PEDS EXAM 3 EXAM VERIFIED
SOLUTIONS, SCORED A+
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 .- .CORRECT .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.
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 .- .CORRECT .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.
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 .- .CORRECT .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.
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 .- .CORRECT .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.
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. .- .CORRECT .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. .
Pain .assessments .should .be .ongoing, .but .this .is .not .the .priority .at .this .time.
.Lowering .the .body .temperature .is .the .priority.
Aspirin .should .never .be .administered .to .a .child, .because .of .the .risk .of .Reye
.syndrome. .Antipyretics, .such .as .acetaminophen .or .ibuprofen, .usually .are .not
.effective .with .temperatures .as .high .as .105º .F .(40. .5ºC).
,The .nurse .is .caring .for .a .comatose .child .with .multiple .injuries. .The .nurse
.should .recognize .that .pain
A. .cannot .occur .if .the .child .is .comatose.
B. .may .occur .if .the .child .regains .consciousness.
C. .requires .astute .nursing .assessment .and .management.
D. .is .best .assessed .by .family .members .who .are .familiar .with .the .child. .-
.CORRECT .ANSWER-C. .requires .astute .nursing .assessment .and .management.
Because .the .child .cannot .communicate .pain .through .one .of .the .standard .pain
.rating .scales, .the .nurse .must .focus .on .physiologic .and .behavioral
.manifestations .to .accurately .assess .pain.
Pain .can .occur .in .the .comatose .child.
The .child .can .be .in .pain .while .comatose.
The .family .can .provide .insight .into .the .child's .different .responses, .but .the
.nurse .should .be .monitoring .physiologic .and .behavioral .manifestations.
What .nursing .intervention .is .used .to .prevent .increased .intracranial .pressure
.(ICP) .in .an .unconscious .child?
A. .Suction .the .child .frequently.
B. .Provide .environmental .stimulation.
C. .Turn .the .head .side .to .side .every .hour.
D. .Avoid .activities .that .cause .pain .or .crying. .- .CORRECT .ANSWER-Avoid
.activities .that .cause .pain .or .crying.
Nursing .interventions .should .focus .on .assessment .and .interventions .to
.minimize .pain. .These .activities .can .cause .the .ICP .to .increase.
Suctioning .is .a .distressing .procedure. .In .addition, .the .resultant .decrease .in
.carbon .dioxide .can .increase .ICP.
Environmental .stimulation .should .be .minimized .because .it .can .increase .ICP.
The .child's .head .should .not .be .turned .side .to .side. .If .the .jugular .vein .is
.compressed, .the .ICP .can .rise.
The .nurse .is .caring .for .a .2-year-old .child .who .is .unconscious .but .stable .after .a
.car .accident. .The .child's .parents .are .staying .at .the .bedside .most .of .the .time.
.What .is .an .appropriate .nursing .intervention?
A. .Suggest .that .the .parents .go .home .until .the .child .is .alert .enough .to .know
.they .are .present.
B. .Use .ointment .on .the .lips .but .do .not .attempt .to .cleanse .the .teeth .until
.swallowing .returns.
C. .Encourage .the .parents .to .hold, .talk .to, .and .sing .to .the .child .as .they .usually
.would.
D. .Position .the .child .with .proper .body .alignment .and .the .head .of .the .bed
.lowered .15 .degrees. .- .CORRECT .ANSWER-C. .Encourage .the .parents .to .hold,
.talk .to, .and .sing .to .the .child .as .they .usually .would.
The .parents .should .be .encouraged .to .interact .with .the .child. .Senses .of .hearing
.and .tactile .perception .may .be .intact, .and .stimulation .is .important .in .the .child's
.recovery.
Suggesting .that .the .parents .go .home .until .the .child .is .awake .is .not
.recommended. .The .child .may .be .able .to .hear .that .they .are .present, .and .this
.stimulation .may .assist .in .recovery.
, Oral .care .is .essential .in .the .unconscious .child. .Mouth .care .should .be .done .at
.least .twice .daily .to .prevent .oral .infections.
The .head .of .the .bed .should .be .elevated, .not .lowered, .in .a .child .with .neurologic
.involvement.
The .nurse .is .instructing .a .group .of .parents .about .head .injuries .in .children. .The
.nurse .should .explain .that .infants .are .particularly .vulnerable .to .acceleration-
deceleration .head .injuries .because .the
A. .anterior .fontanel .is .not .yet .closed.
B. .nervous .tissue .is .not .well .developed.
C. .scalp .of .head .has .extensive .vascularity.
D. .musculoskeletal .support .of .head .is .insufficient. .- .CORRECT .ANSWER-D.
.musculoskeletal .support .of .head .is .insufficient.
