Chapter 41: Cognitive and Sensory Impairment

Question 1

1. Which is accurate for a young child with a moderate level of cognitive impairment?
   a. IQ is within the lower limits of the range of normal intelligence
   b. Is educable
   c. Is trainable
   d. Is completely dependent on others for care

Answer 1

ANS: C
The term educable corresponds to mildly impaired persons. The term trainable applies to children with moderate levels of cognitive impairment. The lower limit of normal intelligence is approximately 70 to 75, and children with a moderate level of cognitive impairment have an IQ lower than normal levels.

Question 2

2. When should children with cognitive impairment be referred for stimulation and educational programs?
   a. As young as possible
   b. As soon as they have the ability to communicate in some way
   c. At age 3 years, when schools are required to provide services
   d. At age 5 or 6 years, when schools are required to provide services

Answer 2

ANS: A
The child’s education should begin as soon as possible. Considerable evidence exists that early intervention programs for children with disabilities are valuable for cognitively impaired children. Early intervention may facilitate the child’s development of communication skills. Under the Education Act (1956–1996) and the Canadian Human Rights Act (1977), provinces and territories are required to provide educational opportunities for all children with complex conditions.

Question 3

3. What is the major consideration when selecting toys for a child who is cognitively impaired?
   a. Safety
   b. Age appropriateness
   c. Ability to provide exercise
   d. Ability to teach useful skills

Answer 3

ANS: A
Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are cognitively impaired. Age appropriateness, the ability to provide exercise, and the ability to teach useful skills are all factors to consider in the selection of toys, but safety is of paramount importance.

Question 4

4. Which is an appropriate intervention to facilitate socialization for a cognitively impaired child?
   a. Providing age-appropriate toys and play activities
   b. Providing peer experiences such as Guides or Scouting when older
   c. Avoiding exposure to strangers who may not understand cognitive development
   d. Emphasizing mastery of physical skills because they are delayed more often than verbal skills

Answer 4

ANS: B
The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to other children, such as group outings, Boy Scouts and Girl Guides, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions will facilitate social development. Parents should expose the child to strangers so he or she can practice social skills. Verbal skills are delayed more than physical skills.

Question 5

ANS: B
The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to other children, such as group outings, Boy Scouts and Girl Guides, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions will facilitate social development. Parents should expose the child to strangers so he or she can practice social skills. Verbal skills are delayed more than physical skills.

Answer 5

ANS: C
Congenital heart malformations, primarily septal defects, are very common anomalies in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are not frequent congenital anomalies associated with Down syndrome.

Question 6

6. Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular grade 3 class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. What knowledge should the nurse’s recommendation be based on?
   a. Programs such as Cub Scouts are inappropriate for children who are cognitively
   impaired.
   b. Children with Down syndrome have the same need for socialization as other
   children.
   c. Children with Down syndrome socialize better with children who have similar
   disabilities.
   d. Parents of children with Down syndrome want access to programs such as Scouts
   because they deny that their children have disabilities.

Answer 6

ANS: B
Children of all ages need peer relationships, including those with Down syndrome. They should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics, which can all help them to develop socialization skills. Although all children should have an opportunity to form a close relationship with someone of the same developmental level, it is appropriate for children with disabilities to develop relationships with children who do not have disabilities. The parents are acting as advocates for their child.

Question 7

7. A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. What are these findings most suggestive of?
   a. Microcephaly
   b. Down syndrome
   c. Cerebral palsy
   d. Fragile X syndrome

Answer 7

ANS: B
These are characteristics associated with Down syndrome. An infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth because no characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, and/or protruding ears; a long, narrow face with prominent jaw; hypotonia; and a high, arched palate.

Question 8

8. The child with Down syndrome should be evaluated for which characteristic before participating in some sports?
   a. Hyperflexibility
   b. Cutis marmorata
   c. Atlantoaxial instability
   d. Speckling of iris (Brushfield spots)

Answer 8

ANS: C
Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiological examination should be done. Although hyperflexibility, cutis marmorata, and Brushfield spots are characteristics of Down syndrome, they do not affect the child’s ability to participate in sports.

Question 9

9. Which should be included in the care of a child with Down syndrome?
   a. Delay feeding solid foods until the tongue thrust has stopped.
   b. Modify diet as necessary to minimize the diarrhea that often occurs.
   c. Provide calories appropriate to the child’s age.
   d. Use a cool-mist vaporizer to keep mucous membranes moist.

Answer 9

NS: D
A constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing susceptibility to upper respiratory infections. A cool mist vaporizer will keep the mucous membranes moist and liquefy secretions. The child has a protruding tongue, which makes feeding difficult. Parents must persist with feeding while the child continues to have the physiological tongue thrust response. The child is predisposed to constipation. Calories should be appropriate to the child’s weight and growth needs, not age.

