Seizures, Parkinson Disease, Spina Bifida (66,70,52)

Question 1

<p>1. A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication?
 A) Hydrochlorothiazide (HydroDIURIL)
 B) Furosemide (Lasix) 
C) Mannitol (Osmitrol) 
D) Spirolactone (Aldactone)</p>

Answer 1

<p>C) Mannitol (Osmitrol)</p>

Question 2

<p>The nurse is providing care for a patient who is unconscious. What nursing intervention takes highestpriority?
A) Maintaining accurate records of intake and output
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control</p>

Answer 2

<p>B) Maintaining a patent airwayMaintaining a patent airway always takes top priority, even though each of the other listed actions isnecessary and appropriate.</p>

Question 3

<p>The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan ofcare, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmoticdiuretic use. What would be an appropriate intervention for this diagnosis?
A) Change the patients position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values.</p>

Answer 3

<p>B) Monitor serum electrolytes.The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on anindividual basis. The volume and composition of fluids are adjusted based on daily serum electrolytevalues, along with fluid intake and output. Fluids may have to be restricted in patients with cerebraledema. Changing the patients position, maintaining an NPO status, and monitoring ABG values do notrelate to the nursing diagnosis of deficient fluid volume.</p>

Question 4

<p>A patient with a documented history of seizure disorder experiences a generalized seizure. What nursingaction is most appropriate?
A) Restrain the patient to prevent injury.
B) Open the patients jaws to insert an oral airway.
C) Place patient in high Fowlers position.
D) Loosen the patients restrictive clothing.</p>

Answer 4

<p>D) Loosen the patients restrictive clothingAn appropriate nursing intervention would include loosening any restrictive clothing on the patient. Noattempt should be made to restrain the patient during the seizure because muscular contractions arestrong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm toinsert anything. Broken teeth and injury to the lips and tongue may result from such an action. Ifpossible, place the patient on one side with head flexed forward, which allows the tongue to fall forwardand facilitates drainage of saliva and mucu</p>

Question 5

<p>A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of theadverse of effects of this medication, the nurse should prioritize which of the following in the patientsplan of care?</p>

Answer 5

<p>C) Administration of thorough oral hygieneGingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin)use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid andprotein restriction are contraindicated and there is no particular need for constant oxygen saturationmonitoring.</p>

Question 6

<p>While completing a health history on a patient who has recently experienced a seizure, the nurse wouldassess for what characteristic associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity</p>

Answer 6

<p>B) ConfusionIn the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleepfor hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chestmuscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body arefollowed by alternating muscle relaxation and contraction (generalized tonicclonic contraction) duringthe seizure.</p>

Question 7

<p>The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know maybe given to halt the seizure immediately?
A) Intravenous phenobarbital (Luminal)
B) Intravenous diazepam (Valium)
C) Oral lorazepam (Ativan)
D) Oral phenytoin (Dilantin)</p>

Answer 7

<p>B) Intravenous diazepam (Valium)Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan)given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital)are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.</p>

Question 8

<p>What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomyexhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
A) Cushing syndrome
B) Syndrome of inappropriate antidiuretic hormone (SIADH)
C) Adrenal crisis
D) Diabetes insipidus</p>

Answer 8

<p>D) Diabetes insipidusDiabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brainsurgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and waterretention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis isundersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.</p>

Question 9

<p>During the examination of an unconscious patient, the nurse observes that the patients pupils are fixedand dilated. What is the most plausible clinical significance of the nurses finding?
A) It suggests onset of metabolic problems.
B) It indicates paralysis on the right side of the body.
C) It indicates paralysis of cranial nerve X.
D) It indicates an injury at the midbrain level</p>

Answer 9

<p>D) It indicates an injury at the midbrain level.</p>

Question 10

<p>Following a traumatic brain injury, a patient has been in a coma for several days. Which of the followingstatements is true of this patients current LOC?

