Ricci Chapter 38 Test Bank UPDATED
ACTUAL Exam Questions and CORRECT
Answers
1. When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse
integrates knowledge of potential complications, being alert for signs and symptoms of what
condition?
A. Neonatal conjunctivitis
B. Facial deformities
C. Intracranial hemorrhage
D. Incomplete myelinization - CORRECT ANSWER - Answer: C
Rationale: Premature infants have more fragile capillaries in the periventricular area than term
infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can
occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial
deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all
newborns.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 1355
2. The nurse knows that children have larger heads in relation to the body and a higher center of
gravity. When developing a teaching plan for parents, the nurse includes information about an
increased risk for which problem?
A. Febrile seizures
,B. Head trauma
C. Caput succedaneum
D. Posterior plagiocephaly - CORRECT ANSWER - Answer: B
Rationale: The larger head size in relation to the body, coupled with a higher center of gravity,
causes children to hit their head more readily when involved in motor vehicle accidents, bicycle
accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput
succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during
head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Reference: p. 1327-1328
3. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of
the illness. The nurse would assess the child most carefully for what finding?
A. Indications of increased intracranial pressure
B. An increase in the blood glucose level
C. A decrease in the liver enzymes
D. A presence of protein in the urine - CORRECT ANSWER - Answer: A
Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if
treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme
levels typically increase. Blood glucose levels and protein in the urine are not characteristic of
this illness.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
, Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 1363
4. The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which
instruction is essential for the nurse to teach the parents?
A. Monitor their child's level of sedation.
B. Watch for fever indicating infection.
C. Gradually reduce the dosage as seizures stop.
D. Monitor for an allergic reaction to the medication. - CORRECT ANSWER - Answer: A
Rationale: Diazepam is useful for home management of prolonged seizures and requires that the
parents be educated on its proper administration. Monitoring the child's level of sedation is key
when giving diazepam because it slows the central nervous system. Parents need to monitor the
overall health of the child, including temperature when needed, but that has nothing to do with
the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is
necessary to prevent seizures or status epilepticus. This is not done without a physician's order.
Monitoring for allergic reactions is necessary when any medications have been prescribed, but is
not specific to diazepam.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Reference: p. 1342
ACTUAL Exam Questions and CORRECT
Answers
1. When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse
integrates knowledge of potential complications, being alert for signs and symptoms of what
condition?
A. Neonatal conjunctivitis
B. Facial deformities
C. Intracranial hemorrhage
D. Incomplete myelinization - CORRECT ANSWER - Answer: C
Rationale: Premature infants have more fragile capillaries in the periventricular area than term
infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can
occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial
deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all
newborns.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 1355
2. The nurse knows that children have larger heads in relation to the body and a higher center of
gravity. When developing a teaching plan for parents, the nurse includes information about an
increased risk for which problem?
A. Febrile seizures
,B. Head trauma
C. Caput succedaneum
D. Posterior plagiocephaly - CORRECT ANSWER - Answer: B
Rationale: The larger head size in relation to the body, coupled with a higher center of gravity,
causes children to hit their head more readily when involved in motor vehicle accidents, bicycle
accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput
succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during
head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Reference: p. 1327-1328
3. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of
the illness. The nurse would assess the child most carefully for what finding?
A. Indications of increased intracranial pressure
B. An increase in the blood glucose level
C. A decrease in the liver enzymes
D. A presence of protein in the urine - CORRECT ANSWER - Answer: A
Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if
treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme
levels typically increase. Blood glucose levels and protein in the urine are not characteristic of
this illness.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
, Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 1363
4. The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which
instruction is essential for the nurse to teach the parents?
A. Monitor their child's level of sedation.
B. Watch for fever indicating infection.
C. Gradually reduce the dosage as seizures stop.
D. Monitor for an allergic reaction to the medication. - CORRECT ANSWER - Answer: A
Rationale: Diazepam is useful for home management of prolonged seizures and requires that the
parents be educated on its proper administration. Monitoring the child's level of sedation is key
when giving diazepam because it slows the central nervous system. Parents need to monitor the
overall health of the child, including temperature when needed, but that has nothing to do with
the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is
necessary to prevent seizures or status epilepticus. This is not done without a physician's order.
Monitoring for allergic reactions is necessary when any medications have been prescribed, but is
not specific to diazepam.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Reference: p. 1342
