Exam 4: Cerebral Dysfunction NCLEX UPDATED ACTUAL
Questions and CORRECT Answers
As the nurse assigned to a child diagnosed with bacterial c
meningitis, you know that
a. the child will not need to be placed in isolation
because antibiotics have been started
b. enteric precautions will remain in place for up to 48
hours
c. respiratory isolation will remain in place for 24 hours
d. due to headache, the child will want the head of the
bed elevated with two pillows
You are caring for a child with a hydrocephalus who is d
postoperative from a shunt revision. Which assessment
finding is your priority for increased intracranial pressure?
a. nausea and refusal to eat postoperatively
b. complaint of a headache
c. irritability and wanting to sleep
d. decrease in heart rate over the last hour
,You are working with a family who brought their child into a
the pediatric clinic. The mother describes what may be a b
type of seizure. What subjective data will help you d
determine the type? Select all that apply
a. the presence or absence of an aura
b. if the child appeared disoriented after the seizure
c. presence of vomiting after the seizure
d. the duration of the seizure
e. if the seizure was related to certain foods or occurred
after a certain activity
What is a clinical manifestation of increased intracranial a
pressure (ICP) in infants?
a. Irritability
b. Photophobia
c. Vomiting and diarrhea
d. Pulsating anterior fontanel
The nurse is caring for a child with multiple injuries who is c
comatose. What information is accurate related to pain in
this child?
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.
The nurse is caring for a 2-year-old girl who is b
unconscious but stable after a car accident. Her parents
are staying at the bedside most of the time. What is an
appropriate nursing intervention?
a. Suggest that the parents go home until she is alert
enough to know they are present.
b. Encourage the parents to hold, talk, and sing to her as
they usually would.
c. Use ointment on her lips but do not attempt to cleanse
her teeth until swallowing returns.
d. Position her with proper body alignment and the head
of the bed lowered 15 degrees.
What findings would indicate to the nurse further d
assessment and treatment is needed for a child with mild
head injury?
a. Vomiting
b. Sleepiness
c. Headache, even if slight
d. Confusion or abnormal behavior
, The nurse is admitting a young child to the hospital c
because bacterial meningitis is suspected. What is a
priority of nursing care?
a. Initiate isolation precautions as soon as diagnosis is
confirmed.
b. Provide environmental stimulation to keep the child
awake.
c. Administer antibiotic therapy as soon as it is available.
d. Administer sedatives and analgesics on a preventive
schedule to manage pain.
A child is brought to the emergency department after c
experiencing a seizure at school. He has no history of
seizures. The father tells the nurse that he cannot believe
the child has epilepsy. What is the best response by the
nurse?
a. "Epilepsy is easily treated."
b. "Very few children have actual epilepsy."
c. "The seizure may or may not mean that your child has
epilepsy."
d. "Your child has had only one convulsion; it probably
won't happen again."
What finding is a clinical manifestation of increased c
intracranial pressure (ICP) in children?
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia, blurred vision
d. Increased blood pressure
The nurse is preparing a school-age child for computed a
tomography (CT) scan to assess cerebral function. The
nurse should include what statement in preparing the
child?
a. The scan will not hurt.
b. Pain medication will be given.
c. You will be able to move once the equipment is in
place.
d. Unfortunately no one can remain in the room with you
during the test.
What is a nursing intervention to reduce the risk of d
increasing intracranial pressure (ICP) in an unconscious
child?
a. Suction the child frequently.
b. Turn the childs head side to side every hour.
c. Provide environmental stimulation.
d. Avoid activities that cause pain or crying.
Questions and CORRECT Answers
As the nurse assigned to a child diagnosed with bacterial c
meningitis, you know that
a. the child will not need to be placed in isolation
because antibiotics have been started
b. enteric precautions will remain in place for up to 48
hours
c. respiratory isolation will remain in place for 24 hours
d. due to headache, the child will want the head of the
bed elevated with two pillows
You are caring for a child with a hydrocephalus who is d
postoperative from a shunt revision. Which assessment
finding is your priority for increased intracranial pressure?
a. nausea and refusal to eat postoperatively
b. complaint of a headache
c. irritability and wanting to sleep
d. decrease in heart rate over the last hour
,You are working with a family who brought their child into a
the pediatric clinic. The mother describes what may be a b
type of seizure. What subjective data will help you d
determine the type? Select all that apply
a. the presence or absence of an aura
b. if the child appeared disoriented after the seizure
c. presence of vomiting after the seizure
d. the duration of the seizure
e. if the seizure was related to certain foods or occurred
after a certain activity
What is a clinical manifestation of increased intracranial a
pressure (ICP) in infants?
a. Irritability
b. Photophobia
c. Vomiting and diarrhea
d. Pulsating anterior fontanel
The nurse is caring for a child with multiple injuries who is c
comatose. What information is accurate related to pain in
this child?
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.
The nurse is caring for a 2-year-old girl who is b
unconscious but stable after a car accident. Her parents
are staying at the bedside most of the time. What is an
appropriate nursing intervention?
a. Suggest that the parents go home until she is alert
enough to know they are present.
b. Encourage the parents to hold, talk, and sing to her as
they usually would.
c. Use ointment on her lips but do not attempt to cleanse
her teeth until swallowing returns.
d. Position her with proper body alignment and the head
of the bed lowered 15 degrees.
What findings would indicate to the nurse further d
assessment and treatment is needed for a child with mild
head injury?
a. Vomiting
b. Sleepiness
c. Headache, even if slight
d. Confusion or abnormal behavior
, The nurse is admitting a young child to the hospital c
because bacterial meningitis is suspected. What is a
priority of nursing care?
a. Initiate isolation precautions as soon as diagnosis is
confirmed.
b. Provide environmental stimulation to keep the child
awake.
c. Administer antibiotic therapy as soon as it is available.
d. Administer sedatives and analgesics on a preventive
schedule to manage pain.
A child is brought to the emergency department after c
experiencing a seizure at school. He has no history of
seizures. The father tells the nurse that he cannot believe
the child has epilepsy. What is the best response by the
nurse?
a. "Epilepsy is easily treated."
b. "Very few children have actual epilepsy."
c. "The seizure may or may not mean that your child has
epilepsy."
d. "Your child has had only one convulsion; it probably
won't happen again."
What finding is a clinical manifestation of increased c
intracranial pressure (ICP) in children?
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia, blurred vision
d. Increased blood pressure
The nurse is preparing a school-age child for computed a
tomography (CT) scan to assess cerebral function. The
nurse should include what statement in preparing the
child?
a. The scan will not hurt.
b. Pain medication will be given.
c. You will be able to move once the equipment is in
place.
d. Unfortunately no one can remain in the room with you
during the test.
What is a nursing intervention to reduce the risk of d
increasing intracranial pressure (ICP) in an unconscious
child?
a. Suction the child frequently.
b. Turn the childs head side to side every hour.
c. Provide environmental stimulation.
d. Avoid activities that cause pain or crying.
