NSG 451 FINAL EXAM TEST BANK
QUESTIONS AND ANSWERS
An injury to which part of the brain will cause a coma?
a. Brainstem
b. Cerebrum
c. Cerebellum
d. Occipital lobe < ANSWER >a. Brainstem
What finding is a clinical manifestation of increased intracranial pressure (ICP) in children?
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia, blurred vision
d. Increased blood pressure < ANSWER >c. Diplopia, blurred vision
What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on
relaxation called?
a. Twitching
b. Spasticity
c. Choreiform movements
d. Associated movements < ANSWER >c. Choreiform movements
What term is used when a patient remains in a deep sleep, responsive only to vigorous and
repeated stimulation?
a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative state < ANSWER >b. Stupor
What term is used to describe a childs level of consciousness when the child is arousable with
stimulation?
a. Stupor
b. Confusion
c. Obtundation
d. Disorientation < ANSWER >c. Obtundation
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child
suddenly has a fixed and dilated pupil. How should the nurse interpret this?
a. Eye trauma
b. Brain death
c. Severe brainstem damage
d. Neurosurgical emergency < ANSWER >d. Neurosurgical emergency
,The nurse is caring for a child with severe head trauma after a car accident. What is an ominous
sign that often precedes death?
a. Delirium
b. Papilledema
c. Flexion posturing
d. Periodic or irregular breathing < ANSWER >d. Periodic or irregular breathing
What test is never performed on a child who is awake?
a. Dolls head maneuver
b. Oculovestibular response
c. Assessment of pyramidal tract lesions
d. Funduscopic examination for papilledema < ANSWER >b. Oculovestibular response
The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro,
tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings?
a. Neurologic health
b. Severe brain damage
c. Decorticate posturing
d. Decerebrate posturing < ANSWER >a. Neurologic health
The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral
function. The nurse should include what statement in preparing the child?
a. The scan will not hurt.
b. Pain medication will be given.
c. You will be able to move once the equipment is in place.
d. Unfortunately no one can remain in the room with you during the test. < ANSWER >a. The
scan will not hurt.
What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an
unconscious child?
a. Suction the child frequently.
b. Turn the childs head side to side every hour.
c. Provide environmental stimulation.
d. Avoid activities that cause pain or crying. < ANSWER >d. Avoid activities that cause pain or
crying.
What nursing intervention is appropriate when caring for an unconscious child?
a. Avoid using narcotics or sedatives to provide comfort and pain relief.
b. Change the childs position infrequently to minimize the chance of increased intracranial
pressure (ICP).
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are
contraindicated. < ANSWER >c. Monitor fluid intake and output carefully to avoid fluid
overload and cerebral edema.
What statement is descriptive of a concussion?
,a. Petechial hemorrhages cause amnesia.
b. Visible bruising and tearing of cerebral tissue occur.
c. It is a transient and reversible neuronal dysfunction.
d. It is a slight lesion that develops remote from the site of trauma. < ANSWER >c. It is a
transient and reversible neuronal dysfunction.
What statement best describes a subdural hematoma?
a. Bleeding occurs between the dura and the skull.
b. Bleeding occurs between the dura and the cerebrum.
c. Bleeding is generally arterial, and brain compression occurs rapidly.
d. The hematoma commonly occurs in the parietotemporal region. < ANSWER >b. Bleeding
occurs between the dura and the cerebrum.
A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse
immediately assesses airway, breathing, and circulation. What should be the next nursing action?
a. Place the child on his side.
b. Take the childs blood pressure.
c. Stabilize the childs neck and spine.
d. Check the childs scalp and back for bleeding. < ANSWER >c. Stabilize the childs neck and
spine.
A school-age child has sustained a head injury and multiple fractures after being thrown from a
horse. The childs level of consciousness is variable. The parents tell the nurse that they think
their child is in pain because of periodic crying and restlessness. What is the most appropriate
nursing action?
a. Explain that analgesia is contraindicated with a head injury.
b. Have the parents describe the childs previous experiences with pain.
c. Consult with a practitioner about what analgesia can be safely administered.
d. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert. <
ANSWER >c. Consult with a practitioner about what analgesia can be safely administered.
