NUR 254 Exam 4 Study Guide | Galen College of
Nursing ___-Questions 1–200 | Questions and
Answers | Exam Review | 100% Pass Guaranteed |
Graded A+
1. A nurse is assessing a child who has increased intracranial pressure
(ICP) and is in stable condition. Which of the following interventions
should the nurse implement to decrease ICP in the child?
A. Limit the number of visitors inside the child's room
B. Keep the child positioned on the left side
C. Administer opioids for pain control
D. Administer hypertonic intravenous (IV) fluids
Correct Answer: A
Explanation: Minimizing environmental stimuli such as light, noise, and
frequent visitors can reduce agitation and prevent increases in ICP.
Positioning on the side does not specifically decrease ICP, and hypertonic
fluids should be administered only with a specific order .
2. The nurse is screening infants for early warning signs of cerebral
palsy. Which of the following should the nurse recognize as one of the
early warning signs of cerebral palsy?
A. Evidence of head lag at age 1 month
B. Failure to sit up without support by age 6 months
C. Poor head control
D. Smiling by age 3 months
Correct Answer: C
Explanation: Infants with cerebral palsy may exhibit poor head control
beyond the expected developmental timeframe. By 3–4 months, infants
should have some head control; persistence of head lag or poor control is a
significant warning sign .
, 3. The nurse is assessing a 6-year-old for manifestations of autism
spectrum disorder. Which of the following manifestations should the
nurse expect to observe in this child?
A. Interest in various activities
B. Continuous eye contact
C. Monotone speech
D. Good social interaction
Correct Answer: C
Explanation: Children with autism often display speech abnormalities,
including monotone or repetitive speech, as well as impairments in social
interaction and communication .
4. The nurse is developing a plan of care for a child diagnosed with
attention-deficit hyperactivity disorder (ADHD). Which of the
following information should the nurse include in the plan of care?
A. Antianxiety medications and homeschooling
B. Psychostimulant medications and behavior modification
C. Anticonvulsant medications and cognitive therapy
D. Antidepressant medications and family therapy
Correct Answer: B
Explanation: First-line treatment for ADHD includes psychostimulant
medications such as methylphenidate, in conjunction with behavioral
interventions. Other medication classes are not indicated as first-line .
5. The nurse is caring for a child who is suspected of having bacterial
meningitis. The results of the lumbar puncture are still pending.
Which of the following actions by the nurse is the priority?
A. Decrease noxious olfactory stimuli
B. Maintain a lighted environment
,C. Assessing neurological status every 2–4 hours
D. Administer morphine sulfate
Correct Answer: C
Explanation: Frequent neurological assessment allows early detection of
deterioration such as increased ICP or seizures in meningitis. This is the first
priority pending diagnostic confirmation .
6. The nurse working in the emergency department is caring for a 2-
month-old child who presents with intraocular bleeding,
bradycardia, and bulging fontanels, but no trauma to the head,
face, or neck. Health history and physical examination is
incongruent, and abuse is suspected. Which of the following actions
should the nurse perform?
A. Apply 2 L of oxygen via face mask
B. Notify child protective services (CPS)
C. Ask the parents if they have a history of abuse
D. Explain the child will be able to go home shortly
Correct Answer: B
Explanation: Mandatory reporting of suspected child abuse is required. The
presence of intraocular bleeding and bulging fontanels without a plausible
Explanation is highly suspicious for nonaccidental trauma (shaken baby
syndrome) .
7. The nurse is caring for a child who is hospitalized for 24-hour
observation following a head injury. Which of the following actions
by the nurse is the priority?
A. Keep the head elevated slightly
B. Checking pupil reaction every 4 hours
C. Assess for neck stiffness
D. Allowing the child to have 2 visitors at a time in the room
, Correct Answer: B
Explanation: Regular monitoring of pupillary response is a critical indicator
of neurological status, allowing early detection of deterioration that could
indicate increased ICP or cerebral herniation .
8. The nurse is assessing a child in a coma and notes that the child has
decorticate posturing. Which of the following findings should the
nurse expect the child to demonstrate?
A. Rigid extension with head arched back, arms extended by the sides, and
legs extended
B. Abnormal flexion of upper and lower extremities
C. Rigid flexion with elbows, wrists and fingers flexed, and legs extended
and rotated inward
D. Abnormal extensions of the upper extremities and flexion of lower
extremities
Correct Answer: C
Explanation: Decorticate posturing involves rigid flexion of the upper
extremities with internal rotation and extension of the lower limbs,
indicating damage to the cerebral hemispheres .
9. The nurse is providing discharge instructions to the parents of a child
who had surgical resection of a neuroblastoma 4 days ago. Which of
the following statements by the parents indicates teaching has been
effective?
A. "I will need to begin slowly reintroducing my child into social
interaction"
B. "We will provide pain relief using pain medication and rest"
C. "A protective helmet will need to be worn until the incision is healed"
D. "An increase in temperature is expected after surgery"
Correct Answer: A
Explanation: After major surgery, infection risk is increased and energy
may be low, so gradual social reintroduction is recommended. Helmets are
Nursing ___-Questions 1–200 | Questions and
Answers | Exam Review | 100% Pass Guaranteed |
Graded A+
1. A nurse is assessing a child who has increased intracranial pressure
(ICP) and is in stable condition. Which of the following interventions
should the nurse implement to decrease ICP in the child?
