TEST 7: The Child with Neurologic Health Problems

Question 1

The Client with Myelomeningocele
1. Parents bring a 10-month-old boy born with myelomeningocele and hydrocephalus with a
ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor
feeding, lethargy, and irritability. What interventions by the nurse are most appropriate? Select all
that apply.
1. Weigh the child.
2. Listen to bowel sounds.
3. Palpate the anterior fontanel.
4. Obtain vital signs.
5. Assess pitch and quality of the child’s cry.

Answer 1

The Client with Myelomeningocele
1. 2,3,4,5. Common shunt complications are obstruction, infection, and disconnection of the
tubing. The signs presented by the child indicate increased intracranial pressure from a shunt
malformation, which could be caused by an infection, such as peritonitis or meningitis. By listening to
bowel sounds, the nurse will note if peritonitis might be a possibility. Palpating the fontanel would
indicate increased intracranial pressure if it were bulging and taut. Obtaining vital signs would assess
for signs of infection, such as elevated temperature or, possibly, Cushing’s triad (elevated blood
pressure, slow pulse, and depressed respirations). A high-pitched cry is a sign of increased
intracranial pressure. Weighing the child at this time would not be a priority, nor would it add to
identifying the cause of the signs and symptoms.
CN: Physiological adaptation; CL: Synthesize

Question 2

2. When positioning a neonate with an unrepaired myelomeningocele, which of the following
   positions is most appropriate?
3. Supine with the hips at 90-degree flexion.
4. Right side-lying position with the knees flexed.
5. Prone with hips in abduction.
6. Supine in semi-Fowler’s position with chest and abdomen elevated.

Answer 2

2. 3. Before surgery, the infant is kept flat in the prone position to decrease tension on the sac.
      This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are
      common. The supine position is unacceptable because it causes pressure on the defect. Flexing the
      knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler’s
      position, even though the chest and abdomen are elevated.
      CN: Physiological adaptation; CL: Synthesize

Question 3

3. The nurse is teaching the parents of a child with myelomeningocele how to prevent urinary
   tract infections. What should the care plan include for this child? Select all that apply.
4. Provide meticulous skin care.
5. Use Crede’s maneuver to empty the bladder.
6. Encourage frequent emptying of the bladder.
7. Assure adequate fluid intake.
8. Use tight-fitting diapers around the meatus.

Answer 3

3. 2,3,4. Prevention of urinary tract infections includes adequate fluid intake, urine acidification,
   frequent emptying of the bladder including the use of Crede’s maneuver if needed. While the nurse
   should keep the skin clean and dry, this will not prevent urinary tract infections. Keeping urine close
   to the meatus with a tight-fitting diaper would increase the risk for infection.
   CN: Reduction of risk potential; CL: Create

Question 4

4. The nurse reports to the primary health care provider signs of increased intracranial pressure
   in an infant with a myelomeningocele who has which of the following?
5. Minimal lower-extremity movement.
6. A high-pitched cry.
7. Overflow voiding only.
8. A fontanel that bulges with crying.

Answer 4

4. 2. A Chiari malformation obstructs the flow of cerebral spinal fluid resulting in hydrocephalus.
      This is a common problem in infants with myelomeningocele and will require surgical intervention
      with a shunt. A high-pitched cry is one sign of increased intracranial pressure that may indicate the
      presence of a Chiari malformation and requires further evaluation. Minimal movement of the lower
      extremities is an expected finding associated with spinal cord damage. Overflow voiding comes from
      a neurogenic bladder, not increased intracranial pressure. It is normal for the fontanel to bulge with
      crying.
      CN: Physiological adaptation; CL: Analyze

Question 5

5. When developing the plan of care for an infant diagnosed with myelomeningocele and the
   parents who have just been informed of the infant’s diagnosis, which action should the nurse include
   as the priority when the parents visit the infant for the first time?
6. Emphasizing the infant’s normal and positive features.
7. Encouraging the parents to discuss their fears and concerns.
8. Reinforcing the doctor’s explanation of the defect.
9. Having the parents feed their infant.

Answer 5

5. 1. The parents should see the neonate as soon as possible, because the longer they must wait to
      see the neonate, the more anxiety they will feel. Because the parents are acutely aware of the deficit,the nurse should emphasize the neonate’s normal and positive features during the visit. All parents, but
      especially those with a child who has a disability or defect, need to hear positive comments and
      comments that reflect how the infant is normal. Although the parents need to discuss their fears and
      concerns, the priority on the first visit is to emphasize the neonate’s normal and positive features.
      Reinforcing the doctor’s explanation of the defect may be necessary later. Reinforcing the explanation
      at this initial visit emphasizes the defect, not the child. The parents should spend time with or care for
      the neonate after birth because parent-infant contact is necessary for attachment. The parents cannot
      feed the neonate before the defect is repaired because the repair typically occurs within 24 hours. The
      infant will be prone in an isolette or warmed and watched closely. However, the parents can fondle
      and stroke the neonate.
      CN: Psychosocial integrity; CL: Synthesize

Question 6

6. The mother of an infant with myelomeningocele asks if her baby is likely to have any other
   defects. The nurse responds based on the understanding that myelomeningocele is commonly
   associated with which disorder?
7. Excessive cerebrospinal fluid within the cranial cavity.
8. Abnormally small head.3. Congenital absence of the cranial vault.
9. Overriding of the cranial sutures.

Answer 6

6. 1. Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most
      common anomaly associated with myelomeningocele. Microencephaly, an abnormally small head, is
      associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence
      of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a
      normal finding after a vaginal delivery, is not associated with myelomeningocele.
      CN: Physiological adaptation; CL: Apply

Question 7

7. The parents of an infant with myelomeningocele ask the nurse about their child’s future mental
   ability. What is the nurse’s best response?
8. “About one-third have an intellectual disability, but it’s too early to tell about your child.”
9. “About two-thirds have an intellectual disability significantly retarded, and you’ll know soon if
   this will occur.”
10. “Your child will probably be of normal intelligence since he demonstrates signs of it now.”
11. “You’ll need to talk with the doctor about that, but you can ask later.”

Answer 7

7. 1. Approximately one-third of infants diagnosed with myelomeningocele are mentally retarded,
      but the degree of retardation is variable and it is difficult to predict intellectual functioning in
      neonates. The parents are asking for an answer now and should not be told to talk with the primary
      health care provider later.
      CN: Physiological adaptation; CL: Synthesize

Question 8

8. After placing an infant with myelomeningocele in an isolette shortly after birth, which
   indicator should the nurse use as the best way to determine the effectiveness of this intervention?
9. The partial pressure of arterial oxygen remains between 94 and 100 mm Hg.
10. The axillary temperature remains between 97°F and 98°F (36.1°C and 36.7°C).
11. The bilirubin level remains stable.
12. Weight increases by about 1 oz (28.35 g) per day.

Answer 8

8. 2. The nurse places the neonate with myelomeningocele in an isolette shortly after birth to help
      to maintain the infant’s temperature. Because of the defect, the neonate cannot be bundled in blankets.
      Therefore, it may be difficult to prevent cold stress. The isolette can be maintained at higher than
      room temperature, helping to maintain the temperature of a neonate who cannot be dressed or
      bundled. Body temperature readings, not arterial oxygen levels, are the best indicator. Typically, an
      infant loses 5% to 10% of body weight before beginning to regain the weight.
      CN: Reduction of risk potential; CL: Analyze

Question 9

9. After surgical repair of a myelomeningocele, which position should the nurse use to prevent
   musculoskeletal deformity in the infant?
10. Placing the feet in flexion.
11. Allowing the hips to be abducted.
12. Maintaining knees in the neutral position.
13. Placing the legs in adduction.

Answer 9

9. 2. Because of the potential for hip dislocation, the neonate’s legs should be slightly abducted,
      hips maintained in slight to moderate abduction, and feet maintained in a neutral position. The infant’s
      knees are flexed to help maintain the hips in abduction.
      CN: Reduction of risk potential; CL: Synthesize

Question 10

10. When developing the discharge plan for the parents of an infant who has undergone a
    myelomeningocele repair, what information is most important for the nurse to include?
11. A list of available hospital services.
12. Schedule for daily home health care.
13. Chaplain referral for psychological support.
14. Daily care required by the infant.

