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Nurs 337 exam 3 Exam Questions and Answers latest 2024/2025 RATED A+
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Nurs 337 exam 3 Exam Questions and Answers latest 2024/2025 RATED A+
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Nurs 337 exam 3 Exam Questions andAnswers latest 2024/2025 RATED A+
Which of the following phrases describes a characteristic of most neonatal seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - CORRECT ANSWERS D. Subtle and
barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip
smacking, tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to maintain a
generalized seizure.
The newborn's central nervous system is not sufficiently developed to maintain a
tonic-clonic (generalized) seizure.
The newborn's central nervous system is not sufficiently developed to maintain a
well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - CORRECT ANSWERS A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP in
infants. The characteristic cry occurs secondary to the pressure being placed on the
meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased ICP
would be seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present with
diarrhea, it is more indicative of a gastrointestinal disturbance.
,Nurs 337 exam 3 Exam Questions and
Answers latest 2024/2025 RATED A+
The nurse is doing a neurologic assessment on a child whose level of consciousness
has been variable since sustaining a cervical neck injury 12 hours ago. What is the
priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - CORRECT ANSWERS
A. Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils should be
assessed for no reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine injury.
Assessing for an oculovestibular response is a painful test that should not be done
for a child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant after a car
accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should
recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - CORRECT ANSWERS A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3
to 4 months of age. Therefore, the presence of these reflexes indicates neurologic
health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate
severe brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and
is not related to the presence of the Moro, tonic neck, or withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is
not related to the presence of the Moro, tonic neck, or withdrawal reflexes.
,Nurs 337 exam 3 Exam Questions and
Answers latest 2024/2025 RATED A+
The temperature of an unconscious adolescent is 105º F (40.5º C). The priority
nursing intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
C. apply a hypothermia blanket.
D. administer aspirin stat. - CORRECT ANSWERS C. apply a hypothermia
blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely
important to institute temperature-lowering interventions such as hypothermia
blankets and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the
priority.
Pain assessments should be ongoing, but this is not the priority at this time.
Lowering the body temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye
syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not
effective with temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse should
recognize that pain
A. cannot occur if the child is comatose.
B. may occur if the child regains consciousness.
C. requires astute nursing assessment and management.
D. is best assessed by family members who are familiar with the child. - CORRECT
ANSWERS C. requires astute nursing assessment and management.
Because the child cannot communicate pain through one of the standard pain rating
scales, the nurse must focus on physiologic and behavioral manifestations to
accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the nurse
should be monitoring physiologic and behavioral manifestations.
, Nurs 337 exam 3 Exam Questions and
Answers latest 2024/2025 RATED A+
What nursing intervention is used to prevent increased intracranial pressure (ICP) in
an unconscious child?
A. Suction the child frequently.
B. Provide environmental stimulation.
C. Turn the head side to side every hour.
D. Avoid activities that cause pain or crying. - CORRECT ANSWERS Avoid
activities that cause pain or crying.
Nursing interventions should focus on assessment and interventions to minimize
pain. These activities can cause the ICP to increase.
Suctioning is a distressing procedure. In addition, the resultant decrease in carbon
dioxide can increase ICP.
Environmental stimulation should be minimized because it can increase ICP.
The child's head should not be turned side to side. If the jugular vein is compressed,
the ICP can rise.
The nurse is caring for a 2-year-old child who is unconscious but stable after a car
accident. The child's parents are staying at the bedside most of the time. What is an
appropriate nursing intervention?
A. Suggest that the parents go home until the child is alert enough to know they are
present.
B. Use ointment on the lips but do not attempt to cleanse the teeth until swallowing
returns.
C. Encourage the parents to hold, talk to, and sing to the child as they usually
would.
D. Position the child with proper body alignment and the head of the bed lowered 15
degrees. - CORRECT ANSWERS C. Encourage the parents to hold, talk to,
and sing to the child as they usually would.
The parents should be encouraged to interact with the child. Senses of hearing and
tactile perception may be intact, and stimulation is important in the child's recovery.
Suggesting that the parents go home until the child is awake is not recommended.
The child may be able to hear that they are present, and this stimulation may assist
in recovery.
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