A) The patient occasionally makes incomprehensible sounds.
B) The patients current LOC will likely become a permanent state.
C) The patient may occasionally make nonpurposeful movements.
D) The patient is incapable of spontaneous respirations.</p>

Answer 10

<p>C) The patient may occasionally make nonpurposeful movements.Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal orexternal stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes maybe present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary. Comas are not permanent states.</p>

Question 11

<p>The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic headinjury. When working with this patient and family, what mutual goal should be prioritized?
A) Achieve as high a level of function as possible.
B) Enhance the quantity of the patients life.
C) Teach the family proper care of the patient.
D) Provide community assistance</p>

Answer 11

<p>A) Achieve as high a level of function as possible</p>

Question 12

<p>2. The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse andother members of the care team are present at the bedside when the patient has a seizure. In preparationfor documenting this clinical event, the nurse should note which of the following?
A) The ability of the patient to follow instructions during the seizure.
B) The success or failure of the care team to physically restrain the patient.
C) The patients ability to explain his seizure during the postictal period.
D) The patients activities immediately prior to the seizure</p>

Answer 12

<p>D) The patients activities immediately prior to the seizure.Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; andhyperventilation. Communication with the patient is not possible during a seizure and physical restraintis not attempted. The patients ability to explain the seizure is not clinically relevant.</p>

Question 13

<p>. The nurse is caring for a patient whose recent health history includes an altered LOC. What should bethe nurses first action when assessing this patient?
A) Assessing the patients verbal response
B) Assessing the patients ability to follow complex commands
C) Assessing the patients judgment
D) Assessing the patients response to pain</p>

Answer 13

<p>A) Assessing the patients verbal responseAssessment of the patient with an altered LOC often starts with assessing the verbal response throughdetermining the patients orientation to time, person, and place. In most cases, this assessment willprecede each of the other listed assessments, even though each may be indicated.</p>

Question 14

<p>. The nurse caring for a patient in a persistent vegetative state is regularly assessing for potentialcomplications. Complications of neurologic dysfunction for which the nurse should assess include whichof the following? Select all that apply.
A) Contractures
B) Hemorrhage
C) Pressure ulcers
D) Venous thromboembolismE) Pneumonia</p>

Answer 14

<p>A) ContracturesC) Pressure ulcersD) Venous thromboembolismE) Pneumonia</p>

Question 15

<p>A patient has experienced a seizure in which she became rigid and then experienced alternating musclerelaxation and contraction. What type of seizure does the nurse recognize?
A) Unclassified seizure
B) Absence seizure
C) Generalized seizure
D) Focal seizure</p>

Answer 15

<p>C) Generalized seizureGeneralized seizures often involve both hemispheres of the brain, causing both sides of the body toreact. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation andcontraction (generalized tonicclonic contraction). This pattern of rigidity does not occur in patients whoexperience unclassified, absence, or focal seizures.</p>

Question 16

<p>1. A patient is recovering from intracranial surgery performed approximately 24 hours ago and iscomplaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action ismost appropriate?
A) Administer morphine sulfate as ordered.
B) Reposition the patient in a prone position.
C) Apply a hot pack to the patients scalp.
D) Implement distraction techniques.</p>

Answer 16

<p>A) Administer morphine sulfate as ordered.</p>

Question 17

<p>A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that thepatients LOC is slightly decreased compared with the day of surgery. What is the nurses best response tothis assessment finding?
A) Recognize that this may represent the peak of post-surgical cerebral edema.
B) Alert the surgeon to the possibility of an intracranial hemorrhage.
C) Understand that the surgery may have been unsuccessful.
D) Recognize the need to refer the patient to the palliative care team.</p>

Answer 17

<p>A) Recognize that this may represent the peak of post-surgical cerebral edema.</p>

Question 18

<p>4. A school nurse is called to the playground where a 6-year-old girl has been found unresponsive andstaring into space, according to the playground supervisor. How would the nurse document the girlsactivity in her chart at school?
A) Generalized seizure
B) Absence seizure
C) Focal seizure
D) Unclassified seizure</p>

Answer 18

<p>B) Absence seizureStaring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, andunclassified seizures involve uncontrolled motor activity.</p>

Question 19

<p>The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. Whatmedication would the nurse expect to administer prophylactically to prevent seizures in this patient?
A) Prednisone
B) Dexamethasone
C) Cafergot
D) Phenytoin</p>

Answer 19

<p>D) PhenytoinAntiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who haveundergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisoneand dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment ofmigraines.</p>

Question 20

<p>A hospital patient has experienced a seizure. In the immediate recovery period, what action best protectsthe patients safety?
A) Place the patient in a side-lying position.
B) Pad the patients bed rails.
C) Administer antianxiety medications as ordered.
D) Reassure the patient and family member</p>

Answer 20

<p>A) Place the patient in a side-lying positionTo prevent complications, the patient is placed in the side-lying position to facilitate drainage of oralsecretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. Noneof the other listed actions promotes safety during the immediate recovery period.</p>

Question 21

A patient with suspected Parkinsons disease is initially being assessed by the nurse. When is the best
time to assess for the presence of a tremor?
A) When the patient is resting
B) When the patient is ambulating
C) When the patient is preparing his or her meal tray to eat
D) When the patient is participating in occupational therapy

Answer 21

A) When the patient is resting

The tremor is present while the patient is at rest; it increases when the patient is walking, concentrating, or feeling anxious. Resting tremor characteristically disappears with purposeful movement, but is
evident when the extremities are motionless. Consequently, the nurse should assess for the presence of a
tremor when the patient is not performing deliberate actions.