Answer 10

10. 4. The most important aspect of the discharge plan is to ensure that the parents understand
       what the daily care of their infant involves and to provide teaching related to carrying out this daily
       care. In addition to the routine care required by the infant, care also may include physical therapy to
       the lower extremities. Providing a list of available hospital services may be helpful to the parents, but
       it is not the most important aspect to include in the discharge plan. Usually, home health care is not
       needed because the parents are able to care for their child. A referral for counseling is initiated
       whenever the need arises, not just at discharge.
       CN: Reduction of risk potential; CL: Synthesize

Question 11

11. Which of the following statements by the mother of an infant with a repaired upper lumbar
    myelomeningocele indicates that she understands the nurse’s teaching at the time of discharge?
12. “I can apply a heating pad to his lower back.”
13. “I’ll be sure to keep him away from other children.”
14. “I will call the doctor if his urine has a funny smell.”
15. “I will prop him on pillows to keep him from rolling over.”

Answer 11

11. 3. Children with a myelomeningocele are prone to urinary tract infections (UTI) and foul-
       smelling urine is one symptom of a UTI. Because of the level of defect, the child may be insensitive to
       pressure or heat. Using a heating pad may lead to thermal injury because the child may not be able to
       sense if the pad is too hot. Keeping the child away from other children is unnecessary and can retard
       social development. Using pillows as props increases the risk of sudden infant death syndrome.
       CN: Safety and infection control; CL: Evaluate

Question 12

12. A preschooler with a history of repaired lumbar myelomeningocele is in the emergency
    department with wheezing and skin rash. Which of the following questions should the nurse ask the
    mother first?
13. “Is your child taking any medications?”
14. “Who brought your child to the emergency department?”
15. “Is your child allergic to bananas or milk products?”
16. “What are you doing to treat your child’s skin rash?”

Answer 12

12. 3. Children with myelomeningocele are at high risk for development of latex allergy because
       of repeated exposure to latex products during surgery and bladder catheterizations. Cross-reactions to
       food items such as bananas, kiwi, milk products, chestnuts, and avocados also occur. These allergic
       reactions vary in severity ranging from mild (such as sneezing) to severe anaphylaxis. While the child
       could have allergies to medications that caused the wheezing, latex and food allergies are more
       common. Asking about the skin rash is not a priority when a child is wheezing. Who brought the child
       to the emergency department is irrelevant at this time.
       CN: Reduction of risk potential; CL: Analyze

Question 13

The Client with Hydrocephalus
13. Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable,
lethargic, and difficult to feed. To maintain the infant’s nutritional status, which of the following
actions would be most appropriate?
1. Feeding the infant just before doing any procedures.
2. Giving the infant small, frequent feedings.
3. Feeding the infant in a horizontal position.
4. Scheduling the feedings for every 6 hours.

Answer 13

The Client with Hydrocephalus
13. 2. An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and
vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at
times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure
is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be
held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian
tubes and subsequent development of ear infections. Most infants are fed on demand every 3 to 4
hours.
CN: Basic care and comfort; CL: Synthesize

Question 14

14. A 4-year-old child with hydrocephalus is scheduled to have a ventroperitoneal shunt in the
    right side of the head. When developing the child’s postoperative plan of care, the nurse should place
    the preschooler in which of the following positions immediately after surgery?
15. On the right side, with the foot of the bed elevated.
16. On the left side, with the head of the bed elevated.
17. Prone, with the head of the bed elevated.
18. Supine, with the head of the bed flat.

Answer 14

14. 4. For at least the first 24 hours after insertion of a ventriculoperitoneal shunt, the child is
       positioned supine with the head of the bed flat to prevent too rapid a decrease in cerebrospinal fluid
       pressure. Although elevating the head increases cerebrospinal fluid drainage and reduces intracranial
       pressure, a rapid reduction in the size of the ventricles can cause subdural hematoma. Positioning on
       the operative or right side is avoided because it places pressure on the shunt valve, possibly blocking
       desired drainage of the cerebrospinal fluid. Elevating the foot of the bed could increase intracranial
       pressure. With continued increased intracranial pressure, the child would be positioned with the head
       of the bed elevated to allow gravity to aid drainage. The child should be kept off the nonoperative
       side (side opposite the shunt), or the left side, to help prevent rapid decompression leading to a
       cerebral hematoma.
       CN: Reduction of risk potential; CL: Synthesize

Question 15

15. Which action should the nurse take when providing postoperative nursing care to a child after
    insertion of a ventriculoperitoneal shunt?
16. Administer narcotics for pain control.
17. Check the urine for glucose and protein.
18. Monitoring for increased temperature.
19. Test cerebrospinal fluid leakage for protein.

Answer 15

15. 3. Monitoring the temperature allows the nurse to assess for infection, the most common and
       the most hazardous postoperative complication after ventroperitoneal shunt placement. Typically, pain
       after insertion of a ventriculoperitoneal shunt is mild, requiring the use of mild analgesics. Usually
       narcotics are not administered because they alter the level of consciousness, making assessment of
       cerebral function difficult. Neither proteinuria nor glycosuria is associated with shunt placement.
       Cerebrospinal fluid leakage commonly occurs with head injury. It is not usually associated with shunt
       placement.CN: Reduction of risk potential; CL: Synthesize

Question 16

16. A nurse evaluates discharge teaching as successful when the parents of a school-age child
    with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt?
17. Decreased urine output with stable intake.
18. Tense fontanel and increased head circumference.
19. Elevated temperature and reddened incisional site.
20. Irritability and increasing difficulty with eating.

Answer 16

16. 4. In a school-age child, irritability, lethargy, vomiting, difficulty with eating, and decreased
       level of consciousness are signs of increased intracranial pressure caused by a blocked shunt.
       Decreased urine output with stable fluid intake indicates fluid loss from a source other than the
       kidneys. A tense fontanel and increased head circumference would be signs of a blocked shunt in an
       infant. Elevated temperature and redness around incisions might suggest an infection.
       CN: Reduction of risk potential; CL: Evaluate

Question 17

The Client with Down Syndrome
17. The mother of a 17-year-old girl with Down syndrome tells the nurse that her daughter
recently stated that she has a boyfriend. The mother is concerned that her daughter might become
pregnant. Which of the following is the most appropriate suggestion made by the nurse?
1. “I understand your concern; you may want to start your daughter on a birth control pill.”
2. “Women with Down syndrome are infertile so you don’t need to worry about her getting
pregnant.”
3. “I understand your concern; you may want to enroll your daughter in an abstinence program.”
4. “I know it may be difficult, but you may want to suggest that your daughter break off the
relationship.”

Answer 17

The Client with Down Syndrome
17. 1. Children with Down syndrome range from severely retarded to low average intelligence,
which questions the adolescent’s ability to make informed choices regarding sexual activity. Starting
her on birth control pills will greatly reduce the risk of unwanted pregnancy. Most women with Down
syndrome are fertile; however, children born to women with Down syndrome often have congenital
defects.
An abstinence program may not be effective due to the intellectual level of children with Down
syndrome. Suggesting that the adolescent break off the relationship does not ensure that she will.
CN: Health promotion and maintenance; CL: Analyze

Question 18

18. A nurse is assessing a child who has a mild intellectual disability. The best indication of how
    this child is progressing can be obtained by observing him:
19. At school with his teacher.
20. At home with his family.
21. In the clinic with his mother.
22. Playing soccer with his friends.

Answer 18

18. 1. Watching the child relate to his teacher and school work is the best indication of how he is
       progressing. School involves interacting with a person who is not a relative and in a situation that is
       not totally familiar. Observing the client in situations with family and friends shows social
       relationships but does not indicate how the child is learning new intellectual skills.
       CN: Health promotion and maintenance; CL: Evaluate

Question 19

19. After talking with the parents of a child with Down syndrome, the nurse should help the
    parents establish which goal?
20. Encouraging self-care skills in the child.
21. Teaching the child something new each day.
22. Encouraging more lenient behavior limits for the child.
23. Achieving age-appropriate social skills.

Answer 19

19. 1. The goal in working with mentally retarded children is to train them to be as independent as
       possible, focusing on developmental skills. The child may not be capable of learning something new
       every day but needs to repeat what has been taught previously. Rather than encouraging more lenient
       behavior limits, the parents need to be strict and consistent when setting limits for the child. Most
       children with Down syndrome are unable to achieve age-appropriate social skills due to their mental
       retardation. Rather, they are taught socially appropriate behaviors.
       CN: Health promotion and maintenance; CL: Synthesize

Question 20

20. The nurse discusses with the parents how best to raise the IQ of their child with Down
    syndrome. Which of the following would be most appropriate?
21. Serving hearty, nutritious meals.
22. Giving vasodilator medications as prescribed.
23. Letting the child play with more able children.
24. Providing stimulating, nonthreatening life experiences.

