
a. A school-age child in a coma with stable vital signs consciousness first (LOC).
b. A preschool child with a head injury and decreasing Assessment of LOC remains the earliest indicator of improvement or
level of consciousness deterioration in neurologic status.
c. An adolescent admitted after a motor vehicle The next child the nurse should assess is a toddler in a persistent vegetative
accident is oriented to person and state with a low-grade fever.
place The school-age child in a coma with stable vital signs and the adolescent
d. A toddler in a persistent vegetative state with a low- admitted to the hospital who is
grade fever oriented to his surroundings would be of least worry to the nurse.
DIF: Cognitive Level: Apply REF: p. 873
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management
of Care
The nurse is performing a Glasgow Coma Scale on a d. 15
school-age child with a head injury. The child opens ANS: D
eyes spontaneously, obeys commands, and is oriented The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye
to person, time, and place. Which is the score the nurse opening, verbal response, and
should record? motor response. Numeric values of 1 through 5 are assigned to the levels of
response in each category.
a. 8 The sum of these numeric values provides an objective measure of the patient's
b. 11 level of consciousness
c. 13 (LOC). A person with an unaltered LOC would score the highest, 15. The child
d. 15 who opens eyes
spontaneously, obeys commands, and is oriented is scored at a 15.
DIF: Cognitive Level: Understand REF: p. 873
TOP: Integrated Process: Nursing Process: Assessment
The nurse is closely monitoring a child who is b. Neurosurgical emergency
unconscious after a fall and notices that the child ANS: B
suddenly has a fixed and dilated pupil. How should the The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical
nurse interpret these findings? emergency. The nurse should
immediately report this finding. Although a dilated pupil may be associated
a. Eye trauma with eye trauma, this child
b. Neurosurgical emergency has experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils for
c. Severe brainstem damage more than 5 minutes are
d. Indication of brain death 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.
DIF: Cognitive Level: Analyze REF: p. 875
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
, Wongs Essentials of Pediatric Nursing 10th Edition | Chapter 27: The Child with Cerebral Dysfunction | Questions & Answers
The nurse is caring for a child with severe head trauma d. Periodic and irregular breathing
after a car accident. Which is an ANS: D
ominous sign that often precedes death? Periodic or irregular breathing is an ominous sign of brainstem (especially
medullary) dysfunction that
a. Papilledema often precedes complete apnea. Papilledema is edema and inflammation of
b. Delirium optic nerve. It is commonly a
c. Doll's head maneuver sign of increased intracranial pressure Delirium is a state of mental confusion
d. Periodic and irregular breathing and excitement marked by
disorientation for time and place. The doll's head maneuver is a test for
brainstem or oculomotor nerve
dysfunction.
DIF: Cognitive Level: Understand REF: p. 880
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is taking care of a child who is alert but a. Oculovestibular response
showing signs of increased intracranial pressure. Which ANS: A
test is contraindicated in this case? The oculovestibular response (caloric test) involves the instillation of ice water
into the ear of a comatose
a. Oculovestibular response child. The caloric test is painful and is never performed on a child who is awake
b. Doll's head maneuver or one who has a
c. Funduscopic examination for papilledema ruptured tympanic membrane. Doll's head maneuver, funduscopic examination
d. Assessment of pyramidal tract lesions for papilledema, and
assessment of pyramidal tract lesions can be performed on children who are
awake.
DIF: Cognitive Level: Analyze REF: p. 887
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is preparing a school-age child for computed b. "The scan will not hurt."
tomography (CT scan) to assess ANS: B
cerebral function. The nurse should include which For CT scans, the child must be immobilized. It is important to emphasize to the
statement in preparing the child? child that at no time is
the procedure painful. Pain medication is not required; however, sedation is
a. "Pain medication will be given." sometimes necessary.
b. "The scan will not hurt." Someone is able to remain with the child during the procedure.
c. "You will be able to move once the equipment is in DIF: Cognitive Level: Apply REF: p. 876
place." TOP: Integrated Process: Teaching/Learning
d. "Unfortunately, no one can remain in the room with MSC: Area of Client Needs: Health Promotion and Maintenance
you during the test."
Which neurologic diagnostic test gives a visualized c. CT scan
horizontal and vertical cross-section ANS: C
of the brain at any axis? A CT scan provides a visualization of the horizontal and vertical cross-sections
of the brain at any axis. A
a. Nuclear brain scan nuclear brain scan uses a radioisotope that accumulates where the blood-brain
b. Echoencephalography barrier is defective.
c. CT scan Echoencephalography identifies shifts in midline structures of the brain as a
d. Magnetic resonance imaging (MRI) result of intracranial lesions.
MRI permits visualization of morphologic features of target structures and
permits tissue discrimination
that is unavailable with any other techniques.
DIF: Cognitive Level: Understand REF: p. 877
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