Question 22

The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the patients
ADLs, what goal should the nurse prioritize?

A) Promoting the patients recovery from the disease
B) Maximizing the patients level of function
C) Ensuring the patients adherence to treatment
D) Fostering the familys participation in care

Answer 22

B) Maximizing the patients level of function

Priority for the care of the child with muscular dystrophy is the need to maximize the patients level of
function. Family participation is also important, but should be guided by this goal. Adherence is not a
central goal, even though it is highly beneficial, and the disease is not curable.

Question 23

A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently
developed adventitious lung sounds. The patients nutritional needs should be met by what method?
A) Total parenteral nutrition (TPN)
B) Provision of a low-residue diet
C) Semisolid food with thick liquids
D) Minced foods and a fluid restriction

Answer 23

C) Semisolid food with thick liquids

The MRI scan is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool
that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.

Question 24

A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently
developed adventitious lung sounds. The patients nutritional needs should be met by what method?
A) Total parenteral nutrition (TPN)
B) Provision of a low-residue diet
C) Semisolid food with thick liquids
D) Minced foods and a fluid restriction

Answer 24

C) Semisolid food with thick liquids

A semisolid diet with thick liquids is easier for a patient with swallowing difficulties to consume than is
a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the
patients nutritional status. The patients status does not warrant TPN.

Question 25

A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients
subsequent care for the home setting. What nursing diagnosis should the nurse address when educating
the patients family?
A) Risk for infection
B) Impaired spontaneous ventilation
C) Unilateral neglect
D) Risk for injury

Answer 25

D) Risk for injury

Individuals with Parkinsons disease face a significant risk for injury related to the effects of dyskinesia. Unilateral neglect is not characteristic of the disease, which affects both sides of the body. Parkinsons
disease does not directly constitute a risk for infection or impaired respiration

Question 26

A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to
this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patients safety.
C) Teach the patients family about the relationship between brain tumors and seizure activity.
D) Ensure that the patient is housed in a private room.

Answer 26

B) Implement precautions to ensure the patients safety.

Patients with seizures are carefully monitored and protected from injury. Patient safety is a priority over
health education, even though this is appropriate and necessary. Specific triggers may or may not be
evident; identifying these is not the highest priority. A private room is preferable, but not absolutely
necessary.

Question 27

A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What
should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patients mouth.
D) Turn the patient on his side.

Answer 27

D) Turn the patient on his side.

The nurses first response should be to place the patient on his side to prevent him from aspirating
emesis. Inserting something into the seizing patients mouth is no longer part of a seizure protocol. Obtaining supplies to suction the patient would be a delegated task. Paging or calling the physician
would only be necessary if this is the patients first seizure.

Question 28

An older adult has encouraged her husband to visit their primary care provider, stating that she is
concerned that he may have Parkinsons disease. Which of the wifes descriptions of her husbands health
and function is most suggestive of Parkinsons disease?
A) Lately he seems to move far more slowly than he ever has in the past.
B) He often complains that his joints are terribly stiff when he wakes up in the morning.
C) Hes forgotten the names of some people that weve known for years.
D) Hes losing weight even though he has a ravenous appetite.

Answer 28

A) Lately he seems to move far more slowly than he ever has in the past.

Parkinsons disease is characterized by bradykinesia. It does not manifest as memory loss, increased
appetite, or joint stiffness.

Question 29

A patient who was diagnosed with Parkinsons disease several months ago recently began treatment with
levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom
relief. The nurse should be aware of what implication of the patients medication regimen
A) The patient is in a honeymoon period when adverse effects oflevodopa-carbidopa are not yet
evident.
B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment.
C) The patients temporary improvement in status is likely unrelated to levodopa-carbidopa.
D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

Answer 29

D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment

The beneficial effects of levodopa therapy are most pronounced in the first year or two of treatment. Benefits begin to wane and adverse effects become more severe over time. However, a honeymoon
period of treatment is not known.

