PEDS EXAM #3 with 236 complete
solutions 100% correct.
PEDS EXAM #3 with 236 complete
solutions 100% correct.
Which of the following phrases describes a characteristic of most neonatal seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - ANSWER D. Subtle and barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting,
eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to maintain a generalized seizure.
The newborn's central nervous system is not sufficiently developed to maintain a tonic-clonic
(generalized) seizure.
The newborn's central nervous system is not sufficiently developed to maintain a well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - ANSWER A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants. The characteristic
cry occurs secondary to the pressure being placed on the meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a
bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present with diarrhea, it is more
indicative of a gastrointestinal disturbance.
,PEDS EXAM #3 with 236 complete
solutions 100% correct.
The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable
since sustaining a cervical neck injury 12 hours ago. What is the priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - ANSWER A. Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no
reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine injury.
Assessing for an oculovestibular response is a painful test that should not be done for a child who is
having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro,
tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - ANSWER A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4 months of age.
Therefore, the presence of these reflexes indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not related to the
presence of the Moro, tonic neck, or withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not related to the
presence of the Moro, tonic neck, or withdrawal reflexes.
The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
,PEDS EXAM #3 with 236 complete
solutions 100% correct.
C. apply a hypothermia blanket.
D. administer aspirin stat. - ANSWER C. apply a hypothermia blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely important to
institute temperature-lowering interventions such as hypothermia blankets and tepid water baths
immediately.
The temperature needs to be monitored, but lowering the temperature is the priority.
Pain assessments should be ongoing, but this is not the priority at this time. Lowering the body
temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye syndrome. Antipyretics, such
as acetaminophen or ibuprofen, usually are not effective with temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain
A. cannot occur if the child is comatose.
B. may occur if the child regains consciousness.
C. requires astute nursing assessment and management.
D. is best assessed by family members who are familiar with the child. - ANSWER C. requires astute
nursing assessment and management.
Because the child cannot communicate pain through one of the standard pain rating scales, the nurse
must focus on physiologic and behavioral manifestations to accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the nurse should be monitoring
physiologic and behavioral manifestations.
What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious
child?
A. Suction the child frequently.
B. Provide environmental stimulation.
C. Turn the head side to side every hour.
D. Avoid activities that cause pain or crying. - ANSWER Avoid activities that cause pain or crying.
, PEDS EXAM #3 with 236 complete
solutions 100% correct.
Nursing interventions should focus on assessment and interventions to minimize pain. These activities
can cause the ICP to increase.
Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase
ICP.
Environmental stimulation should be minimized because it can increase ICP.
The child's head should not be turned side to side. If the jugular vein is compressed, the ICP can rise.
The nurse is caring for a 2-year-old child who is unconscious but stable after a car accident. The child's
parents are staying at the bedside most of the time. What is an appropriate nursing intervention?
A. Suggest that the parents go home until the child is alert enough to know they are present.
B. Use ointment on the lips but do not attempt to cleanse the teeth until swallowing returns.
C. Encourage the parents to hold, talk to, and sing to the child as they usually would.
D. Position the child with proper body alignment and the head of the bed lowered 15 degrees. -
ANSWER C. Encourage the parents to hold, talk to, and sing to the child as they usually would.
The parents should be encouraged to interact with the child. Senses of hearing and tactile perception
may be intact, and stimulation is important in the child's recovery.
Suggesting that the parents go home until the child is awake is not recommended. The child may be able
to hear that they are present, and this stimulation may assist in recovery.
Oral care is essential in the unconscious child. Mouth care should be done at least twice daily to prevent
oral infections.
The head of the bed should be elevated, not lowered, in a child with neurologic involvement.
The nurse is instructing a group of parents about head injuries in children. The nurse should explain that
infants are particularly vulnerable to acceleration-deceleration head injuries because the
A. anterior fontanel is not yet closed.
B. nervous tissue is not well developed.
C. scalp of head has extensive vascularity.
D. musculoskeletal support of head is insufficient. - ANSWER D. musculoskeletal support of head is
insufficient.
The relatively large head size coupled with insufficient musculoskeletal support increases the risk to
infants of acceleration-deceleration head injuries.
solutions 100% correct.
