T3P Ch. 46

T3P CH. 46 EXAM 2024 WITH 100% CORRECT ANSWERS Which term is used to describe a childs level of consciousness when the child can be aroused with stimulation? a. Stupor c. Obtundation b. Confusion d. Disorientation - correct answer ANS: C Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and plac Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma c. Obtundation b. Stupor d. Persistent vegetative state - correct answer ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex. The Glasgow Coma Scale consists of an assessment of: a. Pupil reactivity and motor response. b. Eye opening and verbal and motor responses. c. Level of consciousness and verbal response. d. Intracranial pressure (ICP) and level of consciousness. - correct answer ANS: B Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 774 The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not part of the Glasgow Coma Scale. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. Eye trauma. c. Severe brainstem damage. b. Neurosurgical emergency. d. Indication of brain death. - correct answer ANS: B The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are 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. Which test is never performed on a child who is awake? a. Oculovestibular response b. Dolls head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions - correct answer ANS: A The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Dolls head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which statement should the nurse include? a. Pain medication will be given. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 775 b. The scan will not hurt. 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 - correct answer ANS: B For CT scans, the child will not be allowed to move and must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan c. Computed tomography (CT) scan b. Echoencephalography d. Magnetic resonance imaging (MRI) - correct answer ANS: C A CT scan provides visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and tissue discrimination that is unavailable with any other techniques. The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an adequate airway. b. Perform neurologic assessment. c. Monitor intercranial pressure. d. Determine whether a neck injury is present - correct answer ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 776 after airway, breathing, and circulation are maintained. Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol c. Atropine sulfate b. Epinephrine hydrochloride d. Sodium bicarbonate - correct answer ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.