Answer 20

20. 4. Nonthreatening experiences that are stimulating and interesting to the child have been
       observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with
       more able children have not been supported by research as beneficial in increasing intelligence.
       Vasodilator medications act to increase oxygenation to the tissues, including the brain. However,
       these medications do not increase the child’s IQ.
       CN: Health promotion and maintenance; CL: Synthesize

Question 21

21. When developing a teaching plan for the parents of a child with Down syndrome, the nurse
    focuses on activities to increase which of the following for the parents?
22. Affection for their child.
23. Responsibility for their child’s welfare.
24. Understanding of their child’s disability.
25. Confidence in their ability to care for their child.

Answer 21

21. 4. When teaching the parents of a child with Down syndrome, activities should focus on
       increasing the parents’ confidence in their ability to care for the child. The parents must continue to
       work daily with their child. Most parents feel affection and a sense of responsibility for their child
       regardless of the child’s limitations. Parents usually understand the child’s disability on the cognitive
       level but have difficulty accepting it on the emotional level. As the parents’ confidence in their caring
       abilities increases, their understanding of the child’s disability also increases on all levels.CN: Psychosocial integrity; CL: Create

Question 22

The Client with a Seizure Disorder
22. What should be part of the nurse’s teaching plan for a child with epilepsy being discharged on
a regimen of phenytoin (Dilantin)?
1. Drinking plenty of fluids.
2. Brushing teeth after each meal.
3. Having someone be with the child during waking hours.
4. Reporting signs of infection.

Answer 22

The Client with a Seizure Disorder
22. 2. Phenytoin (Dilantin) can cause gingival hyperplasia. Children taking Dilantin should brush
their teeth after every meal and at bedtime, and visit their dentist on a regular basis. Drinking plenty
of fluids is not required while taking Dilantin. A child on Dilantin does not need to be observed
during waking hours because the seizures should be under control. Infections do not occur with an
increased incidence in clients receiving Dilantin.
CN: Pharmacological and parenteral therapies; CL: Create

Question 23

23. After teaching a group of school teachers about seizures, the teachers role-play a scenario
    involving a child experiencing a generalized tonic-clonic seizure. Which of the following actions,
    when performed first, indicates that the nurse’s teaching has been successful?
24. Asking the other children what happened before the seizure.
25. Moving the child to the nurse’s office for privacy.
26. Removing any nearby objects that could harm the child.
27. Placing a padded tongue blade between the child’s teeth.

Answer 23

23. 3. During a generalized tonic-clonic seizure, the first priority is to keep the child safe and
       protect the child by removing any nearby objects that could cause injury. Although obtaining
       information about events surrounding the seizure is important, this information can be obtained later,
       once the child’s safety is ensured. During a seizure, the child should not be moved. Although
       providing privacy is important, the child’s safety is the priority. During a seizure, nothing should be
       forced into the client’s mouth because this can cause severe damage to the teeth and mouth.
       CN: Physiological adaptation; CL: Evaluate

Question 24

24. A nurse is developing a plan of care with the parents of a 6-year-old girl diagnosed with a
    seizure disorder. To promote growth and development, the nurse should instruct the parents that:
25. The child will need activity limitation and will be unable to perform as well as her peers.
26. There is potential for a learning disability and the child may need tutoring to reach her grade
    level.
27. The child will likely have normal intelligence and be able to attend regular school.
28. There will be problems associated with social stigma and parents should consider home
    schooling.

Answer 24

24. 3. Most children who develop seizures after infancy are intellectually normal. A child with a
       seizure disorder needs the same experiences and opportunities to develop intellectual, emotional, and
       social abilities as any other child. Activity limitation is not needed. Learning disabilities are not
       associated with seizures. The child is able to attend public school, and social stigma is a rarity.
       CN: Health promotion and maintenance; CL: Create

Question 25

25. The parents of a child with occasional generalized seizures want to send the child to summer
    camp. The parents contact the nurse for advice on planning for the camping experience. Which of the
    following activities should the nurse and family decide the child should avoid?
26. Rock climbing.
27. Hiking.
28. Swimming.
29. Tennis.

Answer 25

25. 1. A child who has generalized seizures should not participate in activities that are potentially
       hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a
       seizure were to occur during rock climbing. Someone also should accompany the child during
       activities in the water. At summer camps, hiking and swimming would occur most commonly as group
       activities, so someone should be with the child. Tennis would be considered an appropriate,
       nonhazardous activity for a child with generalized seizures.
       CN: Safety and infection control; CL: Synthesize

Question 26

26. Which of the following statements obtained from the nursing history of a toddler should alert
    the nurse to suspect that the child has had a febrile seizure?
27. The child has had a low-grade fever for several weeks.
28. The family history is negative for convulsions.
29. The seizure resulted in respiratory arrest.
30. The seizure occurred when the child had a respiratory infection.

Answer 26

26. 4. Most febrile seizures occur in the presence of an upper respiratory infection, otitis media,
       or tonsillitis. Febrile seizures typically occur during a temperature rise rather than after prolonged
       fever. There appears to be increased susceptibility to febrile seizures within families. Infrequently,
       febrile seizures may lead to respiratory arrest.
       CN: Physiological adaptation; CL: Analyze

Question 27

27. After teaching the parents of a child with febrile seizures about methods to lower temperature
    other than using medication, which of the following statements indicates successful teaching?
28. “We’ll add extra blankets when he says he is cold.”
29. “We’ll wrap him in a blanket if he starts shivering.”
30. “We’ll make the bath water cold enough to make him shiver.”
31. “We’ll use a solution of half alcohol and half water when sponging him.”

Answer 27

27. 2. Shivering, the body’s defense against rapid temperature decrease, results in an increase in
       body temperature. Therefore, the parents need to take measures to stop the shivering (and the resulting
       increase in body temperature) by increasing the room temperature or the temperature of the child’s
       immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to
       lower the temperature more slowly. Shivering does not necessarily correlate with being cold.
       Alcohol, a toxic substance, can be absorbed through the skin. Its use is to be avoided.
       CN: Physiological adaptation; CL: Evaluate

Question 28

28. An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and
    carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the
    following responses by the nurse would be most appropriate?
29. “You probably shouldn’t consider having children until your seizures are cured.”
30. “Your children won’t necessarily have an increased risk of seizure disorder.”
31. “When you decide to have children, talk to the doctor about changing your medication.”
32. “Women who have seizure disorders commonly have a difficult time conceiving.”

Answer 28

28. 3. Phenytoin sodium (Dilantin) is a known teratogenic agent, causing numerous fetal problems.
       Therefore, the adolescent should be advised to talk to the doctor about changing the medication.
       Additionally, anticonvulsant requirements usually increase during pregnancy. Seizures can be
       controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders
       and infertility are not related.
       CN: Pharmacological and parenteral therapies; CL: Synthesize28. 3. Phenytoin sodium (Dilantin) is a known teratogenic agent, causing numerous fetal problems.
       Therefore, the adolescent should be advised to talk to the doctor about changing the medication.
       Additionally, anticonvulsant requirements usually increase during pregnancy. Seizures can be
       controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders
       and infertility are not related.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 29

29. When teaching an adolescent with a seizure disorder who is receiving valproic acid
    (Depakene), which sign or symptom should the nurse instruct the client to report to the health care
    provider?
30. Three episodes of diarrhea.
31. Loss of appetite.
32. Jaundice.
33. Sore throat.

Answer 29

29. 3. A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with
       jaundice and abdominal pain. If jaundice occurs, the client needs to notify the health care provider as
       soon as possible. Diarrhea and sore throat are not common side effects of this drug. Increased
       appetite is common with this drug.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 30

The Client with Meningitis

30. A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric
    unit. Which nursing intervention has the highest priority?
31. Instituting droplet precautions.
32. Administering acetaminophen (Tylenol).
33. Obtaining history information from the parents.
34. Orienting the parents to the pediatric unit.

Answer 30

The Client with Meningitis
30. 2. Instituting droplet precautions is the priority for a newly admitted infant with
meningococcal meningitis. Acetaminophen may be ordered, but administering it does not take priority
over instituting droplet precautions. Obtaining history information and orienting the parents to the unit
do not take priority.
CN: Safety and infection control; CL: Application

Question 31

31. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the
    following would be most appropriate to institute?
32. Limiting conversation with the child.
33. Keeping extraneous noise to a minimum.
34. Allowing the child to play in the bathtub.
35. Performing treatments quickly.

