Chapter 23: The Child with a Sensory or
Neurological Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds.
What would the nurse expect to assess after a generalized tonic-clonic seizure?
a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiety
ANS: B
Following a generalized tonic-clonic seizure, the child may have some confusion and may
sleep for a time (postictal lethargy) and then return to full consciousness.
DIF: Cognitive Level: Comprehension REF: p. 555 | Table 23.2
OBJ: 13 | 15 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What would the nurse include when creating a teaching plan that includes the long-term
administration of phenytoin (Dilantin)?
a. The medication should be given on an empty stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularly to prevent hyperplasia.
d. Blood pressure should be closely monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin
frequently causes drowsiness and should be given with meals at the same time each day.
DIF: Cognitive Level: Comprehension REF: p. 557 | Table 23.3 | Figure 23.10
, OBJ: 13 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
3. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child
exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which
type of cerebral palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed
ANS: C
Spasticity is characterized by tension in certain muscle groups, which makes voluntary
movements of muscles jerky and uncoordinated.
DIF: Cognitive Level: Comprehension REF: p. 559 OBJ: 14
TOP: Cerebral Palsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which assessment finding in a child with meningitis should be reported immediately?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
ANS: A
Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are
reported immediately, because they could indicate increased intracranial pressure.
DIF: Cognitive Level: Application REF: p. 552 OBJ: 11
TOP: Meningitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
5. The nurse observes a child‘s position is supine with his arms and legs rigidly extended and the
hands pronated. How does the nurse identify this posture?
a. Correct anatomical position
Neurological Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds.
What would the nurse expect to assess after a generalized tonic-clonic seizure?
a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiety
ANS: B
Following a generalized tonic-clonic seizure, the child may have some confusion and may
sleep for a time (postictal lethargy) and then return to full consciousness.
DIF: Cognitive Level: Comprehension REF: p. 555 | Table 23.2
OBJ: 13 | 15 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What would the nurse include when creating a teaching plan that includes the long-term
administration of phenytoin (Dilantin)?
a. The medication should be given on an empty stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularly to prevent hyperplasia.
d. Blood pressure should be closely monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin
frequently causes drowsiness and should be given with meals at the same time each day.
DIF: Cognitive Level: Comprehension REF: p. 557 | Table 23.3 | Figure 23.10
, OBJ: 13 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
3. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child
exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which
type of cerebral palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed
ANS: C
Spasticity is characterized by tension in certain muscle groups, which makes voluntary
movements of muscles jerky and uncoordinated.
DIF: Cognitive Level: Comprehension REF: p. 559 OBJ: 14
TOP: Cerebral Palsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which assessment finding in a child with meningitis should be reported immediately?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
ANS: A
Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are
reported immediately, because they could indicate increased intracranial pressure.
DIF: Cognitive Level: Application REF: p. 552 OBJ: 11
TOP: Meningitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
5. The nurse observes a child‘s position is supine with his arms and legs rigidly extended and the
hands pronated. How does the nurse identify this posture?
a. Correct anatomical position
