Ch 38 Ricci: Peds Neuro UPDATED
ACTUAL Exam Questions and CORRECT
Answers
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this
child. What comment will be most valuable in helping the parent and the child cope?
"You'll always need a monitor in his room."
"If he is out of bed, the helmet's on the head."
"Bike riding and swimming are just too dangerous."
"Use this information to teach family and friends." - CORRECT ANSWER - "Use this
information to teach family and friends."
Families need and want information they can share with relatives, child care providers, and
teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be
modified as the child matures. The child may be able to bike ride and swim with proper
precaution
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences
tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest
priority?
Risk for delayed development
Risk for injury
Risk for ineffective tissue perfusion: cerebral
Risk for self-care deficit: bathing and dressing - CORRECT ANSWER - Risk for injury
Explanation:
A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic
seizures are the most dramatic seizure disorder. It is characterized by a loss of consciousness,
along with the entire body experiencing tonic contractions followed by rhythmic clonic
,contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to
apnea, and saliva may collect in the mouth due to an inability to swallow. All of these symptoms
would make Risk for injury the highest priority.
The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We
just do not understand how this could have happened. Our adolescent has always been healthy
and just received a booster vaccine last year." How should the nurse respond?
"Your child may have been exposed to the type of meningitis that is not covered by the vaccine
received."
"I understand your frustration. Unfortunately, immunizations are not 100% effective in
preventing the infection."
"Meningococcal conjugate vaccine covers only two types of bacterial meningitis."
"Maybe your child's immune system is not strong enough to fight off the infection, even with
having received the vaccine." - CORRECT ANSWER - "I understand your frustration.
Unfortunately, immunizations are not 100% effective in preventing the infection."
Explanation:
Showing empathy while letting the parents know that vaccines are not 100% effective is the best
response. Meningococcal conjugate vaccine protects against four types of meningitis. There is
nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the
infection, or that the adolescent's immune system is compromised.
The nurse helps position a child for a lumbar puncture. Which statement describes the correct
positioning for this procedure?
"The child will be placed in the prone position with the nurse holding the child still."
"When positioning the child, the nurse needs to assist the child to a side-lying position and keep
his back as flat as much as possible."
"The child will be held by the mother on her lap with his back toward the health care provider."
"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck
flexed to assist with arching the back." - CORRECT ANSWER - "For a lumbar puncture,
the child will be placed in a side-lying position with knees bent and neck flexed to assist with
arching the back."
,Explanation:
Correct positioning for a lumbar puncture is to place the child on his or her side with the neck
flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as
possible. Newborns may be seated upright with their head bent forward. The child is not placed
prone; this does not allow the back to be arched.
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-
clonic seizure. Which nursing action is priority?
Administer lorazepam rectally to the client.
Refer the client to a neurologist.
Protect the child from hitting the arms against the bed.
Discuss dietary therapy with the client's caregivers. - CORRECT ANSWER - Protect the
child from hitting the arms against the bed.
Explanation:
Keeping the child safe during a seizure is the highest priority. The nurse will protect the child
from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may
be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care;
however, this is not a priority. Dietary therapy is considered for clients with chronic seizure
disorders who do not respond to medication therapy.
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has
just had an external ventricular drainage system placed. Which question is best to begin the
teaching session?
"What do you know about her autoregulation mechanism failing?"
"What questions or concerns do you have about this device?"
"Why do you always keep her head raised 30 degrees?"
"Do you understand why you clamp the drain before she sits up?" - CORRECT
ANSWER - "What questions or concerns do you have about this device?"
, Always start by assessing the family's knowledge. Ask them what they need to know. Knowing
when to clamp the drain is important, but they might not be listening if they have another
question on their minds. Autoregulation is too technical. Teaching should be based on the
parents' level of understanding. Keeping her head elevated is not part of the information which
would be taught regarding the drainage system.
The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities
surrounding them. What activity would the nurse identify as a possible trigger?
drinking three cans of diet cola
use of nonaccented soap
swimming twice a week
11 p.m. bedtime; 6:30 a.m. wake-up - CORRECT ANSWER - drinking three cans of diet
cola
Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may
be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may
be a trigger.
The nurse is educating parents of a male infant with Chiari type II malformation. Which
statement about their child's condition is most accurate?
"Take your time feeding your baby."
"You won't need to change diapers often."
"You'll see a big difference after the surgery."
"Lay him down after feeding." - CORRECT ANSWER - "Take your time feeding your
baby."