Answer 31

31. 2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and
       light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible.
       There is no need to limit conversations with the child. However, the nurse should speak in a calm,
       gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the
       infection, sponge baths would be more appropriate than tub baths. Although treatments need to be
       completed as quickly as possible to prevent overstressing the child, they should be performed
       carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently
       increasing intracranial pressure.
       CN: Basic care and comfort; CL: Synthesize

Question 32

32. Which sign should lead the nurse to suspect that a child with meningitis has developed
disseminated intravascular coagulation?
1. Hemorrhagic skin rash.
2. Edema.
3. Cyanosis.
4. Dyspnea on exertion

Answer 32

32. 1. Disseminated intravascular coagulation is characterized by skin petechiae and a purpuric
       skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon
       causes the condition. Heparin therapy is often used to interrupt the clotting process. Edema would
       suggest a fluid volume excess. Cyanosis would indicate decreased tissue oxygenation. Dyspnea on
       exertion would suggest respiratory problems, such as pulmonary edema.
       CN: Physiological adaptation; CL: Analyze

Question 33

33. When interviewing the parents of a 2-year-old child, a history of which of the following
    illnesses should lead the nurse to suspect pneumococcal meningitis?
34. Bladder infection.
35. Middle ear infection.
36. Fractured clavicle.
37. Septic arthritis.

Answer 33

33. 2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are
       commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis
       may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a
       pneumococcus. A chronically draining ear is also frequently found. Bladder infections commonly are
       caused by Escherichia coli, unrelated to the development of pneumococcal meningitis. Pneumococcal
       meningitis is unrelated to a fractured clavicle or to septic arthritis, which is commonly caused by
       Staphylococcus aureus, group A streptococci, or Haemophilus influenzae.
       CN: Physiological adaptation; CL: Analyze

Question 34

34. A preschooler with pneumonococci meningitis is receiving intravenous antibiotic therapy.
    When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area
    where the needle is removed. The nurse’s rationale for doing so is based on the interpretation that a
    child in this age group has a need to accomplish which of the following?
35. Trust those caring for her.
36. Find diversional activities.
37. Protect the image of an intact body.
38. Relieve the anxiety of separation from home.

Answer 34

34. 3. Preschool-age children worry about having an intact body and become fearful of any threat
       to body integrity. Allowing the child to participate in required care helps protect her image of an
       intact body. Development of trust is the task typically associated with infancy. Additionally, allowing
       the child to apply a dressing over the intravenous insertion site is unrelated to the development of
       trust. Finding diversional activities is not a priority need for a child in this age group. Separation
       anxiety is more common in toddlers than in preschoolers.
       CN: Health promotion and maintenance; CL: Apply

Question 35

35. A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12
    hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the
    nearest whole number. ___________________ mL/hour.

Answer 35

35. 83 mL/h

1,000 ml / 12 hours= 83 ml / hour

CN: Pharmacological and parenteral therapies; CL: Apply

Question 36

36. Nursing care management of the child with bacterial meningitis includes which of the
    following? Select all that apply.
37. Administration of IV antibiotics.
38. Intravenous fluids at 1 1⁄2 times maintenance.3. Decrease environmental stimuli.
39. Neurologic checks every 4 hours.
40. Administration of IV anticonvulsants.

Answer 36

36. 1,3,4 Antibiotics are indicated for the treatment of bacterial meningitis. Clients with bacterial
    meningitis often have increased ICP. It is necessary to maintain adequate hydration. However,
    infusing fluids at 1 1⁄2 maintenance can increase ICP, further risking neurologic damage due to cerebral
    edema. Most children with meningitis are sensitive to sound, light, and stimulation. Decreasing
    environmental stimuli and keeping the room dim and quiet are essential. Frequent neurologic checks
    are necessary to monitor any changes in the child’s level of consciousness. Anticonvulsants are not
    indicated unless the child experiences seizures as a result of the meningitis.
    CN: Physiological adaptation; CL: Apply

Question 37

37. The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure
    (ICP). The nurse should assess the infant for which symptoms? Select all that apply.
38. Irritability.
39. Headache.
40. Mood swings.
41. Bulging fontanel.
42. Emesis.

Answer 37

37. 1,4,5. Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A
    headache may be present in an infant with increased ICP; however, the infant has no way of
    communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An
    infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.
    CN: Reduction of risk potential; CL: Apply

Question 38

38. A hospitalized preschooler with meningitis who is to be discharged becomes angry when the
    discharge is delayed. Which of the following play activities would be most appropriate at this time?
39. Reading the child a story.
40. Painting with watercolors.
41. Pounding on a pegboard.
42. Stacking a tower of blocks.

Answer 38

38. 3. The child is angry and needs a positive outlet for expression of feelings. An emotionally
       tense child with pent-up hostilities needs a physical activity that will release energy and frustration.
       Pounding on a pegboard offers this opportunity. Listening to a story does not allow the child to
       express emotions. It also places the child in a passive role and does not allow the child to deal with
       feelings in a healthy and positive way. Activities such as painting and stacking a tower of blocks
       require concentration and fine movements, which could add to frustration. However, if the child then
       knocks the tower over, doing so may help to dispel some of the anger.
       CN: Health promotion and maintenance; CL: Synthesize

Question 39

The Client with Near-Drowning
39. The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor’s heated
swimming pool to the emergency department. The nurse should assess the child for:
1. Hypothermia.
2. Hypoxia.
3. Fluid aspiration.
4. Cutaneous capillary paralysis.

Answer 39

The Client with Near-Drowning
39. 2. Hypoxia is the primary problem because it results in brain cell damage. Irreversible brain
damage occurs after 4 to 6 minutes of submersion. Hypothermia occurs rapidly in infants and children
because of their large body surface area. Hypothermia is more of a problem when the child is in cold
water. Although fluid aspiration occurs in most drownings and results in atelectasis and pulmonary
edema, further aggravating hypoxia, hypoxia is the primary problem. Cutaneous capillary paralysis is
not a problem.
CN: Physiological adaptation; CL: Analyze

Question 40

40. The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident.
The nurse should first:
1. Administer oxygen.
2. Institute rewarming.
3. Prepare for intubation.
4. Start an intravenous infusion.

Answer 40

40. 1. Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to
       restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is notunconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming
       protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these
       interventions are secondary to oxygen administration. Intubation is required if the child is comatose,
       shows signs of airway compromise, or does not respond adequately to more conservative therapies.
       CN: Physiological adaptation; CL: Synthesize

Question 41

41. The parents of a child tell the nurse that they feel guilty because their child almost drowned.
    Which of the following remarks by the nurse would be most appropriate?
42. “I can understand why you feel guilty, but these things happen.”
43. “Tell me a little bit more about your feelings of guilt.”
44. “You should not have taken your eyes off of your child.”
45. “You really shouldn’t feel guilty; you’re lucky because your child will be all right.”

Answer 41

41. 2. Guilt is a common parental response. The parents need to be allowed to express their
       feelings openly in a nonthreatening, nonjudgmental atmosphere. Telling the parents that these things
       happen does not allow them to verbalize their feelings. Telling the parents that they should not have
       taken their eyes off the child blames them, possibly further contributing to their guilt. Telling the
       parents that they shouldn’t feel guilty denies the parents’ feelings of guilt and is inappropriate. Telling
       the parents that they are lucky that the child will be okay does not remove the feelings of guilt.
       CN: Psychosocial integrity; CL: Synthesize

Question 42

The Client with Guillain-Barré
(Infectious Polyneuritis)
Syndrome
42. Which of the following assessments would be most important for the nurse to make initially
in a school-age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling
weak, and generally is not feeling well?
1. Difficulty swallowing.
2. Diet intake for the last 24 hours.
3. Exposure to illnesses.
4. Difficulty urinating.

Answer 42

The Client
Polyneuritis)
with
Guillain-Barré
Syndrome
(Infectious
42. 1. Most children with sore throat have some difficulty swallowing, so it is important for the
nurse to determine the extent of difficulty to aid in determining what action is necessary. Typically a
sore throat precedes the paralysis of this disorder. Muscle tenderness is an initial symptom. Distal
muscle weakness follows proximal muscle weakness, ultimately progressing to paralysis. Diet
history and difficulty urinating will not contribute to assessment of the cause of a sore throat or
difficulty swallowing. After determining the extent of difficulty swallowing, the nurse can obtain
information about exposure to illness.
CN: Health promotion and maintenance; CL: Analyze

Question 43

43. Which of the following actions should be the priority when caring for a school-age child
    admitted to the pediatric unit with the diagnosis of Guillain-Barré syndrome?
44. Assessing the child’s ability to follow simple commands.
45. Evaluating the child’s bilateral muscle strength.
46. Making a game of the range-of-motion exercises.
47. Providing the child with a diversional activity.

