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NCLEX Peds Ch 30 -14
Neurological, Cognitive, Psychosocial Disorders
| Question | Answer |
|---|---|
| A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by: | Obtaining a history regarding factors that precipitate seizure activity – fever, infections, dehydration, electrolyte imbalance, falls, increased ICP, cerebral edema |
| A child has a basilar skull fracture. Which of the following physician orders should the nurse question? A.Restrict fluid intake, B.Insert indwelling urinary catheter, C.Keep an IV line patent, D.Suction via nasotracheal route as needed | D – nasotracheal suctioning is contraindicated in a child with a basilar skull fracture |
| Which lab result would verify the Dx bacterial meningitis: A.Clear cerebrospinal fluid,high protein,low glucose, B.Cloudy cerebrospinal fluid,high protein,low glucose, C.Cloudy CSF,high protein,low glucose, D.Decreased pressure,cloudy CSF,high protein | C – cloudy cerebrospinal fluid with high protein and low glucose |
| A child is diagnosed with meningococcal meningitis. Which isolation techniques is appropriate? A.Enteric precautions, B.Neutropenic precautions, C.No precautions when antibiotics are started, D.Isolation precautions for 24 hours after antibiotics begin | D – isolation precautions for at least 24 hours after the initiation of antibiotics – transmitted by droplet infection |
| Which of the following represents a primary characteristic of autism? A.Normal social play, B.Consistent imitation of others’ actions, C.Lack of social interaction and awareness, D.Normal verbal and nonverbal communications | C – lack of social interaction and awareness = primary characteristic |
| Which assessment finding would indicate the possibility of the sexual abuse of a child? A.Poor hygiene, B.Fear of the parents, C.Bald spots on the scalf, D.Swelling of the genitals | D – most likely findings of abuse = difficulty walking or sitting, torn or stained or bloody underclothing, swelling or itching of the genitals, bruises, bleeding, lacerations in the genital or anal area |
| A nurse is assisting data collection from an infant Dx hydrocephalus. If the infant’s LOC diminishes, a primary nursing intervention is: A.Take the apical pulse, B.Take the blood pressure, C.Test the urine for protein, D.Palpate the anterior fontanelle | D – a full or bulging anterior fontanelle indicates an increase in cerebrospinal fluid collection in the cerebral ventricle |
| Mother arrives at ER with her 5 year old and says the child fell.Head injury is suspected.Nurse is assessing for increased ICP.Which is a late sign of increased ICP in this child: A.Nausea, B.Bradycardia, C.Bulging fontanelle, D.Dilated scalp veins | B – late signs of increased ICP = decrease in level of consciousness, bradycardia, fixed and dilated pupils |
| A child has been diagnosed with Reye’s syndrome. The nurse understands that the major symptom associated with Reye’s syndrome is: A.Persistent vomiting, B.Protein in urine, C.Symptoms of hyperglycemia, D.History of staphylococcus infection | A – persistent vomiting is a major symptom associated with increased ICP – Reye’s syndrome is related to a history of viral infections and hypoglycemia is a symptom of this disease |
| The nurse assists with preparing a nursing care plan for Dx Reye’s syndrome.Which is the priority nursing intervention? A.Monitor output, B.Check for hearing loss, C.Change body position every 2 hours, D.Provide a quiet atmosphere with dimmed lights | D – major elements of care are to maintain effective cerebral perfusion and control ICP – decreasing stimuli would decrease stress on cerebral tissue and neuron responses – should be in a head elevated position |
| Which of the following is indicative of a potential complication associated with a tonic clonic seizure? A.High pitched cry, B.Blanced toenails, C.Blood on the pillow, D.Migraine headaches | C – complications = airway compromise, extremity and teeth injuries, tongue lacerations – night seizures can cause tongue biting – cyanosis can occur, but blanching does not |
| A nurse is initiating seizure precautions. Which of the following items should the nurse place at the bedside? A.Oxygen with nasal cannula, B.Suction apparatus and oxygen, C.An airway and tracheotomy set, D.An emergency cart and oxygen mask | B – seizures cause tightening of all body muscles that is followed by tremors. An obstructed airway and increased oral secretions are major complications during and after the seizure. Suction and oxygen prevents choking and cyanosis |
| Nurse instructing an adolescent with seizure history about an anticonvulsant.Which remark indicates understanding? A.I will never drive,B.This will clear up my skin, C.I can’t drink alcohol while I am taking this, D.If I forget my AM dose, add it to my PM | C – alcohol will lower the seizure threshold and should be avoided – in most states a driver’s license can be obtained after being seizure free for 1 year, anticonvulsants cause acne and oily skin – if a dose is missed, the physician should be notified |
| A nurse is developing a plan of care for a seizure risk child.Which apply if the child has a seizure: A.Time it,B.Restrain the child,C.Stay with the child,D.Place in prone position,E.Move furniture away child,F.Insert a padded tongue blade into the mouth | A, C, E – during a seizure, the child is placed on the side in a lateral position to prevent aspiration of saliva – restraints could cause injury – nothing is placed in the mouth – the nurse would stay, and would time the seizure |