Question 30

The nurse caring for a patient diagnosed with Parkinsons disease has prepared a plan of care that would
include what goal?
A) Promoting effective communication
B) Controlling diarrhea
C) Preventing cognitive decline
D) Managing choreiform movements

Answer 30

A) Promoting effective communication

A) Promoting effective communication

Question 31

The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing
problems with rising from the sitting to the standing position. What should the nurse suggest to the
patient to use that will aid in getting from the sitting to the standing position as well as aid in improving
bowel elimination?
A) Promoting effective communication
B) Use of a raised toilet seat
C) Sitting quietly on the toilet every 2 hours
D) Following the outlined bowel program

Answer 31

B) Use of a raised toilet seat

A raised toilet seat is useful, because the patient has difficulty in moving from a standing to a sitting
position. A handicapped toilet is not high enough and will not aid in improving bowel elimination. Sitting quietly on the toilet every 2 hours will not aid in getting from the sitting to standing position;
neither will following the outlined bowel program.

Question 32

A patient with Parkinsons disease is experiencing episodes of constipation that are becoming
increasingly frequent and severe. The patient states that he has been achieving relief for the past few
weeks by using OTC laxatives. How should the nurse respond?

A) Its important to drink plenty of fluids while youre taking laxatives.
B) Make sure that you supplement your laxatives with a nutritious diet.
C) Lets explore other options, because laxatives can have side effects and create dependency.
D) You should ideally be using herbal remedies rather than medications to promote bowel function

Answer 32

C) Lets explore other options, because laxatives can have side effects and create dependency

Laxatives should be avoided in patients with Parkinsons disease due to the risk of adverse effects and
dependence. Herbal bowel remedies are not necessarily less risky.

Question 33

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?

a. Headache
b. Bulging fontanel
c. Tachypnea
d. Increase in head circumference

Answer 33

a. Headache

Headaches are a clinical manifestation of increased ICP in children. A change in the child’s normal behavior pattern may be an important early sign of increased ICP. Bulging fontanel or increased head circumference is seen in infants. A change in respiratory pattern is a late sign of increased ICP. Cheyne–Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length.

Question 34

Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain?

a. “You won’t be able to move your head during the procedure.”
b. “You will have to drink a special fluid before the test.”
c. “You will have to lie flat after the test is finished.”
d. “You will have electrodes placed on your head with glue.”

Answer 34

a. “You won’t be able to move your head during the procedure.”

To reduce fear and enhance cooperation during the MRI, the child should be made aware that head movement will be restricted to obtain accurate information. The child does not need to drink special liquids, lie on the back afterward, or have electrodes placed.

Question 35

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?

a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative state

Answer 35

b. Stupor

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

Question 36

The Glasgow Coma Scale consists of an assessment of

a. pupil reactivity and motor response.
b. eye opening and verbal and motor responses.
c. level of consciousness and verbal response.
d. ICP and level of consciousness.

Answer 36

b. eye opening and verbal and motor responses.

The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness is not a part of the Glasgow Coma Scale. Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale.

Question 37

Nursing care of the infant who has had a myelomeningocele repair should include

a. securely fastening the diaper.
b. measurement of pupil size.
c. measurement of head circumference.
d. administration of seizure medications.

Answer 37

c. measurement of head circumference.

Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Seizure medications are not routinely given to infants who do not have seizures.

Question 38

The most common problem of children born with a myelomeningocele is

a. bladder incontinence.
b. intellectual impairment.
c. respiratory compromise.
d. cranioschisis.

Answer 38

a. bladder incontinence.

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children, leading to incontinence. Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

Question 39

A recommendation to prevent neural tube defects is the supplementation of

a. vitamin A throughout pregnancy.
b. multivitamin preparations as soon as pregnancy is suspected.
c. folic acid for all women of childbearing age.
d. folic acid during the first and second trimesters of pregnancy.

Answer 39

c. folic acid for all women of childbearing age.

The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. Vitamin A, multivitamins, and folic acid only during specific points during the pregnancy have not been shown to prevent neural tube defects.

Question 40

How much folic acid does the nurse tell female patients is recommended for women of childbearing age?

a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg

Answer 40

b. 0.4 mg

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age has contributed to a reduction in the number of children with neural tube defects. The other doses are not the recommended dose.