Answer 43

43. 2. With Guillain-Barré syndrome, progressive ascending paralysis occurs. Therefore, the
       nurse should assess the child’s muscle strength bilaterally to determine the extent of involvement and
       progression of the illness. Assessing the child’s ability to follow simple commands evaluates brain
       function. Range-of-motion exercises are an important part of treatment, but they are not a priority
       initially. Although the child may need diversional activities later, they also are not an initial priority.
       CN: Physiological adaptation; CL: Synthesize

Question 44

44. The nurse asks a school-age child with Guillain-Barré syndrome to cough and also assesses
    the child’s speech for decreased volume and clarity. The underlying rationale for these assessments is
    to determine which of the following?
45. Inflammation of the larynx and epiglottis.
46. Increased intracranial pressure.
47. Involvement of facial and cranial nerves.
48. Regression to an earlier developmental phase.

Answer 44

44. 3. In a child with Guillain-Barré syndrome, decreased volume and clarity of speech and
       decreased ability to cough voluntarily indicate ascending progression of neural inflammation,
       specifically affecting the cranial nerves. Inflammation of the larynx and epiglottis is manifested by
       hoarseness, stridor, and dyspnea. A child with laryngeal inflammation still retains the ability to cough.
       Irritability, behavior changes, headache, and vomiting are common signs of increased intracranial
       pressure in a school-age child. Regression would be manifested by being more dependent and less
       able to care for self.
       CN: Physiological adaptation; CL: Apply

Question 45

45. Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and
    cough reflexes. Which of the following problems should receive the highest priority during the acute
    phase?
46. Risk for infection due to altered immune system.
47. Ineffective breathing pattern related to neuromuscular impairment.
48. Impaired swallowing related to neuromuscular impairment.
49. Total urinary incontinence related to fluid losses.

Answer 45

45. 2. An ineffective breathing pattern caused by the ascending paralysis of the disorder interferes
       with the child’s ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes
       precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on
       the child’s ability to maintain respirations. An increased risk for infection related to an alteredimmune system is not associated with Guillain-Barré syndrome. Although impaired swallowing and
       incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority.
       CN: Physiological adaptation; CL: Analyze

Question 46

46. A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which
    action should the nurse take?
47. Maintain the child in a supine position to prevent unnecessary nerve stimulation.
48. Transfer the child to a bedside chair three times a day to prevent postural hypotension.
49. Engage the child in vigorous passive range-of-motion exercises to prevent loss of muscle
    function.
50. Turn the child slowly and gently from side to side to prevent respiratory complications.

Answer 46

46. 4. Even in the absence of respiratory problems or distress, the child must be turned frequently
       to help prevent the cardiopulmonary complications associated with immobility, such as atelectasis
       and pneumonia. Maintaining the child in a supine position is unnecessary. Doing so does not prevent
       unnecessary nerve stimulation. In addition, maintaining a supine position may lead to stasis of
       secretions, placing the child at risk for pneumonia. Transferring the child to a chair will not prevent
       postural hypotension. However, doing so will increase vascular tone and help prevent respiratory and
       skin complications. During the acute disease phase, vigorous physiotherapy is contraindicated
       because the child may experience muscle pain and be hypersensitive to touch. Careful and gentle
       handling is essential.
       CN: Physiological adaptation; CL: Synthesize

Question 47

47. The mother brings her child to the clinic after discharge from the hospital for Guillain-Barré
    syndrome. Which of the following statements by the mother indicates that she is following the
    discharge plan?
48. “She and her sister argue all day.”2. “I have to bribe her to get her to do her exercises.”
49. “I take her to the pool where she can exercise with other children.”
50. “She’s missed a few of her therapy sessions because she often sleeps.”

Answer 47

47. 3. Developmentally appropriate activities and therapeutic play should be used as
       rehabilitation modalities. Taking the child to the pool to exercise with other children indicates that the
       child is participating in exercise as well as engaging with other children, thus fostering development.
       Arguing with the sister does not address the discharge plan. Inappropriate rewards or threats should
       not be used to coerce a child into compliance. Although the mother is attempting to comply with the
       discharge plan, bribery is an inappropriate technique to foster compliance. Missing therapy sessions
       delays recovery. The parents need to help set the child’s schedule to ensure that she gets adequate rest
       to be able to follow her treatment plan.
       CN: Physiological adaptation; CL: Evaluate

Question 48

The Client with a Head Injury
48. A 12-year-old child has had a traumatic head injury from playing in a football game. He is
admitted to the emergency department and transferred to the pediatric intensive care unit. He has an
IV of dextrose 5% in water at 21 mL/h and nasal oxygen at 2 L/min. The nurse is assessing the child at
the beginning of the shift (11:00 PM ) and reviews the Glasgow Coma Scale flow sheet below. The
nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal
flexion of the limbs. What should the nurse do first?

1. Notify the primary health care provider.
2. Lower the head of the bed.
3. Increase the rate of nasal oxygen.
4. Increase the rate of the IV infusion.

Answer 48

The Client with a Head Injury
48. 1. This client is experiencing neurologic changes consistent with increasing intracranial
pressure (ICP). The nurse should first notify the primary health care provider. The primary health
care provider may intubate the child to ensure a patent airway. The nurse should not lower the head of
the bed as this will cause increased ICP. The nurse should ensure an adequate fluid balance. The
primary health care provider will likely prescribe hypertonic saline to draw fluid from the brain.
CN: Management of care; CL: Synthesize

Question 49

Notify the primary health care provider.

2. Lower the head of the bed.
3. Increase the rate of nasal oxygen.
4. Increase the rate of the IV infusion.
5. A 10-year-old with a severe head

Answer 49

49. 1. An ICP level greater than 15 mm Hg is abnormal. This child’s vital signs indicate increased
       ICP. Mannitol is an osmotic diuretic and will decrease the child’s ICP. Suctioning the child will
       increase the ICP. Encouraging the parent to talk to the child may be comforting but will not decrease
       the ICP. The priority for this child is decreasing the ICP to avoid further brain injury. The fever is
       likely due to the head injury and will not decrease with Tylenol. A cooling blanket is the most
       effective means of reducing a fever in a client with a head injury.
       CN: Reduction of risk potential; CL: Apply

Question 50

50. The nurse is inserting a nasogastric (NG) tube in a child admitted with head trauma. The
    nurse should explain to the parents that the NG tube will be used for what purpose?
51. Administer medications.
52. Decompress the stomach.
53. Obtain gastric specimens for analysis.
54. Provide adequate nutrition.

Answer 50

50. 2. For the child with serious head trauma, a nasogastric tube is inserted initially to
       decompress the stomach and to prevent vomiting and aspiration. Medications would be administered
       intravenously in the initial period. The tube will not be used to obtain gastric specimens. Nutrition is
       not a priority initially. Later on, the tube may be used to administer feedings.
       CN: Reduction of risk potential; CL: Apply

Question 51

51. A nasogastric tube is prescribed to be inserted for a child with severe head trauma.
    Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
52. Ask for the prescription to be changed to oral gastric tube.
53. Attempt to place the tube into the duodenum.
54. Test the gastric aspirate for blood.
55. Use extra lubrication when inserting the nasogastric tube.

Answer 51

51. 1. Because a basilar skull fracture can involve the frontal and ethmoid bones, inserting a
       nasogastric tube carries the risk of introducing the tube into the cranial cavity through the fracture. An
       oral gastric tube is preferred for a client with a basilar skull fracture. The tube would not be placed
       into the duodenum. Gastric aspirate is not routinely tested for blood unless there is an indication to
       suggest bleeding, such as a falling hemoglobin or visible blood in the drainage.
       CN: Reduction of risk potential; CL: Synthesize

Question 52

52. The parents of a child in a coma with a serious head injury ask the nurse if the child is going
    to be all right. Which of the following responses by the nurse would be most appropriate?
53. “Children usually don’t do very well after head injuries like this.”
54. “Children usually recover rapidly from head injuries.”
55. “It’s hard to tell this early, but we’ll keep you informed of the progress.”
56. “That’s something you’ll have to talk to the doctor about.”

Answer 52

52. 3. As a rule, children demonstrate more rapid and more complete recovery from coma than do
       adults. However, it is extremely difficult to predict a specific outcome. Reassuring the parents that
       they will be kept informed helps open lines of communication and establish trust. Telling the parents
       that children do not do well would be extremely negative, destroying any hope that the parents might
       have. Telling the parents that children recover rapidly may give the parents false hopes. Telling the
       parents to talk to the doctor ignores the parents’ concerns and interferes with trust-building.
       CN: Physiological adaptation; CL: Synthesize

Question 53

53. A parent of a child with a moderate head injury asks the nurse, “How will you know if my
    child is getting worse?” The nurse should tell the parents that best indicator of the child’s brain
    function is:
54. The vital signs.
55. Level of consciousness.
56. Reactions of the pupils.
57. Motor strength.