| When making a plan of care for an infant with myelomeningocele, which nursing Dx is wrong? Risk for A-trauma r/t delicate spinal lesion B-injury r/t repeated latex exposure C-injury r/t musculoskeletal impairment D-trauma r/t impaired CSF circulation | C - it is a neurotube defect and does not involve the skeletal system |
| Which is most commonly the 1st sign of inceased ICF? A-setting sun sign B-frontal bossing C-cracked pot sound D-bulging fontanels | D - all are signs of increased ICP, but the others are late signs |
| Newborn is born with bilateral talipes equinovarus.Which shows need for surgical intervention? A-heels pulled in & toes point in B-Heels of casted feet are out & toes are out C-No response to serial casting D-casting manipulation done for 8 weeks | C - treatment is serial casting every 1 to 2 weeks for 8 weeks with heels turned out and toes pointed in - if ineffective, surgery is needed |
| 22 month old has otitis media infections often.Mom asks why? A-narrow Eustachian tubes B-Undeveloped cartilage lining the ear C-Short Eustachian tubes D-Formula/breast milk is primary nutrition E-Normal positioning of child F-Hormonal defense responses | B,C,E,F – middle ear infections are common b/c short, wide, straight Eustachian tubes – undeveloped cartilage lining, horizontal lie of Eustachian tubes, immature hormonal defense, frequent lying position of infants |
| Put Piaget’s stages in order, young – old: A-Formal operations B-Concrete operations C-Preoperational thought, intuitive phase D-Preoperational though preconceptual phase E-Sensorimotor | E,D,C,B,A - Sensorimotor, Preoperational thought (preconceptual phase), Preoperational thought (intuitive phase), Concrete operations, Formal operations |
| To distract a 4 year old from the pain after bone marrow aspiration, which toy would not be appropriate for the developmental stage? A-Books with different textures B-Building blocks C-Play carpentry tools D-Crayons | A - preschool aged children need fine motor skill toys |
| Newborn with cleft palate, scheduled for surgery, is showing signs of growth failure. Which factor related to defect contributes? A-Sucking difficulties B-Improper digestion C-Frequent regurgitation D-Constipation | A - Prior to surgery, feeding a newborn with cleft palate can be difficult due to decreased sucking ability and escape of food from the nose |
| When assessing development of a 13 month old boy, inability to perform which would indicate delay? A-Stand alone B-Walk backwards C-Scribble on paper D-Play pat-a-cake | D - according to Denver II, 90% of children at 11 1/2 months are able to play pat a cake |
| A friend says her 2 year old will not play with other children and is possessive with her toys. You say: A-It’s not too soon for counseling B-This is normal for her age C-She has her dad’s personality D-You should make her share | B - toddlers want instant gratification and has no comprehesion of, or desire to, share - prefers parallel play |
| A 2 year old says NO to everything and insists on doing things herself. According to Erikson, she is in the stage of: A-Autonomy B-Initiative C-Industry D-Identity | A - toddlers begin to realize they have control and test the extent of their power |
| Freud referred to late childhood as the period of: A-Oral stage B-Anal stage C-Latency D-Oedipal stage | C - Latency - quiet time without obvious changes |
| Erikson designates late childhood as a time of: A-Trust B-Autonomy C-Initiative D-Industry | D - Industry, when energy is channeled into learning |
| Intellectual development of a school age child becomes more flexible and systematic. Piaget called this: A-Sensorimotor B-Preoperational C-Concrete D-Formal | C - the ability to see and organized whole and its parts for application are developing |
| Knowing there is as much water in a low quart container as in a small quart container is which of Piaget's stages? A-Preoperational B-Concrete C-Formal D-Generavity | B - the ability to transfer and conserve a volume is developed |
| Shyness in a school age child may be produced by: A-Shaming B-Encouraging C-Lying D-Ignoring | A - the school age child listens to negative remarks and internalizes them to be true |
| A congenital defect that results in increased ICP and head size is: A-Microcephalus B-Hydrocele C-Hydrocephalus D-Anincephaly | C - Hydrocephalus |
| Which of the following problems are expected to develop in an infant with Down's syndrome? A-slowed development at 1 year B-Profound mental retardation C-Respiratory tract infections D-Hearing problems | C - Infants with down's syndrom have decreased muscle tone which compromises breathing and coughing leading to likely upper respiratory infections |
| Which of the following physcial characteristics are expected in an infant with down syndrome? A-asymetrical gluteal folds B-hypertonic muscles C-rounded occiput D-simian crease | D - Simean creases are the only choice ALWAYS present - the others sometimes are |
| A common defect associated with down syndrome is: A-Deafness B-Congenital heart defects C-Hydrocephaly D-Muscular hypertonicity | B - Infants with down syndrom have a high incidence of congenital heart disease, especially atrial defects |
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