Question 41

Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which of the following?

a. Avoiding using any latex product
b. Using only non-allergenic latex products
c. Administering medication for long-term desensitization
d. Teaching family about long-term management of allergic manifestations

Answer 41

a. Avoiding using any latex product

Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75% of this patient population. There are no non-allergenic latex products. At this time, desensitization is not an option. There are no treatment options for long-term management of allergic symptoms for latex allergy.

Question 42

When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of which disorder?

a. Hydrocephalus
b. Syndrome of inappropriate antidiuretic hormone (SIADH)
c. Cerebral palsy
d. Reye’s syndrome

Answer 42

a. Hydrocephalus

The combination of signs is strongly suggestive of hydrocephalus. SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reye’s syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

Question 43

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis?

a. CSF appears cloudy.
b. CSF pressure is decreased.
c. Few leukocytes are present.
d. Glucose level is increased compared with blood.

Answer 43

a. CSF appears cloudy.
ANS: A
In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually decreased compared with the serum glucose level.

Question 44

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child?

a. “You will be on your knees with your head down on the table.”
b. “You will be able to sit up with your chin against your chest.”
c. “You will be on your side with the head of your bed slightly raised.”
d. “You will lie on your side and bend your knees so that they touch your chin.”

Answer 44

d. “You will lie on your side and bend your knees so that they touch your chin.”

The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The other positions are not used for a lumbar puncture.

Question 45

A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure?

a. Absence
b. Atonic
c. Tonic–clonic
d. Simple partial

Answer 45

a. Absence
Absence seizures are very brief episodes of altered awareness. The child has a blank expression. Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic–clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms

Question 46

What is the best response to a father who tells the nurse that his son “daydreams” at home and that his teacher has observed this behavior at school?

a. “Your son must have an active imagination.”
b. “Can you tell me exactly how many times this occurs in one day?”
c. “Tell me about your son’s activity when you notice the daydreams.”
d. “He is probably overtired and needs more rest.”

Answer 46

c. “Tell me about your son’s activity when you notice the daydreams.”

The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained. Describing an active imagination or an overtired child does not address the symptoms of the father’s concern. Determining the number of times the behavior occurs is not as helpful as information about the behavior.

Question 47

The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures?

a. Weight loss
b. Bruising
c. Anorexia
d. Drowsiness

Answer 47

b. Bruising

Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. Weight gain, not loss, is a side effect of valproic acid. Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications. Anorexia is not a side effect of valproic acid.

Question 48

A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child’s level of consciousness?

a. Disoriented
b. Obtunded
c. Lethargic
d. Stuporous

Answer 48

b. Obtunded
ANS: B
Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

Question 49

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of nursing assessment to detect early signs of a worsening condition?

a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness

Answer 49

d. Level of consciousness

The most important nursing observation is assessment of the child’s level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

Question 50

A 5-year-old sustained a concussion after falling out of a tree. In preparation for discharge, the nurse is discussing home care with the parents. Which statement made by the parents indicates a correct understanding of the teaching?

a. “I should expect my child to have a few episodes of vomiting.”
b. “If I notice sleep disturbances, I should contact the physician immediately.”
c. “I should expect my child to have some behavioral changes after the accident.”
d. “If I notice diplopia, I will have my child rest for 1 hour.”

Answer 50

c. “I should expect my child to have some behavioral changes after the accident.”

The parents are advised of probable posttraumatic symptoms. These include behavioral changes and sleep disturbances. Vomiting and diplopia should be reported immediately. Sleep disturbances may occur with postconcussive syndrome, but difficulty waking the child up should be reported.

Question 51

Which type of seizure involves both hemispheres of the brain?

a. Focal
b. Partial
c. Generalized
d. Acquired

Answer 51

c. Generalized

Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

Question 52

What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic–clonic seizure?

a. Guide the child to the floor if standing and go for help.
b. Turn the child’s body on the side.
c. Place a padded tongue blade between the teeth.
d. Quickly slip soft restraints on the child’s wrists.

Answer 52

b. Turn the child’s body on the side.

ANS: B
Positioning the child on his side will prevent aspiration. It is inappropriate to leave the child during the seizure. Nothing should be inserted into the child’s mouth during a seizure to prevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

Question 53

After a tonic–clonic seizure, it would not be unusual for a child to display

a. irritability and hunger.
b. lethargy and confusion.
c. nausea and vomiting.
d. nervousness and excitability.

Answer 53

b. lethargy and confusion.