Answer 53

53. 2. The level of consciousness (LOC) is the best indicator of brain function. If the child’s
       condition deteriorates, the nurse would notice changes in LOC before any other changes and should
       notify the primary health care provider that these changes are occurring. Changes in vital signs and
       pupils typically follow changes in LOC. Motor strength is primarily assessed as a voluntary function.
       With changes in levels of consciousness, there may be motor changes.
       CN: Physiological adaptation; CL: Apply

Question 54

54. When developing the plan of care for a child who is unconscious after a serious head injury,
    in which of the following positions should the nurse expect to place the child?
55. Prone with hips and knees slightly elevated.
56. Lying on the side, with the head of the bed elevated.
57. Lying on the back, in the Trendelenburg position.
58. In the semi-Fowler’s position, with arms at the side.

Answer 54

54. 2. The unconscious child is positioned to prevent aspiration of saliva and minimize
       intracranial pressure. The head of the bed should be elevated, and the child should be in either the
       semiprone or the side-lying position. Lying prone with hips and knees slightly elevated increases
       intracranial pressure, as does lying on the back in the Trendelenburg position. The semi-Fowler’s
       position with arms at the side is not the best choice.
       CN: Physiological adaptation; CL: Synthesize

Question 55

55. The primary health care provider has prescribed intravenous mannitol (Osmitrol) for a child
    with a head injury. The best indicator that the drug has been effective is:
56. Increased urine output.
57. Improved level of consciousness.
58. Decreased intracranial pressure.
59. Decreased edema.

Answer 55

55. 3. Mannitol is an osmotic diuretic used to reduce intracranial pressure. The use of the drug is
       controversial and should be reserved to cases that do not respond to other treatments or when brain
       herniation is likely. Children this sick should be on intracranial pressure (ICP) monitoring. The best
       indicator that the drug has produced the desired results is a reduction in the ICP. Improved levels of
       consciousness should follow reduced ICP. While the drug will cause increased urine output, that
       measurement in and of itself does not indicate successful treatment. Because the drug is being used for
       head injuries, not to improve urine output in acute renal failure, the child may not have visible edema.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 56

56. The nurse assigned to telephone triage returns the call of a parent whose teenager
    experienced a hard tackle last night. The parent reports, “He seemed dazed after it happened and the
    coach had him sit out the rest of the game, but he is fine now.” What are the most appropriate
    instructions for the nurse to give?
57. “Take him immediately to the emergency department.”
58. “He cannot return to play until he has been evaluated a health care provider.”
59. “If he seems fine now and had no other symptom, it probably was not a concussion.”
60. “Watch him closely and call us back if you see any changes.”

Answer 56

56. 2. Appearing dazed or stunned after a head injury is a symptom of a concussion. Concussion
       care includes removing the athlete from play and having the injury evaluated. Athletes should not
       return to play until they have been cleared by a health care provider (HCP). Concussions require
       ongoing monitoring. Since the client has no signs of deterioration neurologic function, it may best be
       provided by a consistent HCP rather than through an emergency department.
       CN: Reduction of risk potential; CL: Apply

Question 57

57. A history of which factors will complicate the recovery from a concussion? Select all that
apply.
1. Asthma.
2. Attention deficit/hyperactivity disorder (ADHD).
3. Depression.
4. Migraines.
5. Obesity.
6. Previous concussion.

Answer 57

57. 2,3,4,6. Concussion recovery can be complicated by any previous brain injury, such as a
    previous concussion. Recovery can also be complicated by the presence of other neurologic problem,such as migraines, ADHD, and depression. Asthma and obesity have not been linked to concussion
    recovery.
    CN: Risk reduction; CL: Analyze

Question 58

58. A 3-year-old is recovering from a concussion. The persistence of which finding is least
concerning?
1. Lack interest in favorite toys.
2. Change in eating habits.
3. Inability to hop.
4. Increased temper tantrums.

Answer 58

58. 3. The inability to hop is not concerning because it is a milestone for a 4-year-old not a 3-
       year-old. Lack of interest in toys, changes in eating habits, and increased temper tantrums that persist
       several weeks all require an evaluation by a neurologist or other specialist.
       CN: Physiologic adaptation; CL: Analyze

Question 59

59. The nurse teaches an adolescent about returning to school after a concussion. Which statement
    by the client reflects the need for more teaching?
60. “I should limit my activities that require concentration.”
61. “I must slowly return to my previous activity level as my symptoms improve.”
62. “My symptoms may reemerge with exertion.”
63. “Time is the most important factor in my recovery.”

Answer 59

59. 4. While recovery from a concussion takes time, adequate rest and limiting exertion facilitate
       recovery. Both physical and cognitive exertion can cause the reemergence of symptoms and delay
       recovery. As symptoms resolve, clients may slowly return to previous levels of activity.
       CN: Risk reduction; CL: Evaluate.

Question 60

The Client with a Brain Tumor
60. A child with a brain tumor is less responsive to verbal commands than he was when the nurse
assessed the client the previous hour. The nurse should next:
1. Raise the head of the bed.
2. Notify the primary health care provider.
3. Administer an analgesic.
4. Obtain an oximeter reading.

Answer 60

The Client with a Brain Tumor
60. 2. A decreasing level of consciousness, decerebrate positioning, or Cushing’s triad (elevated
systolic blood pressure, decreased pulse, and decreased respiratory rate) indicates that there is
pressure on the brain stem and the client could require intubation and cardiac resuscitation unless the
primary health care provider can prescribe a medication or surgical procedure to reduce the
intracranial pressure. Raising the head of the bed could offer some reduction in the intracranial
pressure by increasing venous blood return from the head, but it is not the priority at this time. An
analgesic administered at this time would mask the sign of decreasing level of consciousness and
hinder assessment. An oximeter would measure the oxygen level in the blood, but not necessarily in
the brain.
CN: Physiological adaptation; CL: Synthesize

Question 61

61. The nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving
    chemotherapy for the last 4 weeks. His lab results indicate an Hgb of 12.5 g/dL (125 g/L), an HCT of
    36.8% (0.37), a WBC of 2,000 mm 3 (2 × 10 9 /L), and a platelet count of 150,000 μL (150 × 10 9 /L).
    Based on the child’s lab values, what is the highest priority nursing intervention?
62. Encourage meticulous handwashing by client and visitors.
63. Prepare to give the child a transfusion of platelets.
64. Encourage mouth care with a soft tooth brush.
65. Prepare to give the child a transfusion of packed red blood cells.

Answer 61

61. 1. A WBC of 2,000 mm 3 (2 × 10 9 /L) is low and increases risk for infection. Meticulous
       handwashing is a universal precaution and the first line of defense in combating infection. A platelet
       count of 150,000 μL (150 × 10 9 /L) is normal, so there is no need for a platelet transfusion. Mouth
       care will help decrease the risk of infection. However, handwashing is the priority as it will have the
       greatest impact on diminishing the risk of infection. An Hgb of 12.5 g/dL (125 g/L) and an HCT of
       36.8% (0.37) are within normal range, so there is no need to transfuse packed red blood cells.
       CN: Reduction of risk potential; CL: Analyze

Question 62

62. A 13-year-old child has seen the school nurse several times with headache, vomiting, and
    difficulty walking. When calling the adolescent’s mother about these symptoms, what should the nurse
    suggest the mother do first?
63. Schedule an appointment with the eye doctor.
64. Begin psychological counseling for her adolescent.
65. Make an appointment with the adolescent’s primary health care provider.
66. Meet with the adolescent’s teachers to determine academic progress.

Answer 62

62. 3. A child who has symptoms of vomiting, headaches, and problems walking needs to be
       evaluated by a health care provider to determine the cause. Unexplained headaches and vomiting
       along with difficulty walking (eg, ataxia) may suggest a brain tumor. Evaluation by an eye doctor
       would be appropriate once a complete medical evaluation has been accomplished. Psychological
       counseling may be indicated for this adolescent, but only after medical evaluation to determine that
       she is physically healthy. Meeting with the child’s teachers would be appropriate after medical
       evaluation.
       CN: Physiological adaptation; CL: Synthesize

Question 63

63. A school-age child is admitted to the hospital with the diagnosis of probable infratentorial
    brain tumor. During the child’s admission to the pediatric unit, which action should the nurse
    anticipate taking first?
64. Eliminating the child’s anxiety.
65. Implementing seizure precautions.
66. Introducing the child to other clients of the same age.
67. Preparing the child and parents for diagnostic procedures.