One of the problems associated with Chiari type II malformation is poor gag and swallowing
reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the
child be placed in an upright position after feeding. The goal of surgery is to prevent further
ACTUAL Exam Questions and CORRECT
Answers
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this
child. What comment will be most valuable in helping the parent and the child cope?
"You'll always need a monitor in his room."
"If he is out of bed, the helmet's on the head."
"Bike riding and swimming are just too dangerous."
"Use this information to teach family and friends." - CORRECT ANSWER - "Use this
information to teach family and friends."
Families need and want information they can share with relatives, child care providers, and
teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be
modified as the child matures. The child may be able to bike ride and swim with proper
precaution
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences
tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest
priority?
Risk for delayed development
Risk for injury
Risk for ineffective tissue perfusion: cerebral
Risk for self-care deficit: bathing and dressing - CORRECT ANSWER - Risk for injury
Explanation:
A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic
seizures are the most dramatic seizure disorder. It is characterized by a loss of consciousness,
along with the entire body experiencing tonic contractions followed by rhythmic clonic
,contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to
apnea, and saliva may collect in the mouth due to an inability to swallow. All of these symptoms
would make Risk for injury the highest priority.
The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We
just do not understand how this could have happened. Our adolescent has always been healthy
and just received a booster vaccine last year." How should the nurse respond?
"Your child may have been exposed to the type of meningitis that is not covered by the vaccine
received."
"I understand your frustration. Unfortunately, immunizations are not 100% effective in
preventing the infection."
"Meningococcal conjugate vaccine covers only two types of bacterial meningitis."
"Maybe your child's immune system is not strong enough to fight off the infection, even with
having received the vaccine." - CORRECT ANSWER - "I understand your frustration.
Unfortunately, immunizations are not 100% effective in preventing the infection."
Explanation:
Showing empathy while letting the parents know that vaccines are not 100% effective is the best
response. Meningococcal conjugate vaccine protects against four types of meningitis. There is
nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the
infection, or that the adolescent's immune system is compromised.
The nurse helps position a child for a lumbar puncture. Which statement describes the correct
positioning for this procedure?
"The child will be placed in the prone position with the nurse holding the child still."
"When positioning the child, the nurse needs to assist the child to a side-lying position and keep
his back as flat as much as possible."
"The child will be held by the mother on her lap with his back toward the health care provider."
"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck
flexed to assist with arching the back." - CORRECT ANSWER - "For a lumbar puncture,
the child will be placed in a side-lying position with knees bent and neck flexed to assist with
arching the back."
,Explanation:
Correct positioning for a lumbar puncture is to place the child on his or her side with the neck
flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as
possible. Newborns may be seated upright with their head bent forward. The child is not placed
prone; this does not allow the back to be arched.
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-
clonic seizure. Which nursing action is priority?
Administer lorazepam rectally to the client.
Refer the client to a neurologist.
Protect the child from hitting the arms against the bed.
Discuss dietary therapy with the client's caregivers. - CORRECT ANSWER - Protect the
child from hitting the arms against the bed.
Explanation:
Keeping the child safe during a seizure is the highest priority. The nurse will protect the child
from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may
be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care;
however, this is not a priority. Dietary therapy is considered for clients with chronic seizure
disorders who do not respond to medication therapy.
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has
just had an external ventricular drainage system placed. Which question is best to begin the
teaching session?
"What do you know about her autoregulation mechanism failing?"
"What questions or concerns do you have about this device?"
"Why do you always keep her head raised 30 degrees?"
"Do you understand why you clamp the drain before she sits up?" - CORRECT
ANSWER - "What questions or concerns do you have about this device?"
, Always start by assessing the family's knowledge. Ask them what they need to know. Knowing
when to clamp the drain is important, but they might not be listening if they have another
question on their minds. Autoregulation is too technical. Teaching should be based on the
parents' level of understanding. Keeping her head elevated is not part of the information which
would be taught regarding the drainage system.
The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities
surrounding them. What activity would the nurse identify as a possible trigger?
drinking three cans of diet cola
use of nonaccented soap
swimming twice a week
11 p.m. bedtime; 6:30 a.m. wake-up - CORRECT ANSWER - drinking three cans of diet
cola
Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may
be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may
be a trigger.
The nurse is educating parents of a male infant with Chiari type II malformation. Which
statement about their child's condition is most accurate?
"Take your time feeding your baby."
"You won't need to change diapers often."
"You'll see a big difference after the surgery."
"Lay him down after feeding." - CORRECT ANSWER - "Take your time feeding your
baby."
One of the problems associated with Chiari type II malformation is poor gag and swallowing
reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the
child be placed in an upright position after feeding. The goal of surgery is to prevent further
