Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care for a pediatric patient who received a concussion while playing football. The patient had brief loss of consciousness and now reports a headache with a pain level of 6 o...
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care for a pediatric patient who received a concussion while
playing football. The patient had brief loss of consciousness and now reports a headache
with a pain level of 6 on a 0 to 10 scale. The patient states, “My team plays again in five
days and I should be better.” Which information is vital for the patient and parents to
understand?
a. A realistic time frame regarding complete recovery
b. Type of equipment to prevent a second head injury
c. The risk of acquiring second impact syndrome
d. The potential for long-term headaches
ANS: C
Chapter: Chapter 14 Neurological and Sensory Disorders
Chapter Learning Objective: 5. Identify the clinical presentation and nursing care of
the pediatric patient with nervous system disorders.
Page: 316
Heading: Headaches and Migraines > Types of Headaches
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Teaching and Learning
Difficulty: Moderate
Feedback
A. This is incorrect. The nurse needs to inform the patient and parents that full
recovery from a concussion may take days, weeks, or months. This information
is important, but it is not considered vital.
B. This is incorrect. Information about the type of equipment needed to avoid a
second head injury is important; however, it is not vital.
C. This is correct. There is risk for a lethal condition known as second impact
syndrome, in which the brain swells rapidly and the person succumbs quickly if a
second concussion occurs before the first concussion has resolved. The patient’s
remark makes this information vitally important.
D. This is incorrect. Head injuries may or may not cause long-term headaches.
PTS: 1 CON: Teaching and Learning
2. The pediatric nurse is examining the skin of a young child and notices eight café-au-lait
, spots between 1.5 and 3 inches in diameter on the body, along with axillary freckling.
Which recommendation does the nurse make to the parent?
a. Refrain from having additional children without counseling.
b. Make an appointment with a physician for testing and evaluation.
c. Agree to blood testing of the child to identify a defect in the NF1 gene.
d. Arrange for psychological therapy to address self-esteem problems.
ANS: B
Chapter: Chapter 14 Neurological and Sensory Disorders
Chapter Learning Objective: 5. Identify the clinical presentation and nursing care of
the pediatric patient with nervous system disorders.
Page: 318
Heading: Neurocutaneous Disorders > Neurofibromatosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Difficult
Feedback
A. This is incorrect. Without a valid diagnosis, it is not appropriate for the nurse to
recommend the parents refrain from having additional children.
B. This is correct. The nurse may recognize that the child’s skin manifestations are
related to a strong possibility of neurofibromatosis. The nurse needs to
recommend seeing a physician for testing and evaluation.
C. This is incorrect. Part of the routine testing on the child is likely to involve a
blood test to evaluate for a defect in the NF1 gene.
D. This is incorrect. Once a valid diagnosis is obtained, the nurse will recommend
that psychological therapy may become necessary for self-esteem issues from the
presence of visible skin tumors.
PTS: 1 CON: Health Promotion
3. The nurse is assessing a 7-year-old child at a pediatric clinic. The nurse notices that
several developmental milestones have been missed or are late during previous visits. The
parent states, “I know she is a little slow, but she will catch up quickly.” Which action by
the nurse is warranted?
a. Explain to the parent that rapid development takes place in infancy and early
childhood.
b. Suggest activities in the home that may improve mental and physical
development.
c. Recommend that the child be placed in special classes aimed at promoting
development.
d. Ask the parent detailed questions about the pregnancy, birth, and early childhood
, health.
ANS: D
Chapter: Chapter 14 Neurological and Sensory Disorders
Chapter Learning Objective: 2. Describe normal growth and development of the brain
and spinal cord.
Page: 291
Heading: Neurological Development
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Growth and Development
Difficulty: Difficult
Feedback
A. This is incorrect. Explaining the expected periods and time frames when
development rapidly occurs is not beneficial to the parent.
B. This is incorrect. Suggesting home activities that improve mental and physical
development may or may not be effective. Further assessment is needed to better
define the findings.
C. This is incorrect. It is premature for the nurse to recommend special classes for
the child.
D. This is correct. The nurse needs to further assess for possible contributing factors
for the child’s developmental delays. Along with information about the
pregnancy, birth, and early childhood health, the nurse will explore the family
health history and home environment.
PTS: 1 CON: Growth and Development
4. The nurse is assessing an 8-month-old infant during a routine well-baby visit. During the
neurological assessment, which finding is a reason for concern?
a. The infant starts to suck when the mouth is touched.
b. Toes fan out when the sole of the food is stroked upward.
c. Placing a small object in the palm inconsistently elicits a grasp.
d. A light puff of air in the face causes the eyes to close.
ANS: C
Chapter: Chapter 14 Neurological and Sensory Disorders
Chapter Learning Objective: 1. Identify the normal assessment of anatomy and
physiology of the pediatric nervous system.
Page: 291
Heading: Table 14-3: Primitive Reflexes
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
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