C HAPTER 23: T HE C HILD WITH A S ENSORY OR
N EUROLOGICAL C ONDITION
Introduction to Maternity and Pediatric Nursing , 8th Edition ; Leifer
MULTIPLE CHOICE
1. What is an appropriate nursing action when a child is experiencing a
generalized tonic -clonic seizure?
a. Guide the child to the floor if the child is standing, and then go for
help.
b. Move objects out of the childs immediate area.
c. Stick a padded tongue blade between the childs teeth.
d. Manuall y restrain the child.
ANS: B
During a generalized tonic -clonic seizure, th e immediate area is
cleared to protect the child from injury.
DIF: Cognitive Level: Application REF: Page 553 OBJ: 10
TOP: Epilepsy KEY: Nursing Process Step:
Implementation MSC: NC LEX: Safe, Effective Care
Environment: Safet y and Infection Control
2. A child diagnosed with epilepsy had a generalized tonic -clonic seizure
that lasted 90 seconds. What would the nurse expect to assess after a
generalized tonic -clonic seizure?
, a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiet y
ANS: B
Following a generalized tonic -clonic seizure, the child may have some
confusion and may sleep for a time (postictal lethargy) and then return
to full consciousness.
DIF: Cognitive Level: Comprehension REF: Page 553
OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing
Process Step: Data Collect ion MSC: NC LEX:
Physiological Integrity: Physiological Adaptation
3. What would the nurse include when creating a teaching plan that includes
the long-term administration of phenytoin (Dilantin)?
a. The medication should be given on an empt y stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularl y to prevent hyperplasia.
d. Blood pressure should be closel y monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular
massaging. Dilantin frequentl y causes drow siness and should be given
with meals at the same time each day.
, DIF: Cognitive Level: Comprehension REF: Page 556
OBJ: 10 TOP: Epilepsy KEY: Nursing Process
Step: Implementation MSC: NC LEX: Physiological
Integrit y: Pharmacological Therapies
4. The nurse observes that the legs of a child with cerebral palsy cross
involuntaril y, and the child exhibits jerky movements with his arms as he
tries to eat. The nurse recognizes that he has which t ype of cerebral palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed
ANS: C
Spasticit y is characterized by tension in certain muscle groups, which
makes voluntary movements of muscles jerky and uncoordinated.
DIF: Cognitive Level: Comprehension REF: Page 557
OBJ: 12 TOP: Cerebral Palsy KEY: Nursing
Process Step: Data Collectio n MSC: NC LEX:
Physiological Integrity: Physiological Adaptation
5. Which assessment finding in a child with meningitis should be reported
immediatel y?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
N EUROLOGICAL C ONDITION
Introduction to Maternity and Pediatric Nursing , 8th Edition ; Leifer
MULTIPLE CHOICE
1. What is an appropriate nursing action when a child is experiencing a
generalized tonic -clonic seizure?
a. Guide the child to the floor if the child is standing, and then go for
help.
b. Move objects out of the childs immediate area.
c. Stick a padded tongue blade between the childs teeth.
d. Manuall y restrain the child.
ANS: B
During a generalized tonic -clonic seizure, th e immediate area is
cleared to protect the child from injury.
DIF: Cognitive Level: Application REF: Page 553 OBJ: 10
TOP: Epilepsy KEY: Nursing Process Step:
Implementation MSC: NC LEX: Safe, Effective Care
Environment: Safet y and Infection Control
2. A child diagnosed with epilepsy had a generalized tonic -clonic seizure
that lasted 90 seconds. What would the nurse expect to assess after a
generalized tonic -clonic seizure?
, a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiet y
ANS: B
Following a generalized tonic -clonic seizure, the child may have some
confusion and may sleep for a time (postictal lethargy) and then return
to full consciousness.
DIF: Cognitive Level: Comprehension REF: Page 553
OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing
Process Step: Data Collect ion MSC: NC LEX:
Physiological Integrity: Physiological Adaptation
3. What would the nurse include when creating a teaching plan that includes
the long-term administration of phenytoin (Dilantin)?
a. The medication should be given on an empt y stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularl y to prevent hyperplasia.
d. Blood pressure should be closel y monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular
massaging. Dilantin frequentl y causes drow siness and should be given
with meals at the same time each day.
, DIF: Cognitive Level: Comprehension REF: Page 556
OBJ: 10 TOP: Epilepsy KEY: Nursing Process
Step: Implementation MSC: NC LEX: Physiological
Integrit y: Pharmacological Therapies
4. The nurse observes that the legs of a child with cerebral palsy cross
involuntaril y, and the child exhibits jerky movements with his arms as he
tries to eat. The nurse recognizes that he has which t ype of cerebral palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed
ANS: C
Spasticit y is characterized by tension in certain muscle groups, which
makes voluntary movements of muscles jerky and uncoordinated.
DIF: Cognitive Level: Comprehension REF: Page 557
OBJ: 12 TOP: Cerebral Palsy KEY: Nursing
Process Step: Data Collectio n MSC: NC LEX:
Physiological Integrity: Physiological Adaptation
5. Which assessment finding in a child with meningitis should be reported
immediatel y?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