The nurse is assessing a child who was just admitted to the hospital for observation after a head
injury. What clinical manifestation is the most essential part of the nursing assessment to detect
early signs of a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness < ANSWER >d. Level of consciousness
A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge,
the nurse is discussing home care with her mother. What sign or symptom is considered a
manifestation of postconcussion syndrome and does not necessitate medical attention?
a. Vomiting
b. Blurred vision
c. Behavioral changes
d. Temporary loss of consciousness < ANSWER >c. Behavioral changes
, An 18-month-old child is brought to the emergency department after being found unconscious in
the family pool. What does the nurse identify as the primary problem in drowning incidents?
a. Hypoxia
b. Aspiration
c. Hypothermia
d. Electrolyte imbalance < ANSWER >a. Hypoxia
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis
like the childs younger brother had when he was an infant. The nurse should base a response on
which information?
a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.
d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are
available. < ANSWER >d. Vaccinations to prevent pneumococcal and Haemophilus influenzae
type B meningitis are available.
A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial
orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows
that antibiotic therapy will begin when?
a. After the diagnosis is confirmed
b. When the medication is received from the pharmacy
c. After the childs fluid and electrolyte balance is stabilized
d. As soon as the practitioner is notified of the culture results < ANSWER >b. When the
medication is received from the pharmacy
The nurse is planning care for a school-age child with bacterial meningitis. What intervention
should be included?
a. Keep environmental stimuli to a minimum.
b. Have the child move her head from side to side at least every 2 hours.
c. Avoid giving pain medications that could dull sensorium.
d. Measure head circumference to assess developing complications. < ANSWER >a. Keep
environmental stimuli to a minimum.
A young childs parents call the nurse after their child is bitten by a raccoon in the woods. The
nurses recommendation should be based on what knowledge?
a. Antirabies prophylaxis must be initiated immediately.
b. The child should be hospitalized for close observation.
c. No treatment is necessary if thorough wound cleaning is done.
d. Antirabies prophylaxis must be initiated as soon as clinical manifestations appear. <
ANSWER >a. Antirabies prophylaxis must be initiated immediately.
What intervention should be beneficial in reducing the risk of Reye syndrome?
a. Immunization against the disease
b. Medical attention for all head injuries
QUESTIONS AND ANSWERS
An injury to which part of the brain will cause a coma?
a. Brainstem
b. Cerebrum
c. Cerebellum
d. Occipital lobe < ANSWER >a. Brainstem
What finding is a clinical manifestation of increased intracranial pressure (ICP) in children?
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia, blurred vision
d. Increased blood pressure < ANSWER >c. Diplopia, blurred vision
What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on
relaxation called?
a. Twitching
b. Spasticity
c. Choreiform movements
d. Associated movements < ANSWER >c. Choreiform movements
What term is used when a patient remains in a deep sleep, responsive only to vigorous and
repeated stimulation?
a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative state < ANSWER >b. Stupor
What term is used to describe a childs level of consciousness when the child is arousable with
stimulation?
a. Stupor
b. Confusion
c. Obtundation
d. Disorientation < ANSWER >c. Obtundation
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child
suddenly has a fixed and dilated pupil. How should the nurse interpret this?
a. Eye trauma
b. Brain death
c. Severe brainstem damage
d. Neurosurgical emergency < ANSWER >d. Neurosurgical emergency
,The nurse is caring for a child with severe head trauma after a car accident. What is an ominous
sign that often precedes death?
a. Delirium
b. Papilledema
c. Flexion posturing
d. Periodic or irregular breathing < ANSWER >d. Periodic or irregular breathing
What test is never performed on a child who is awake?
a. Dolls head maneuver
b. Oculovestibular response
c. Assessment of pyramidal tract lesions
d. Funduscopic examination for papilledema < ANSWER >b. Oculovestibular response
The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro,
tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings?
a. Neurologic health
b. Severe brain damage
c. Decorticate posturing
d. Decerebrate posturing < ANSWER >a. Neurologic health
The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral
function. The nurse should include what statement in preparing the child?
a. The scan will not hurt.
b. Pain medication will be given.
c. You will be able to move once the equipment is in place.
d. Unfortunately no one can remain in the room with you during the test. < ANSWER >a. The
scan will not hurt.