In the period after a tonic–clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. The other manifestations are not normally seen after a seizure.

Question 54

What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures?

a. The child should use a soft toothbrush and floss the teeth after every meal.
b. The child will require monitoring of renal function while taking this medication.
c. Dilantin should be taken with food because it causes gastrointestinal distress.
d. The medication can be stopped when the child has been seizure free for 1 month.

Answer 54

ANS: A
A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

Question 55

The father of a newborn infant with myelomeningocele asks about the cause of this condition. What response by the nurse is most appropriate?

a. “One of the parents carries a defective gene that causes myelomeningocele.”
b. “A deficiency in folic acid in the father is the most likely cause.”
c. “Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele.”
d. “There may be no definitive cause identified.”

Answer 55

ANS: D
The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.

Question 56

Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

a. Rapid, shallow breathing
b. Irregular, rapid heart rate
c. Increased diastolic pressure with narrowing pulse pressure
d. Confusion and altered mental status

Answer 56

ANS: D
The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema. Respiratory changes occur with ICP. One pattern that may be evident is Cheyne–Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with ICP. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

Question 57

What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain–Barré syndrome (GBS)?

a. Immunosuppressive medications
b. Respiratory assessment
c. Passive range-of-motion exercises
d. Anticoagulant therapy

Answer 57

ANS: B
Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This is not the priority nursing intervention.

Question 58

A child is brought to the emergency department in status epilepticus. Which medication should the nurse expect to be given initially in this situation?

a. Clorazepate dipotassium (Tranxene)
b. Fosphenytoin (Cerebyx)
c. Phenobarbital
d. Lorazepam (Ativan)

Answer 58

ANS: D
Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic–clonic status epilepticus and may also be used for seizures lasting more than 5 minutes. The other drugs are used for seizures but are not the first-line treatment for status.

Question 59

What should be the nurse’s first action when a child with a head injury complains of double vision and a headache, and then vomits?

a. Immobilize the child’s neck.
b. Report this information to the physician.
c. Darken the room and put a cool cloth on the child’s forehead.
d. Restrict the child’s oral fluid intake.

Answer 59

ANS: B
Any indication of ICP such as double vision, headache, or vomiting should be promptly reported to the physician. Stabilizing the child’s neck does not address the child’s symptoms. Darkening the room and giving a cool cloth are comfort measures. A fluid restriction is not needed.

Question 60

A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences?

a. The infant has 150 mL of CSF compared with 50 mL in the adult.
b. Papilledema is a common manifestation of ICP in the very young child.
c. The brain of a term infant weighs less than half of the weight of the adult brain.
d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

Answer 60

ANS: D
Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the child’s coordination and fine muscle movements. An infant has about 50 mL of CSF compared with 150 mL in an adult. Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP. The brain of the term infant is two thirds the weight of an adult’s brain.

Question 61

The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when 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.”

Answer 61

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, sedation is sometimes necessary. The child will not be allowed to move and will be immobilized. Someone is able to remain with the child during the procedure.

Question 62

Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?

a. Nuclear brain scan
b. Echoencephalography
c. CT scan
d. MRI

Answer 62

ANS: C
A CT scan provides a visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood–brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and permits tissue discrimination that is unavailable with any other techniques.

Question 63

What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? (Select all that apply.)

a. It must be given with D51/2 NS.
b. Occasional blood levels will be assessed.
c. Dilantin should be given with food because it causes gastrointestinal distress.
d. It must be given in normal saline.
e. It must be filtered.

Answer 63

ANS: B, D, E
The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D51/2 NS. The IV dose must be filtered. The IV dose must be given in normal saline, not D51/2 NS. Dilantin has not been found to cause gastrointestinal upset, and since it is being given by the IV route, this is not a concern. The medication can be taken without food.

Question 64

A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? (Select all that apply.)

a. Elevated white blood count (WBC)
b. Decreased protein
c. Decreased glucose
d. Cloudy in color
e. Increase in red blood cells (RBC)

Answer 64

ANS: A, C, D
The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

Question 65

A 14-year-old is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes (Select all that apply.)

a. monitoring and maintaining systemic blood pressure.
b. administering corticosteroids.
c. minimizing environmental stimuli.
d. discussing long-term care issues with the family.
e. monitoring for respiratory complications.

Answer 65

ANS: A, B, E
Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. Spinal cord injury is a catastrophic event. Discussion of long-term care should be delayed until the child is stable.