Answer 63

63. 4. When a brain tumor is suspected, the child and parents are likely to be very apprehensive
       and anxious. It is unrealistic to expect to eliminate their fears; rather, the nurse’s goal is to decrease
       them. Preparing both the child and family during hospitalization can help them cope with some oftheir fears. Although the nurse may be able to decrease some of the child’s anxiety, it would be
       impossible to eliminate it. Children with infratentorial tumors seldom have seizures, so seizure
       precautions are not indicated. Although introducing the child to other children is a positive action,
       this action would be more appropriate once the nurse has decreased some of the child’s and parents’
       anxiety by preparing them.
       CN: Psychosocial integrity; CL: Synthesize

Question 64

64. The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches
    the back (see figure). The nurse should:
65. Notify the primary health care provider.
66. Stroke the back to release the arching.
67. Pad the side rails of the crib.
68. Place the child prone.

Answer 64

64. 1. The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify
       the primary health care provider immediately and have resuscitation equipment ready. Stroking the
       back will not relieve the herniation or release the arching. Although the infant may also have a
       seizure, and padded side rails will prevent injury, the first action is to notify the primary health care
       provider. Placing the child in a prone position will not relieve the herniation or release the arching.
       CN: Management of care; CL: Synthesize

Question 65

65. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and
symptoms should the nurse expect the child to demonstrate? Select all that apply.
1. Head tilt.
2. Vomiting.
3. Polydipsia.
4. Lethargy.
5. Increased appetite.
6. Increased pulse.

Answer 65

65. 1,2,4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain
    tumor. Clinical manifestations are the result of location and size of the tumor. Polydipsia is rare with
    a brain tumor. It is more often a sign of diabetes insipidus following a closed head injury. Increased
    appetite occurs during a growth spurt and is not necessarily a sign of a brain tumor. Increased pulse is
    a nonspecific sign and can occur with many illnesses, cardiac anomalies, fever, or exercise.
    CN: Physiological adaptation; CL: Analyze

Question 66

66. After a child undergoes a craniotomy for an infratentorial brain tumor, the nurse should place
    the child in which of the following positions to prevent undue strain on the sutures?
67. Prone.
68. Semi-Fowler’s.
69. Side-lying.
70. Trendelenburg.

Answer 66

66. 3. After surgery for an infratentorial tumor, the child is usually positioned flat on either side,
       with the head and neck in midline and the body slightly extended. Pillows against the back, not the
       head, help maintain position. Such a position helps avoid pressure on the operative site. Placing the
       child in a prone or semi-Fowler’s position will cause pressure on the operative site. The
       Trendelenburg position is usually contraindicated because keeping the head below the level of the
       heart increases intracranial pressure as well as the risk of hemorrhage.
       CN: Physiological adaptation; CL: Synthesize

Question 67

67. A child who was intubated after a craniotomy now shows signs of decreased level of
    consciousness. The primary health care provider prescribes manual hyperventilation to keep the
    Paco 2 between 25 and 29 mm Hg and the Pao 2 between 80 and 100 mm Hg. The nurse interprets this
    prescription based on the understanding that this action will accomplish which of the following?
68. Decrease intracranial pressure.
69. Ensure a patent airway.
70. Lower the arousal level.
71. Produce hypoxia.

Answer 67

67. 1. Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can
       cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen
       level through hyperventilation is the most effective short-term method of reducing intracranial
       pressure. Although ensuring a patent airway is important, this is not accomplished by manual
       hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level
       may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.
       CN: Reduction of risk potential; CL: Evaluate

Question 68

68. Which action should the nurse do first when noting clear drainage on the child’s dressing and
    bed linen after a craniotomy for a brain tumor?
69. Change the dressing.
70. Elevate the head of the bed.
71. Test the fluid for glucose.
72. Notify the primary health care provider.

Answer 68

68. 3. Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid.
       Excessive fluid leakage should be reported to the primary health care provider. The nurse should not
       change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon.
       Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures.
       The nurse should notify the primary health care provider after testing the fluid for glucose.
       CN: Reduction of risk potential; CL: Synthesize

Question 69

69. An 8-year-old child does well after infratentorial tumor removal and is transferred back to
    the pediatric unit. Although she had been told about having her head shaved for surgery, she is very
    upset. After exploring the child’s feelings, which action should the nurse take?
70. Ask the child if she’d like to wear a hat.
71. Reassure the child that her hair will grow back.
72. Explain to the child’s parents that her reaction is normal.
73. Suggest that the parents buy the child a wig as a surprise.

Answer 69

69. 1. It is not uncommon for a child to be concerned about a change in appearance when the
       entire head or only part of the head has been shaved. The child should be encouraged to participate in
       decisions about her care when possible. Asking her if she would like to wear a hat is one way toencourage this participation. Reassuring the child that her hair will grow back does not address the
       immediate change in appearance, and it ignores the child’s current feelings. Explaining that this type
       of reaction is normal does not address the child’s feelings. The child needs to be able to express
       feelings and be involved in care as much as possible. Buying the child a wig as a surprise does not
       address the child’s feelings and does not allow her to participate in decision making. Rather, the
       parents should ask the child if she would like a wig and then work with the child to determine what
       kind of wig she would like.
       CN: Psychosocial integrity; CL: Synthesize

Question 70

70. Which of the following statements made by the mother of a school-age child who has had a
    craniotomy for a brain tumor would warrant further exploration by the nurse?
71. “After this, I’ll never let her out of my sight again.”2. “I hope that she’ll be able to go back to school soon.”
72. “I wonder how long it will be before she can ride her bike.”
73. “Her best friend is eager to see her; I hope she won’t be upset.”

Answer 70

70. 1. Parents of a child who has undergone neurosurgery can easily become overprotective. Yet
       the parents must foster independence in the convalescing child. It is important for the child to resume
       age-appropriate activities, and parents play an important role in encouraging this. Statements about
       going back to school would be expected. Parents want the child to return to normal activities after a
       serious illness or injury as a sign that the child is doing well.
       CN: Psychosocial integrity; CL: Evaluate

Question 71

The Client with a Spinal Cord Injury
71. A nurse who witnesses an accident involving an adolescent riding a motorcycle, hitting a
tree, and being thrown 30 feet (914.4 cm) into a field stops to help. The adolescent reports that he is
now unable to move his legs. While waiting for the emergency medical service to arrive, what should
the nurse do?
1. Flex the adolescent’s knees to relieve stress on his back.
2. Leave the adolescent as he is, staying close by.
3. Remove the adolescent’s helmet as soon as possible.
4. Assess the adolescent for abdominal trauma.

Answer 71

The Client with a Spinal Cord Injury
71. 2. The adolescent’s signs and symptoms suggest a spinal cord injury. A client with suspected
spinal cord injury should not be moved until the spine has been immobilized. Removing the helmet
could further aggravate a spinal cord injury. The nurse could assess for abdominal trauma, but only if
it can be done without moving the adolescent.
CN: Reduction of risk potential; CL: Synthesize

Question 72

72. An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a
    nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the
    intensive care unit. What should the nurse do next when assessment reveals that the adolescent’s feet
    and legs are cool to the touch?
73. Cover the adolescent’s legs with blankets.
74. Report this finding to the primary health care provider immediately.
75. Reposition the adolescent’s legs.
76. Lay the adolescent flat to aid circulation.

Answer 72

72. 1. In spinal cord injury, temperature regulation is lost below T3. Body temperature must be
       maintained by adjusting room temperature or bed linens, such as covering the client’s legs with
       blankets. Coolness of the extremities is an expected finding. Therefore, it is not necessary to notify the
       primary health care provider immediately. Repositioning the client’s legs does not alleviate the
       temperature regulation problem and could be harmful, considering the client’s diagnosis. Moving the
       legs before the spine is stabilized could lead to further cord damage. Laying the client flat will not
       increase the warmth to the legs and feet.
       CN: Physiological adaptation; CL: Synthesize

Question 73

73. During assessment of an adolescent who has sustained a recent thoracic spinal injury, the
    nurse auscultates the adolescent’s abdomen. The nurse explains to the parents that this is necessary
    because clients with spinal cord injury often develop which of the following?
74. Abdominal cramping.
75. Hyperactive bowel sounds.
76. Paralytic ileus.
77. Profuse diarrhea.

