ESSENTIALS OF PEDIATRIC NURSING 4TH EDITION KYLE CARMAN TEST BANK CHAPTER 16 NURSING CARE OF THE CHILD WITH AN ALTERATION IN INTRACRANIAL REGULATION/ NEUROLOGIC DISORDER

ESSENTIALS OF PEDIATRIC NURSING 4TH EDITION KYLE CARMAN TEST BANK CHAPTER 16 NURSING CARE OF THE CHILD WITH AN ALTERATION IN INTRACRANIAL REGULATION/ NEUROLOGIC DISORDER MULTIPLE CHOICE 1. The nurse has documented that a childs level of consciousness is obtunded. Which describes this level of consciousness? a. Slow response to vigorous and repeated stimulation b. Impaired decision making c. Arousable with stimulation d. Confusion regarding time and place ANS: C Obtunded describes a level of consciousness in which the child is arousable 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 place. PTS: 1 DIF: Cognitive Level: Understand REF: 929 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. The nurse has received report on four children. Which child should the nurse assess first? a. A school-age child in a coma with stable vital signs Estudy b. A preschool child with a head injury and decreasing level of consciousness c. An adolescent admitted after a motor vehicle accident is oriented to person and place d. A toddler in a persistent vegetative state with a low-grade fever ANS: B The nurse should assess the child with a head injury and decreasing level of consciousness first (LOC). Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his surroundings would be of least worry to the nurse. PTS: 1 DIF: Cognitive Level: Apply REF: 928 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 b. 11 c. 13 d. 15 ANS: D The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patients level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15. PTS: 1 DIF: Cognitive Level: Understand REF: 929 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. 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. b. neurosurgical emergency. c. severe brainstem damage. d. indication of brain death. 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 bilateral fixed 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. PTS: 1 DIF: Cognitive Level: Analyze REF: 942 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 5. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema b. Delirium Estudy c. Dolls head maneuver d. Periodic and irregular breathing ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of optic nerve. It is commonly a sign of increased ICP. Delirium is a state of mental confusion and excitement marked by disorientation for time and place. The dolls head maneuver is a test for brainstem or oculomotor nerve dysfunction. PTS: 1 DIF: Cognitive Level: Understand REF: 930 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. The nurse is taking care of a child who is alert but showing signs of increased intracranial pressure. Which test is contraindicated in this case? a. Oculovestibular response b. Dolls head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions 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 an awake child or one who has a ruptured tympanic membrane. Dolls head maneuver, funduscopic examination for papilledema, and assessment of pyramidal tract lesions can be performed on awake children. PTS: 1 DIF: Cognitive Level: Analyze REF: 931 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 7. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. The nurse should include which statement in preparing the child? a. Pain medication will be given. 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. ANS: B For CT scans, the child 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. PTS: 1 DIF: Cognitive Level: Apply REF: 933 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 8. Which neurologic diagnostic test gives a visualized horizontal and vertical crosssection of the brain at any axis? a. Nuclear brain scan b. Echoencephalography c. CT scan d. Magnetic resonance imaging (MRI) ANS: C A CT scan provides a 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 Estudy 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 permits tissue discrimination that is unavailable with any other techniques. PTS: 1 DIF: Cognitive Level: Understand REF: 933 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 9. Which is the priority nursing intervention for an unconscious child after a fall? a. Establish adequate airway. b. Perform neurologic assessment. c. Monitor intracranial pressure. d. Determine whether a neck injury is present. ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority. A neurologic assessment and determination of whether a neck injury is present will be performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained. PTS: 1 DIF: Cognitive Level: Apply REF: 935 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 10. Which drug should the nurse expect to administer to a preschool child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol (Osmitrol) b. Epinephrine hydrochloride (Adrenalin) c. Atropine sulfate (Atropine) d. Sodium bicarbonate (Sodium bicarbonate) ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium bicarbonate are not used to decrease ICP. PTS: 1 DIF: Cognitive Level: Apply REF: 936 TOP: Integrated Process: Nursing Process: Implementation MSC: Area