What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an
unconscious child?
a. Suction the child frequently.
b. Turn the childs head side to side every hour.
c. Provide environmental stimulation.
d. Avoid activities that cause pain or crying. < ANSWER >d. Avoid activities that cause pain or
crying.
What nursing intervention is appropriate when caring for an unconscious child?
a. Avoid using narcotics or sedatives to provide comfort and pain relief.
b. Change the childs position infrequently to minimize the chance of increased intracranial
pressure (ICP).
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are
contraindicated. < ANSWER >c. Monitor fluid intake and output carefully to avoid fluid
overload and cerebral edema.
What statement is descriptive of a concussion?
,a. Petechial hemorrhages cause amnesia.
b. Visible bruising and tearing of cerebral tissue occur.
c. It is a transient and reversible neuronal dysfunction.
d. It is a slight lesion that develops remote from the site of trauma. < ANSWER >c. It is a
transient and reversible neuronal dysfunction.
What statement best describes a subdural hematoma?
a. Bleeding occurs between the dura and the skull.
b. Bleeding occurs between the dura and the cerebrum.
c. Bleeding is generally arterial, and brain compression occurs rapidly.
d. The hematoma commonly occurs in the parietotemporal region. < ANSWER >b. Bleeding
occurs between the dura and the cerebrum.
A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse
immediately assesses airway, breathing, and circulation. What should be the next nursing action?
a. Place the child on his side.
b. Take the childs blood pressure.
c. Stabilize the childs neck and spine.
d. Check the childs scalp and back for bleeding. < ANSWER >c. Stabilize the childs neck and
spine.
A school-age child has sustained a head injury and multiple fractures after being thrown from a
horse. The childs level of consciousness is variable. The parents tell the nurse that they think
their child is in pain because of periodic crying and restlessness. What is the most appropriate
nursing action?
a. Explain that analgesia is contraindicated with a head injury.
b. Have the parents describe the childs previous experiences with pain.
c. Consult with a practitioner about what analgesia can be safely administered.
d. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert. <
ANSWER >c. Consult with a practitioner about what analgesia can be safely administered.
The nurse is assessing a child who was just admitted to the hospital for observation after a head
injury. What clinical manifestation is the most essential part of the nursing assessment to detect
early signs of a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness < ANSWER >d. Level of consciousness
A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge,
the nurse is discussing home care with her mother. What sign or symptom is considered a
manifestation of postconcussion syndrome and does not necessitate medical attention?
a. Vomiting
b. Blurred vision
c. Behavioral changes
d. Temporary loss of consciousness < ANSWER >c. Behavioral changes
, An 18-month-old child is brought to the emergency department after being found unconscious in
the family pool. What does the nurse identify as the primary problem in drowning incidents?
a. Hypoxia
b. Aspiration
c. Hypothermia
d. Electrolyte imbalance < ANSWER >a. Hypoxia
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis
like the childs younger brother had when he was an infant. The nurse should base a response on
which information?
a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.
d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are
available. < ANSWER >d. Vaccinations to prevent pneumococcal and Haemophilus influenzae
type B meningitis are available.
A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial
orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows
that antibiotic therapy will begin when?
a. After the diagnosis is confirmed
b. When the medication is received from the pharmacy
c. After the childs fluid and electrolyte balance is stabilized
d. As soon as the practitioner is notified of the culture results < ANSWER >b. When the
medication is received from the pharmacy
The nurse is planning care for a school-age child with bacterial meningitis. What intervention
should be included?
a. Keep environmental stimuli to a minimum.
b. Have the child move her head from side to side at least every 2 hours.
c. Avoid giving pain medications that could dull sensorium.
d. Measure head circumference to assess developing complications. < ANSWER >a. Keep
environmental stimuli to a minimum.
A young childs parents call the nurse after their child is bitten by a raccoon in the woods. The
nurses recommendation should be based on what knowledge?
a. Antirabies prophylaxis must be initiated immediately.
b. The child should be hospitalized for close observation.
c. No treatment is necessary if thorough wound cleaning is done.
d. Antirabies prophylaxis must be initiated as soon as clinical manifestations appear. <
ANSWER >a. Antirabies prophylaxis must be initiated immediately.
What intervention should be beneficial in reducing the risk of Reye syndrome?
a. Immunization against the disease
b. Medical attention for all head injuries