The .relatively .large .head .size .coupled .with .insufficient .musculoskeletal .support
.increases .the .risk .to .infants .of .acceleration-deceleration .head .injuries.
The .lack .of .closure .of .the .anterior .fontanel .is .not .relevant .to .the .development
.of .acceleration-deceleration .head .injuries .in .infants.
The .lack .of .well-developed .nervous .tissue .is .not .relevant .to .the .development .of
.acceleration-deceleration .head .injuries .in .infants.
The .vascularity .of .the .scalp .is .not .relevant .to .the .development .of .acceleration-
deceleration .injuries .in .infants.
The .nurse .is .caring .for .a .toddler .who .has .had .surgery .for .a .brain .tumor.
.During .an .assessment, .the .nurse .notes .that .the .child .is .becoming .irritable .and
.the .pupils .are .unequal .and .sluggish. .The .most .appropriate .nursing .action .is .to
A. .notify .the .practitioner .immediately.
B. .assess .for .level .of .consciousness .(LOC).
C. .observe .closely .for .signs .of .increased .intracranial .pressure .(ICP).
D. .administer .pain .medication .and .assess .for .response. .- .CORRECT .ANSWER-
A. .notify .the .practitioner .immediately.
The .worsening .of .symptoms .may .indicate .that .the .ICP .is .increasing. .The
.practitioner .should .be .notified .immediately .because .this .is .considered .a
.medical .emergency.
Assessing .for .the .LOC .should .be .done .as .part .of .the .assessment. .
The .nurse .is .noting .signs .of .potentially .increased .ICP .as .described; .therefore,
.this .has .already .been .completed.
Pain .medication .should .not .be .given, .because .it .can .often .mask .the .signs .of
.increasing .ICP. .The .priority .nursing .intervention .is .to .consult .with .the
.practitioner .immediately.
The .postoperative .care .of .a .preschool .child .who .has .had .a .brain .tumor
.removed .should .include
A. .recording .of .colorless .drainage .as .normal .on .the .nurse's .notes.
B. .close .supervision .of .the .child .while .he .or .she .is .regaining .consciousness.
C. .positioning .the .child .on .the .right .side .in .the .Trendelenburg .position.
D. .no .administration .of .analgesics. .- .CORRECT .ANSWER-B. .close .supervision
.of .the .child .while .he .or .she .is .regaining .consciousness
SOLUTIONS, SCORED A+
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 .- .CORRECT .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.
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 .- .CORRECT .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.
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 .- .CORRECT .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.
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 .- .CORRECT .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.
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. .- .CORRECT .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. .
Pain .assessments .should .be .ongoing, .but .this .is .not .the .priority .at .this .time.
.Lowering .the .body .temperature .is .the .priority.
Aspirin .should .never .be .administered .to .a .child, .because .of .the .risk .of .Reye
.syndrome. .Antipyretics, .such .as .acetaminophen .or .ibuprofen, .usually .are .not
.effective .with .temperatures .as .high .as .105º .F .(40. .5ºC).
,The .nurse .is .caring .for .a .comatose .child .with .multiple .injuries. .The .nurse
.should .recognize .that .pain
A. .cannot .occur .if .the .child .is .comatose.
B. .may .occur .if .the .child .regains .consciousness.
C. .requires .astute .nursing .assessment .and .management.
D. .is .best .assessed .by .family .members .who .are .familiar .with .the .child. .-
.CORRECT .ANSWER-C. .requires .astute .nursing .assessment .and .management.
Because .the .child .cannot .communicate .pain .through .one .of .the .standard .pain
.rating .scales, .the .nurse .must .focus .on .physiologic .and .behavioral
.manifestations .to .accurately .assess .pain.
Pain .can .occur .in .the .comatose .child.
The .child .can .be .in .pain .while .comatose.
The .family .can .provide .insight .into .the .child's .different .responses, .but .the
.nurse .should .be .monitoring .physiologic .and .behavioral .manifestations.
What .nursing .intervention .is .used .to .prevent .increased .intracranial .pressure
.(ICP) .in .an .unconscious .child?
A. .Suction .the .child .frequently.
B. .Provide .environmental .stimulation.
C. .Turn .the .head .side .to .side .every .hour.
D. .Avoid .activities .that .cause .pain .or .crying. .- .CORRECT .ANSWER-Avoid
.activities .that .cause .pain .or .crying.
Nursing .interventions .should .focus .on .assessment .and .interventions .to
.minimize .pain. .These .activities .can .cause .the .ICP .to .increase.
Suctioning .is .a .distressing .procedure. .In .addition, .the .resultant .decrease .in
.carbon .dioxide .can .increase .ICP.