Question 10

10. What is fragile X syndrome?
    a. It is a chromosome defect affecting only females.
    b. It is a chromosome defect that follows the pattern of X-linked recessive disorders.
    c. It is the second most common genetic cause of cognitive impairment.
    d. It is the most common cause of non inherited cognitive impairment.

Answer 10

ANS: C
Fragile X syndrome is the most common inherited cause of cognitive impairment, and the second most common cause of cognitive impairment after Down syndrome. This syndrome primarily affects males, follows the pattern of X-linked dominant with reduced penetrance, and is inherited.

Question 11

11. Distortion of sound and problems in discrimination are characteristic of which type of hearing loss?
    a. Conductive
    b. Sensorineural
    c. Mixed conductive-sensorineural
    d. Central auditory imperceptive

Answer 11

ANS: B
Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to the inner ear structures or the auditory nerve. It results in the distortion of sounds and problems with discrimination. Conductive hearing loss involves mainly interference with loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination of both sensorineural and conductive loss. The central auditory imperceptive category includes all hearing losses that do not demonstrate defects in the conduction or sensory structures

Question 12

12. What is the most common type of hearing loss that results from interference of transmission of sound to the middle ear?
    a. Conductive
    b. Sensorineural
    c. Mixed conductive-sensorineural
    d. Central auditory imperceptive

Answer 12

ANS: A
Conductive or middle-ear hearing loss is the most common type. It results from interference of the transmission of sound to the middle ear, most often from recurrent otitis media. Sensorineural, mixed conductive-sensorineural, and central auditory imperceptive are less common types of hearing loss.

Question 13

13. Which is the classification of a child with a hearing level of 60 decibels?
    a. Slight
    b. Mild to moderate
    c. Moderately severe
    d. Severe

Answer 13

ANS: C
A child with a hearing level of 60 decibels is classified as moderately severe. Slight levels range from 16 to 25 dB. Mild to moderate levels range from 26 to 55 dB. Severe levels range from 71 to 90 dB.

Question 14

14. The nurse should suspect hearing impairment in an infant who demonstrates which behaviour?
    a. Absence of the Moro reflex
    b. Absence of babbling by age 7 months
    c. Lack of eye contact when being spoken to
    d. Lack of gesturing to indicate wants after age 15 months

Answer 14

ANS: B
The absence of babbling or inflections in voice by age 7 months is an indication of hearing difficulties. Failure to develop intelligible speech would not be considered a problem by 12 months, but would be considered a problem at 24 months. The lack of a startle reflex would indicate a problem with hearing. A child with a hearing impairment uses gestures rather than vocalizations to express desires at age 15 months.

Question 15

15. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What is the most appropriate nursing action?
    a. Ignore the sound.
    b. Ask him to reverse the hearing aids in his ears.
    c. Suggest that he reinsert the hearing aid.
    d. Suggest that he raise the volume of the hearing aid.

Answer 15

ANS: C
The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure that no hair is caught between the ear mould and ear canal. Ignoring the sound and suggesting that he raise the volume of the hearing aid would be annoying to others. Hearing aids are moulded specifically for each ear, so they cannot be interchanged.

Question 16

16. Which is an implanted ear prosthesis for children with sensorineural hearing loss?
    a. Hearing aid
    b. Cochlear implant
    c. Auditory implant
    d. Amplification device

Answer 16

ANS: B
Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have severe or profound hearing loss of sensorineural origin. Hearing aids are external devices for enhancing hearing. An auditory implant does not exist. An amplification device is an external device for enhancing hearing.

Question 17

17. Which facilitates lip-reading by the hearing-impaired child?
    a. Speaking at an even rate
    b. Exaggerating the pronunciation of words
    c. Avoiding the use of facial expressions
    d. Repeating words in exactly the same way if a child does not understand

Answer 17

ANS: A
Speaking at an even rate should help the child to learn and understand how to read lips. Exaggerating word pronunciation, avoiding facial expressions, and repeating words are characteristics of communication that would interfere with the child’s comprehension of the spoken word.

Question 18

18. Preventing hearing impairment in children is a major goal for a nurse. What is one way that this can be achieved?
    a. Be involved in immunization clinics for children.
    b. Assess a newborn for hearing loss.
    c. Answer parents’ questions about hearing aids.
    d. Participate in hearing screening in the community.

Answer 18

ANS: A
Childhood immunizations can eliminate the possibility of acquired sensorineural hearing loss from rubella, mumps, or measles encephalitis. Assessing a newborn for hearing loss, answering parents’ questions about hearing aids, and participating in community hearing screenings are all interventions to identify the presence of hearing loss, not prevent it.

