NUR253 FINAL EXAM 2025 QUESTIONS
AND ANSWERS
Myelination of the nerves brings at what age? - ANS 3 months
The brain consists of 3 sections: - ANS cerebrum
cerebellum
brainstem
Increased intracranial pressure is when - ANS there is excessive pressure exerted by the
blood, brain, or CSF
20 mmHg or higher for 5 minutes or longer
What tool is used to assess LOC in infants and children? - ANS Glasgow Coma Scale
Obtunded state -> - ANS sleeps, and once aroused, has limited interaction with environment
Stupor state - ANS stimulation is needed to arouse
Lethargic state - ANS awakens easily but exhibits limited responsiveness
Changes in behavior in children with increased intracranial pressure - ANS Irritability
Mild confusion
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,Agitation
Decreased response to painful stimuli
Pupil evaluation in patients with increased ICP - ANS sluggish or absent constriction in
response to light
fixed, dilated pupils!!!
Motor function S/S of increased ICP - ANS Decreased purposeful movements
Abnormal posturing
Flexion or extension
The progression from ______ to ______ usually indicates deteriorating neurological function
(think about motor function) - ANS flexion to extension
Vital sign changes with increased ICP - ANS Cheyne-Stoke Respirations
Temperature elevation
Cushing's response - increased SBP, widened pulse pressure, bradycardia, changes in RR and
pattern
Cheyne-Stoke Respirations - ANS Repetitive pattern of breathing -> increased rate and depth
then decreased rate and depth with pauses
Signs and symptoms of increased ICP in infants - ANS Poor feeding or vomiting
Irritability, restlessness, lethargy
Bulging fontanel
High-pitched cry
Increased head circumference
Separation of cranial structures
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,Distended scalp veins
Eyes deviated downward (setting sun sign)
Increased or decreased response to pain
S/S of increased ICP in children - ANS Headache
Diplopia (double vision)
Mood swings
Slurred speech
Papilledema (after 48 hours): swelling of the optic nerve after injury
Altered LOC
Nausea, vomiting (especially in the morning)
Spina bifida is when - ANS incomplete closure of the vertebrae
Spina bifida occulta is - ANS looks like a small tuft of hair or dimple in the lower lumbar sacral
area; no herniation and spinal cord and meninges are still intact
spina bifidia myelomeningocele - ANS most serious; nerves and spinal fluid bulging out back
CM related to spina bifida - ANS paralysis
partial paralysis
sensory deficits
Common problems in those with spina bifida - ANS club feet
scoliosis
dislocated hips
hydrocephalus
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, latex allergy
What is taken during the prenatal period to prevent spina bifida? - ANS folic acid
Nursing consideration for patient with spina bifida - ANS the child cannot lie on their back,
the sac must be protected
Hydrocephalus is - ANS imbalance between production and absorption of CSF, leading to an
enlarged head size
Treatment of hydrocephalus - ANS ventriculoperitoneal shunt
Goal of treatment with hydrocephalus - ANS keep the ICP WNL so the head does not grow
and brain is not being damaged
What is cerebral palsy due to - ANS this is a acquired condition; possibly due to hypoxia
during labor or pregnancy
Cerebral palsy CM - ANS difficulty controlling muscles
Contusion vs concussion - ANS Contusion: petechial hemorrhage along the superficial
aspects of the brain
Concussion: transient and reversible neuronal dysfunction
Epidural hematoma - ANS hemorrhage/bleeding between the dura and skull
Subdural hematoma - ANS hemorrhage/bleeding between the dura and cerebrum
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AND ANSWERS
Myelination of the nerves brings at what age? - ANS 3 months
The brain consists of 3 sections: - ANS cerebrum
cerebellum
brainstem
Increased intracranial pressure is when - ANS there is excessive pressure exerted by the
blood, brain, or CSF
20 mmHg or higher for 5 minutes or longer
What tool is used to assess LOC in infants and children? - ANS Glasgow Coma Scale
Obtunded state -> - ANS sleeps, and once aroused, has limited interaction with environment
Stupor state - ANS stimulation is needed to arouse
Lethargic state - ANS awakens easily but exhibits limited responsiveness
Changes in behavior in children with increased intracranial pressure - ANS Irritability
Mild confusion
1 @COPYRIGHT THEBRIGHT 2025/2026
,Agitation
Decreased response to painful stimuli
Pupil evaluation in patients with increased ICP - ANS sluggish or absent constriction in
response to light
fixed, dilated pupils!!!
Motor function S/S of increased ICP - ANS Decreased purposeful movements
Abnormal posturing
Flexion or extension
The progression from ______ to ______ usually indicates deteriorating neurological function
(think about motor function) - ANS flexion to extension
Vital sign changes with increased ICP - ANS Cheyne-Stoke Respirations
Temperature elevation
Cushing's response - increased SBP, widened pulse pressure, bradycardia, changes in RR and
pattern
Cheyne-Stoke Respirations - ANS Repetitive pattern of breathing -> increased rate and depth
then decreased rate and depth with pauses
Signs and symptoms of increased ICP in infants - ANS Poor feeding or vomiting
Irritability, restlessness, lethargy
Bulging fontanel
High-pitched cry
Increased head circumference
Separation of cranial structures
2 @COPYRIGHT THEBRIGHT 2025/2026
,Distended scalp veins
Eyes deviated downward (setting sun sign)
Increased or decreased response to pain
S/S of increased ICP in children - ANS Headache
Diplopia (double vision)
Mood swings
Slurred speech
Papilledema (after 48 hours): swelling of the optic nerve after injury
Altered LOC
Nausea, vomiting (especially in the morning)
Spina bifida is when - ANS incomplete closure of the vertebrae
Spina bifida occulta is - ANS looks like a small tuft of hair or dimple in the lower lumbar sacral
area; no herniation and spinal cord and meninges are still intact
spina bifidia myelomeningocele - ANS most serious; nerves and spinal fluid bulging out back
CM related to spina bifida - ANS paralysis
partial paralysis
sensory deficits
Common problems in those with spina bifida - ANS club feet
scoliosis
dislocated hips
hydrocephalus
3 @COPYRIGHT THEBRIGHT 2025/2026
, latex allergy
What is taken during the prenatal period to prevent spina bifida? - ANS folic acid
Nursing consideration for patient with spina bifida - ANS the child cannot lie on their back,
the sac must be protected
Hydrocephalus is - ANS imbalance between production and absorption of CSF, leading to an
enlarged head size
Treatment of hydrocephalus - ANS ventriculoperitoneal shunt
Goal of treatment with hydrocephalus - ANS keep the ICP WNL so the head does not grow
and brain is not being damaged
What is cerebral palsy due to - ANS this is a acquired condition; possibly due to hypoxia
during labor or pregnancy
Cerebral palsy CM - ANS difficulty controlling muscles
Contusion vs concussion - ANS Contusion: petechial hemorrhage along the superficial
aspects of the brain
Concussion: transient and reversible neuronal dysfunction
Epidural hematoma - ANS hemorrhage/bleeding between the dura and skull
Subdural hematoma - ANS hemorrhage/bleeding between the dura and cerebrum
4 @COPYRIGHT THEBRIGHT 2025/2026