Environmental .stimulation .should .be .minimized .because .it .can .increase .ICP.
The .child's .head .should .not .be .turned .side .to .side. .If .the .jugular .vein .is
.compressed, .the .ICP .can .rise.
The .nurse .is .caring .for .a .2-year-old .child .who .is .unconscious .but .stable .after .a
.car .accident. .The .child's .parents .are .staying .at .the .bedside .most .of .the .time.
.What .is .an .appropriate .nursing .intervention?
A. .Suggest .that .the .parents .go .home .until .the .child .is .alert .enough .to .know
.they .are .present.
B. .Use .ointment .on .the .lips .but .do .not .attempt .to .cleanse .the .teeth .until
.swallowing .returns.
C. .Encourage .the .parents .to .hold, .talk .to, .and .sing .to .the .child .as .they .usually
.would.
D. .Position .the .child .with .proper .body .alignment .and .the .head .of .the .bed
.lowered .15 .degrees. .- .CORRECT .ANSWER-C. .Encourage .the .parents .to .hold,
.talk .to, .and .sing .to .the .child .as .they .usually .would.
The .parents .should .be .encouraged .to .interact .with .the .child. .Senses .of .hearing
.and .tactile .perception .may .be .intact, .and .stimulation .is .important .in .the .child's
.recovery.
Suggesting .that .the .parents .go .home .until .the .child .is .awake .is .not
.recommended. .The .child .may .be .able .to .hear .that .they .are .present, .and .this
.stimulation .may .assist .in .recovery.
, Oral .care .is .essential .in .the .unconscious .child. .Mouth .care .should .be .done .at
.least .twice .daily .to .prevent .oral .infections.
The .head .of .the .bed .should .be .elevated, .not .lowered, .in .a .child .with .neurologic
.involvement.
The .nurse .is .instructing .a .group .of .parents .about .head .injuries .in .children. .The
.nurse .should .explain .that .infants .are .particularly .vulnerable .to .acceleration-
deceleration .head .injuries .because .the
A. .anterior .fontanel .is .not .yet .closed.
B. .nervous .tissue .is .not .well .developed.
C. .scalp .of .head .has .extensive .vascularity.
D. .musculoskeletal .support .of .head .is .insufficient. .- .CORRECT .ANSWER-D.
.musculoskeletal .support .of .head .is .insufficient.
The .relatively .large .head .size .coupled .with .insufficient .musculoskeletal .support
.increases .the .risk .to .infants .of .acceleration-deceleration .head .injuries.
The .lack .of .closure .of .the .anterior .fontanel .is .not .relevant .to .the .development
.of .acceleration-deceleration .head .injuries .in .infants.
The .lack .of .well-developed .nervous .tissue .is .not .relevant .to .the .development .of
.acceleration-deceleration .head .injuries .in .infants.
The .vascularity .of .the .scalp .is .not .relevant .to .the .development .of .acceleration-
deceleration .injuries .in .infants.
The .nurse .is .caring .for .a .toddler .who .has .had .surgery .for .a .brain .tumor.
.During .an .assessment, .the .nurse .notes .that .the .child .is .becoming .irritable .and
.the .pupils .are .unequal .and .sluggish. .The .most .appropriate .nursing .action .is .to
A. .notify .the .practitioner .immediately.
B. .assess .for .level .of .consciousness .(LOC).
C. .observe .closely .for .signs .of .increased .intracranial .pressure .(ICP).
D. .administer .pain .medication .and .assess .for .response. .- .CORRECT .ANSWER-
A. .notify .the .practitioner .immediately.
The .worsening .of .symptoms .may .indicate .that .the .ICP .is .increasing. .The
.practitioner .should .be .notified .immediately .because .this .is .considered .a
.medical .emergency.
Assessing .for .the .LOC .should .be .done .as .part .of .the .assessment. .
The .nurse .is .noting .signs .of .potentially .increased .ICP .as .described; .therefore,
.this .has .already .been .completed.
Pain .medication .should .not .be .given, .because .it .can .often .mask .the .signs .of
.increasing .ICP. .The .priority .nursing .intervention .is .to .consult .with .the
.practitioner .immediately.
The .postoperative .care .of .a .preschool .child .who .has .had .a .brain .tumor
.removed .should .include
A. .recording .of .colorless .drainage .as .normal .on .the .nurse's .notes.
B. .close .supervision .of .the .child .while .he .or .she .is .regaining .consciousness.
C. .positioning .the .child .on .the .right .side .in .the .Trendelenburg .position.
D. .no .administration .of .analgesics. .- .CORRECT .ANSWER-B. .close .supervision
.of .the .child .while .he .or .she .is .regaining .consciousness