Answer 73

73. 3. A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and
       rectum. Paralytic ileus often occurs as a result of decreased gastrointestinal muscle innervation. The
       nurse evaluates this by auscultating the abdomen. Because the client has a thoracic spinal cord injury,
       the client may not feel abdominal cramping. Additionally, auscultation would provide no evidence of
       cramping. Hyperactive bowel sounds would be evidenced with increased peristalsis; peristalsis
       would probably be diminished with this injury. Profuse diarrhea, resulting from increased peristalsis,
       would not be an expected finding. Diarrhea would be more commonly associated with a
       gastrointestinal infection.
       CN: Physiological adaptation; CL: Analyze

Question 74

74. Which of the following findings should lead the nurse to decide that spinal shock was
    resolving in the adolescent with a spinal cord injury?
75. Atonic urinary bladder.
76. Flaccid paralysis.
77. Hyperactive reflexes.
78. Widened pulse pressure.

Answer 74

74. 3. Spinal shock causes a loss of reflex activity below the level of the injury, resulting in
       bladder atony and flaccid paralysis. When the reflex arc returns, it tends to be overactive, resulting in
       spasticity. The reflexes and bladder become hypertonic during this phase of spinal shock resolution;
       sensation does not return. A widened pulse pressure is not associated with resolution of spinal shock.CN: Physiological adaptation; CL: Evaluate

Question 75

75. A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse
    notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this
    behavior as indicative of which of the following?
76. A stage of grief reaction.
77. A phase of rebellion.
78. A reaction to sensory overload.
79. A response to too much attention.

Answer 75

75. 1. After a catastrophic injury, individuals commonly experience grief. Initially, the person
       experiences denial, the most common response. With gradual awareness of the situation, anger
       commonly occurs. The child is demonstrating anger, not rebellion, as he gradually becomes aware of
       his situation. Rebellion is the child’s way to maintain autonomy and individuality. It is a reaction to
       rigid rules. Examples include refusing to follow a treatment protocol when the child had no input and
       running away. Sensory overload would cause the child to be irritable and tired and to have difficulty
       sleeping. Too much attention usually would lead to irritability, difficulty sleeping, and mood swings.
       CN: Psychosocial integrity; CL: Analyze

Question 76

76. Two months after an adolescent’s thoracic spinal cord injury, he has a pounding headache.
    The nurse notes that the client’s arms and face are flushed and he is diaphoretic. What should the
    nurse do next?
77. Check the patency of the urinary catheter.2. Lower the adolescent’s head below his knees.
78. Place the adolescent flat on his back.
79. Prepare to administer epinephrine subcutaneously.

Answer 76

76. 1. The adolescent is exhibiting signs of autonomic dysreflexia, a generalized sympathetic
       response usually caused by bladder or bowel distention. Immediate treatment involves eliminating the
       cause. Because bladder distention is a common cause of this problem, the nurse should immediately
       determine the patency of the indwelling (Foley) catheter. Lowering the head below the knees would
       increase the blood pressure and is contraindicated because of the spinal cord injury. Lying flat will
       not decrease blood pressure. Epinephrine is contraindicated because it elevates blood pressure and
       therefore can exacerbate the problem.
       CN: Physiological adaptation; CL: Synthesize

Question 77

Managing Care Quality and Safety
77. The nurse is admitting a child who has been diagnosed with bacterial meningitis to the
pediatric unit. The nurse should implement which type of isolation?
1. Standard or routine precautions.
2. Contact precautions.
3. Airborne precautions.
4. Droplet precautions.

Answer 77

Managing Care Quality and Safety
77. 4. Bacterial meningitis is caused by one of three organisms, H. influenzae type b, Neisseria
meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact
with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the
client. Droplet precautions require, in addition to standard (routine) precautions, that health care
providers wear masks when coming into close contact with the client. Standard or routine
precautions, previously referred to as universal precautions, are general measures used for all clients.
Contact precautions are used when direct or indirect contact with the client causes disease
transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet
in that the particles are smaller and may stay suspended in the air for longer periods of time. These
clients require negative pressure rooms and all heath care workers must wear respirators.
CN: Safety and infection control; CL: Apply

Question 78

78. The nurse manager on a pediatric floor is updating safety recommendations for the unit.
    Which strategy would help reduce pediatric medication errors? Select all that apply.
79. Eliminate the pediatric satellite pharmacy.
80. Increase the steps in the medication administration procedure.
81. Avoid using parenteral syringes when administering liquid oral medications.
82. Limit the size of IV fluid bags that can be hung on small children.
83. Reduce the available concentrations or dose strengths of high-alert medications to the
    minimum.

Answer 78

78. 3,4,5. Using only oral syringes to administer oral medications reduces the chance that the
    medication will be given intravenously. The use of smart pumps alone is not enough to prevent IV
    fluid administration. An additional measure that pediatric floors can institute to prevent accidental
    fluid overload is to use smaller IV fluid bags, such as 250 mL. Whenever a medication comes in
    multiple concentrations and doses, there is risk of administering the wrong dose. The use of pediatric
    satellite pharmacies with pediatric pharmacists greatly increases the safety of medication
    administration. Any time steps are added to the medication administration process, there is one more
    place where an error might occur.
    CN: Safety and infection control; CL: Synthesize

Question 79

79. The primary health care provider prescribes carbamazapine extended release (Tegretol-XR)
    for a client with a cerebral palsy who also has a seizure disorder. The client has a gastrostomy
    feeding tube, and carbamazapine is on the hospital’s “no crush” list. In order to administer the
    medication, the nurse should:
80. Cut the medication into four pieces that can be placed in the feeding tube.
81. Dissolve the medication in 30 mL of juice.
82. Ask the pharmacist for an oral suspension.
83. Contact the primary care provider to change the prescription.

Answer 79

79. 4. The coating on an extended-release medication helps assure slow absorption of the
       medication. If the nurse crushes the medication, the medication may enter the client’s system too
       quickly and result in toxic levels. The only appropriate action is to contact the prescriber and ask thatthe prescription be changed. Cutting the medication or trying to dissolve a whole tablet would have
       similar results as crushing it. Carbamazapine comes as an oral suspension, but it is not extended
       release. Therefore, a prescription would be needed to address dosing if switching to this form.
       CN: Safety and infection control; CL: Synthesize

Question 80

80. When making rounds on the pediatric neurology unit, the nurse manager notes that when
    giving IV medications many of the staff nurses are disconnecting the flush syringe first and then
    clamping the intermittent infusion device. The nurse is concerned that the nurses do not understand the
    benefits of positive pressure technique and turbulence flow flush in preventing clots. After discussing
    the problem with the staff educator, which intervention would be the most effective way to improve
    the nursing practice?
81. Create a poster presentation on the topic with a required post test.
82. Send a group email discussing the importance of clamping the device first.
83. Ask each nurse if they are aware that their practice is not current.
84. Post an evidence-based article on the unit.

Answer 80

80. 1. A poster presentation is an eye-catching way to disseminate information that can be used to
       educate nurses on all shifts. The addition of the post test will verify that the poster information has
       been received. Because of the large volume of emails the typical employee receives, information sent
       this way may be overlooked. If several nurses are observed not using the most current practice, it is
       quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article
       will not alone assure that the information is read.
       CN: Reduction of risk potential; CL: Create

Question 81

81. The emergency room nurse has admitted an infant with bulging fontanels, setting sun eyes, and
    lethargy. Which of the following diagnostic procedures would be contraindicated in this infant?
82. Lumbar puncture.
83. Magnetic resonance imaging.
84. Arterial blood draw.
85. Computerized tomography scan.

Answer 81

81. 1. The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A
       lumbar puncture is contraindicated in children with increased ICP due to the risk of herniation.
       Magnetic resonance imaging and a computerized tomography scan are indicated in children with
       suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP
       such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client.
       However, there is no contraindication for performing an arterial blood draw on a child with
       increased ICP.
       CN: Reduction of risk potential; CL: Analyze

Question 82

82. A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes.
    The child weighs 22 kg and currently has an IV of D5 NS + 20 mEq KCL/L running at 60 mL/h. Thevital signs are temperature 38°C, heart rate 120, a respiratory rate 28, and oxygen saturation 92%.
    Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication,
    the nurse calls the primary health care provider with the recommendation for:
83. Rectal diazepam.
84. IV lorazepam.
85. Rectal acetaminophen.
86. IV fosphenytoin.

Answer 82

82. 2. IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV
       benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA)
       neurotransmitter; stopping seizure activity. If an IV is not available, rectal diazepam is the
       benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by
       the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce
       neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the
       seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.
       CN: Pharmacological and parenteral therapies; CL: Apply