A. Limit the number of visitors inside the child's room
B. Keep the child positioned on the left side
C. Administer opioids for pain control
D. Administer hypertonic intravenous (IV) fluids
Correct Answer: A
Explanation: Minimizing environmental stimuli such as light, noise, and
frequent visitors can reduce agitation and prevent increases in ICP.
Positioning on the side does not specifically decrease ICP, and hypertonic
fluids should be administered only with a specific order .
2. The nurse is screening infants for early warning signs of cerebral
palsy. Which of the following should the nurse recognize as one of the
early warning signs of cerebral palsy?
A. Evidence of head lag at age 1 month
B. Failure to sit up without support by age 6 months
C. Poor head control
D. Smiling by age 3 months
Correct Answer: C
Explanation: Infants with cerebral palsy may exhibit poor head control
beyond the expected developmental timeframe. By 3–4 months, infants
should have some head control; persistence of head lag or poor control is a
significant warning sign .
, 3. The nurse is assessing a 6-year-old for manifestations of autism
spectrum disorder. Which of the following manifestations should the
nurse expect to observe in this child?
A. Interest in various activities
B. Continuous eye contact
C. Monotone speech
D. Good social interaction
Correct Answer: C
Explanation: Children with autism often display speech abnormalities,
including monotone or repetitive speech, as well as impairments in social
interaction and communication .
4. The nurse is developing a plan of care for a child diagnosed with
attention-deficit hyperactivity disorder (ADHD). Which of the
following information should the nurse include in the plan of care?
A. Antianxiety medications and homeschooling
B. Psychostimulant medications and behavior modification
C. Anticonvulsant medications and cognitive therapy
D. Antidepressant medications and family therapy
Correct Answer: B
Explanation: First-line treatment for ADHD includes psychostimulant
medications such as methylphenidate, in conjunction with behavioral
interventions. Other medication classes are not indicated as first-line .
5. The nurse is caring for a child who is suspected of having bacterial
meningitis. The results of the lumbar puncture are still pending.
Which of the following actions by the nurse is the priority?
A. Decrease noxious olfactory stimuli
B. Maintain a lighted environment
,C. Assessing neurological status every 2–4 hours
D. Administer morphine sulfate
Correct Answer: C
Explanation: Frequent neurological assessment allows early detection of
deterioration such as increased ICP or seizures in meningitis. This is the first
priority pending diagnostic confirmation .
6. The nurse working in the emergency department is caring for a 2-
month-old child who presents with intraocular bleeding,
bradycardia, and bulging fontanels, but no trauma to the head,
face, or neck. Health history and physical examination is
incongruent, and abuse is suspected. Which of the following actions
should the nurse perform?
A. Apply 2 L of oxygen via face mask
B. Notify child protective services (CPS)
C. Ask the parents if they have a history of abuse
D. Explain the child will be able to go home shortly
Correct Answer: B
Explanation: Mandatory reporting of suspected child abuse is required. The
presence of intraocular bleeding and bulging fontanels without a plausible
Explanation is highly suspicious for nonaccidental trauma (shaken baby
syndrome) .
7. The nurse is caring for a child who is hospitalized for 24-hour
observation following a head injury. Which of the following actions
by the nurse is the priority?
A. Keep the head elevated slightly
B. Checking pupil reaction every 4 hours
C. Assess for neck stiffness
D. Allowing the child to have 2 visitors at a time in the room
, Correct Answer: B
Explanation: Regular monitoring of pupillary response is a critical indicator
of neurological status, allowing early detection of deterioration that could
indicate increased ICP or cerebral herniation .
8. The nurse is assessing a child in a coma and notes that the child has
decorticate posturing. Which of the following findings should the
nurse expect the child to demonstrate?
A. Rigid extension with head arched back, arms extended by the sides, and
legs extended
B. Abnormal flexion of upper and lower extremities
C. Rigid flexion with elbows, wrists and fingers flexed, and legs extended
and rotated inward
D. Abnormal extensions of the upper extremities and flexion of lower
extremities
Correct Answer: C
Explanation: Decorticate posturing involves rigid flexion of the upper
extremities with internal rotation and extension of the lower limbs,
indicating damage to the cerebral hemispheres .
9. The nurse is providing discharge instructions to the parents of a child
who had surgical resection of a neuroblastoma 4 days ago. Which of
the following statements by the parents indicates teaching has been
effective?
A. "I will need to begin slowly reintroducing my child into social
interaction"
B. "We will provide pain relief using pain medication and rest"
C. "A protective helmet will need to be worn until the incision is healed"
D. "An increase in temperature is expected after surgery"
Correct Answer: A
Explanation: After major surgery, infection risk is increased and energy
may be low, so gradual social reintroduction is recommended. Helmets are