Question 19

19. Which term refers to the ability to see objects clearly at close range but not at a distance? a. Myopia
    b. Amblyopia c. Cataract
    d. Glaucoma

Answer 19

ANS: A
Myopia or nearsightedness refers to the ability to see objects clearly at close range but not at a distance. Amblyopia, or lazy eye, is reduced visual acuity in one eye. A cataract is opacity of the lens of the eye. Glaucoma is a group of eye diseases characterized by increased intraocular pressure.

Question 20

20. Which term refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina? a. Myopia
    b. Amblyopia c. Cataract
    d. Glaucoma

Answer 20

ANS: C
A cataract refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina. Myopia or nearsightedness refers to the ability to see objects clearly at close range but not at a distance Amblyopia, or lazy eye, is reduced visual acuity in one eye. Glaucoma is a group of eye diseases characterized by increased intraocular pressure.

Question 21

21. Which behaviour would the nurse suspect a possible visual impairment in a child?
    a. Excessive rubbing of the eyes
    b. Rapid lateral movement of the eyes
    c. Delay in speech development
    d. Lack of interest in casual conversation with peers

Answer 21

ANS: A
Excessive rubbing of the eyes is a clinical manifestation of visual impairment. Rapid lateral movement of the eyes, delay in speech development, and lack of interest in casual conversation with peers are not associated with visual impairment.

Question 22

22. The school nurse is caring for a child with a penetrating eye injury. Which is included in emergency treatment?
    a. Apply a regular eye patch.
    b. Apply a Fox shield to the affected eye and any type of patch to the other eye.
    c. Apply ice until the physician is seen.
    d. Irrigate the eye copiously with a sterile saline solution.

Answer 22

ANS: B
The nurse’s role in treating a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye, and a regular eye patch to the other eye to prevent bilateral movement. Depending on the injury, applying a regular eye patch or ice until the physician is seen or irrigating the eye with a copious amount of sterile saline may cause more damage.

Question 23

23. A father calls the emergency department nurse, saying that his daughter’s eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. What should the nurse recommend the parents do before transporting the child?
    a. Keep the eyes closed.
    b. Apply cold compresses.
    c. Irrigate eyes copiously with tap water for 20 minutes.
    d. Prepare a normal saline solution (salt and water) and irrigate eyes for 20 minutes.

Answer 23

ANS: C
The first action is to flush the eyes with clean tap water, to rinse the detergent from the eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do further harm during transport. Normal saline is not necessary, and the delay to prepare it can allow the detergent to cause continued injury to the eyes.

Question 24

24. An adolescent gets hit in the eye during a fight. The school nurse, using a flashlight, notes the presence of a gross hyphema. What should the nurse do?
    a. Apply a Fox shield.
    b. Instruct the adolescent to apply ice for 24 hours.
    c. Have the adolescent rest with eye closed and ice applied.
    d. Notify the parents that the adolescent needs to see an ophthalmologist.

Answer 24

ANS: D
The parents should be notified that the adolescent needs to see an ophthalmologist as soon as possible. Applying a Fox shield, instructing the adolescent to apply ice for 24 hours, and having the adolescent rest with the eye closed and ice applied may cause further damage.

Question 25

25. What is the most common clinical manifestation of retinoblastoma?
    a. Glaucoma
    b. Amblyopia
    c. White eye reflex
    d. Sunken eye socket

Answer 25

ANS: C
When examining the eye, the light will reflect off of the tumour, giving the eye a whitish appearance. This is called white eye reflex. A late sign of retinoblastoma is a red, painful eye with glaucoma. Amblyopia, or lazy eye, is reduced visual acuity in one eye. The eye socket is not sunken by retinoblastoma.

Question 26

1. Which developmental milestones, when not achieved, warrant a hearing and language evaluation? Select all that apply. Express answer in small letters followed by a comma and a space—e.g., a, b, c.
   a. An increase in extant expressive speech at age 3 years.
   b. Absence of babbling by age 6 months.
   c. Absence of gesturing by age 12 months.
   d. No single-word vocabulary by age 16 months.
   e. No two-word phrases by age 18 months.

Answer 26

ANS: C, D
Any child who does not display language skills as babbling or gesturing by 12 months, single words by 16 months, and two-word phrases by 24 months should undergo further evaluation. A sudden deterioration in extant expressive speech is also an indication for further evaluation.

Question 27

2. Which clinical manifestations would the nurse expect when completing an assessment on a child with Fragile X syndrome? Select all that apply. Express answer in small letters followed by a comma and a space—e.g., a, b, c.
   a. Increased head circumference
   b. Long and wide ears
   c. Strabismus
   d. Hypertonia
   e. Short, wide face
   f. Receding jaw

Answer 27

ANS: A, B, C
Children with Fragile X syndrome have an increased head circumference; long, wide, and protruding ears; long, narrow face with prominent jaw; strabismus; mitral valve prolapse; hypotonia; and enlarged testicles.