PEDS EXAM #3 with 236 complete
solutions 100% correct.
Which of the following phrases describes a characteristic of most neonatal seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - ANSWER D. Subtle and barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting,
eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to maintain a generalized seizure.
The newborn's central nervous system is not sufficiently developed to maintain a tonic-clonic
(generalized) seizure.
The newborn's central nervous system is not sufficiently developed to maintain a well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - ANSWER A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants. The characteristic
cry occurs secondary to the pressure being placed on the meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a
bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present with diarrhea, it is more
indicative of a gastrointestinal disturbance.
,PEDS EXAM #3 with 236 complete
solutions 100% correct.
The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable
since sustaining a cervical neck injury 12 hours ago. What is the priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - ANSWER A. Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no
reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine injury.
Assessing for an oculovestibular response is a painful test that should not be done for a child who is
having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro,
tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - ANSWER A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4 months of age.
Therefore, the presence of these reflexes indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not related to the
presence of the Moro, tonic neck, or withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not related to the
presence of the Moro, tonic neck, or withdrawal reflexes.
The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
,PEDS EXAM #3 with 236 complete
solutions 100% correct.
C. apply a hypothermia blanket.
D. administer aspirin stat. - ANSWER C. apply a hypothermia blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely important to
institute temperature-lowering interventions such as hypothermia blankets and tepid water baths
immediately.
The temperature needs to be monitored, but lowering the temperature is the priority.
Pain assessments should be ongoing, but this is not the priority at this time. Lowering the body
temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye syndrome. Antipyretics, such
as acetaminophen or ibuprofen, usually are not effective with temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain
A. cannot occur if the child is comatose.
B. may occur if the child regains consciousness.
C. requires astute nursing assessment and management.
D. is best assessed by family members who are familiar with the child. - ANSWER C. requires astute
nursing assessment and management.
Because the child cannot communicate pain through one of the standard pain rating scales, the nurse
must focus on physiologic and behavioral manifestations to accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the nurse should be monitoring
physiologic and behavioral manifestations.
What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious
child?
A. Suction the child frequently.
B. Provide environmental stimulation.
C. Turn the head side to side every hour.
D. Avoid activities that cause pain or crying. - ANSWER Avoid activities that cause pain or crying.
, PEDS EXAM #3 with 236 complete
solutions 100% correct.
Nursing interventions should focus on assessment and interventions to minimize pain. These activities
can cause the ICP to increase.
Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase
ICP.
Environmental stimulation should be minimized because it can increase ICP.
The child's head should not be turned side to side. If the jugular vein is compressed, the ICP can rise.
The nurse is caring for a 2-year-old child who is unconscious but stable after a car accident. The child's
parents are staying at the bedside most of the time. What is an appropriate nursing intervention?
A. Suggest that the parents go home until the child is alert enough to know they are present.
B. Use ointment on the lips but do not attempt to cleanse the teeth until swallowing returns.
C. Encourage the parents to hold, talk to, and sing to the child as they usually would.
D. Position the child with proper body alignment and the head of the bed lowered 15 degrees. -
ANSWER C. Encourage the parents to hold, talk to, and sing to the child as they usually would.
The parents should be encouraged to interact with the child. Senses of hearing and tactile perception
may be intact, and stimulation is important in the child's recovery.
Suggesting that the parents go home until the child is awake is not recommended. The child may be able
to hear that they are present, and this stimulation may assist in recovery.
Oral care is essential in the unconscious child. Mouth care should be done at least twice daily to prevent
oral infections.
The head of the bed should be elevated, not lowered, in a child with neurologic involvement.
The nurse is instructing a group of parents about head injuries in children. The nurse should explain that
infants are particularly vulnerable to acceleration-deceleration head injuries because the
A. anterior fontanel is not yet closed.
B. nervous tissue is not well developed.
C. scalp of head has extensive vascularity.
D. musculoskeletal support of head is insufficient. - ANSWER D. musculoskeletal support of head is
insufficient.
The relatively large head size coupled with insufficient musculoskeletal support increases the risk to
infants of acceleration-deceleration head injuries.
