COMPLETION
1. The nurse explains ____________________ test determines the childs susceptibility to
tuberculosis.
ANS: Mantoux
DIF: Cognitive Level: Knowledge REF: Text Reference: 717
OBJ: Objective: 4 TOP: Topic: Mantoux
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
NOT: Rationale: The Mantoux is a screening test for the susceptibility to TB. An
intradermal injection is given and read 3 days later. An erythema and induration of more
than 5 mm is considered a positive reading.
____________________ in the transmission of Lyme disease.
h a
2. The nurse uses a diagram showing how the wood tick acts as a
ANS: vector
Ta
DIF: Cognitive Level: Comprehension REF: Text Reference: 716
OBJ: Objective: 4 TOP: Topic: Vector
b
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
e
NOT: Rationale: A vector is an insect or animal that carries a communicable disease.
b e
3. The school nurse recognizes the presence of macules, papules, vesicles, pustules, and
scabs on the child as the particular sign of the communicable disease of
____________________.
a
ANS: varicella or chickenpox
H
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.
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,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
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
a
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
h
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
a
3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head
T
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
eb
e
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal
a b
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,
H
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
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, 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
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
a
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
PTS: 1 DIF: Cognitive Level: Understand REF: 930
TOP: Integrated Process: Nursing Process: Assessment
ah
maneuver is a test for brainstem or oculomotor nerve dysfunction.
T
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
eb
c. Funduscopic examination for papilledema
e
d. Assessment of pyramidal tract lesions
ANS: A
a b
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
H
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,
WWW.THENURSINGMASTERY.COM
WWW.NURSYLAB.COM
1. The nurse explains ____________________ test determines the childs susceptibility to
tuberculosis.
ANS: Mantoux
DIF: Cognitive Level: Knowledge REF: Text Reference: 717
OBJ: Objective: 4 TOP: Topic: Mantoux
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
NOT: Rationale: The Mantoux is a screening test for the susceptibility to TB. An
intradermal injection is given and read 3 days later. An erythema and induration of more
than 5 mm is considered a positive reading.
____________________ in the transmission of Lyme disease.
h a
2. The nurse uses a diagram showing how the wood tick acts as a
ANS: vector
Ta
DIF: Cognitive Level: Comprehension REF: Text Reference: 716
OBJ: Objective: 4 TOP: Topic: Vector
b
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
e
NOT: Rationale: A vector is an insect or animal that carries a communicable disease.
b e
3. The school nurse recognizes the presence of macules, papules, vesicles, pustules, and
scabs on the child as the particular sign of the communicable disease of
____________________.
a
ANS: varicella or chickenpox
H
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.
WWW.THENURSINGMASTERY.COM
WWW.NURSYLAB.COM
,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
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
a
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
h
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
a
3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head
T
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
eb
e
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal
a b
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,
H
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
WWW.THENURSINGMASTERY.COM
WWW.NURSYLAB.COM
, 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
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
a
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
PTS: 1 DIF: Cognitive Level: Understand REF: 930
TOP: Integrated Process: Nursing Process: Assessment
ah
maneuver is a test for brainstem or oculomotor nerve dysfunction.
T
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
eb
c. Funduscopic examination for papilledema
e
d. Assessment of pyramidal tract lesions
ANS: A
a b
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
H
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,
WWW.THENURSINGMASTERY.COM
WWW.NURSYLAB.COM
