CLAEX CH 16 NEURO Questions and
Answers A+ Graded (2025)
The .nurse .assesses .a .child .and .finds .that .the .child's .pupils .are .pinpoint. .The
.nurse .interprets .this .finding .as .indicating .which .of .the .following?
Seizure .activity
Brain .stem .dysfunction
Intracranial .mass
Brain .stem .herniation .- .CORRECT .ANSWER-Brain .stem .dysfunction
Pinpoint .pupils .are .commonly .observed .in .poisonings, .brain .stem .dysfunction,
.and .opiate .use.
The .nurse .is .caring .for .an .8-year-old .girl .who .was .in .a .car .accident. .Which .of .the
.following .would .lead .the .nurse .to .suspect .a .concussion?
The .child .is .bleeding .from .the .ear .and .draining .fluid .from .the .nose.
The .child .is .easily .distracted .and .can't .concentrate.
The .child .is .weak .and .has .blurry .vision.
The .child .has .vomited .and .has .bruising .behind .her .ear. .- .CORRECT .ANSWER-
The .child .is .easily .distracted .and .can't .concentrate.
A .child .with .a .concussion .will .be .distracted .and .unable .to .concentrate.
A .6-month-old .infant .is .admitted .with .suspected .bacterial .meningitis. .She .is
.crying, .irritable, .and .lying .in .the .opisthotonic .position. .Which .of .the .following
.interventions .should .the .nurse .take .initially?
Palpate .the .child's .fontanels.
Educate .the .family .about .preventing .bacterial .meningitis.
Encourage .the .mother .to .hold .and .comfort .the .infant.
Institute .droplet .precautions .in .addition .to .standard .precautions. .- .CORRECT
.ANSWER-Institute .droplet .precautions .in .addition .to .standard
.precautions.Bacterial .meningitis .is .a .medical .emergency. .The .child .must .be
.placed .on .droplet .precautions .until .24 .hours .of .antibiotics .have .been .given.
Palpating .the .fontanels .is .used .to .assess .for .hydrocephalus.Educating .the
.family .about .preventing .bacterial .meningitis .would .be .appropriate .later .on .once
.the .initial .infection .has .been .controlled.Encouraging .the .mother .to .hold .and
.comfort .the .child .is .an .intervention .but . not .the .priority .one: .the .focus .is .to .get
, the .infant .the .appropriate .medications .to .fight .the .infection .and .to .prevent .its
.
spread.
.
The .nurse .is .providing .education .to .the .parents .of .a .2-year-old .boy .with
.hydrocephalus .who . has .just .had .a .ventriculoperitoneal .shunt .placed. .Which
.information .is .most .important .for .the .parents .to .be .taught?
"Always .keep .his .head .raised .30 .degrees."
"Limit .the .amount .of .television .he .watches."
"Watch .for .changes .in .his .behavior .or .eating .patterns."
"Call .the .doctor .if .he .gets .a .headache." .- .CORRECT .ANSWER-"Watch .for
.changes .in .his .behavior .or .eating .patterns."Changes .in .behavior .or .in .eating
.patterns .can .suggest .a .problem .with .his .shunt, .such .as .infection .or .blockage.
.Irritability, .lack .of .appetite, .increased .crying, .or .inability .to .settle .down .may
.indicate .increased .intracranial .pressure.
A .child .is .diagnosed .with .aseptic .meningitis. .The .child's .mother .states, ."I .don't
.know .where .she .would .have .picked .this .up." .The .nurse .prepares .to .respond .to
.the .mother, .based .on .the .understanding .that .this .disorder .is .most .likely .caused
.by .which .of .the .following?
Haemophilus .influenza .type .B
Enterovirus
Escherichia .coli
Streptococcus .group .B .- .CORRECT .ANSWER-Enterovirus
Aseptic .meningitis .is .the .most .common .type .of .meningitis, .and .if .a .causative
.organism .can .be .identified, .it .is .usually .a . virus .such .as .enterovirus.
H. .influenza .type .B .is .a .cause .of .bacterial .meningitis.
E. .coli .is .a .cause .of .bacterial .meningitis.
Streptococcus .group .B .is .a .cause .of .bacterial .meningitis.
During .the .physical .assessment .of .a .2r-month-old .infant, .the .nurse .suspects .the
.child .may . have . hydrocephalus. .Which .of .the .following .signs .or .symptoms .was
.observed?
Dramatic .increase .in .head .circumference
Pupil .of .one .eye .dilated .and .reactive
Posterior .fontanel .is .closed
Vertical .nystagmus .- .CORRECT .ANSWER-Dramatic .increase .in .head
.circumference
A .dramatic .increase .in .head .circumference .is .a .symptom .of .hydrocephalus,
.suggesting .that .there .is .a .build-up .of .fluid .in .the .brain.
The .nurse .knows .that .the .heads .of .infants .and .toddlers .are .large .in .proportion
.to .their .bodies, .placing .them .at .risk .for .which .of .the .following?
Closed .head .injury
Intracranial .hemorrhaging
Congenital .hydrocephalus
Positional .plagiocephaly .- .CORRECT .ANSWER-Closed .head .injury
Answers A+ Graded (2025)
The .nurse .assesses .a .child .and .finds .that .the .child's .pupils .are .pinpoint. .The
.nurse .interprets .this .finding .as .indicating .which .of .the .following?
Seizure .activity
Brain .stem .dysfunction
Intracranial .mass
Brain .stem .herniation .- .CORRECT .ANSWER-Brain .stem .dysfunction
Pinpoint .pupils .are .commonly .observed .in .poisonings, .brain .stem .dysfunction,
.and .opiate .use.
The .nurse .is .caring .for .an .8-year-old .girl .who .was .in .a .car .accident. .Which .of .the
.following .would .lead .the .nurse .to .suspect .a .concussion?
The .child .is .bleeding .from .the .ear .and .draining .fluid .from .the .nose.
The .child .is .easily .distracted .and .can't .concentrate.
The .child .is .weak .and .has .blurry .vision.
The .child .has .vomited .and .has .bruising .behind .her .ear. .- .CORRECT .ANSWER-
The .child .is .easily .distracted .and .can't .concentrate.
A .child .with .a .concussion .will .be .distracted .and .unable .to .concentrate.
A .6-month-old .infant .is .admitted .with .suspected .bacterial .meningitis. .She .is
.crying, .irritable, .and .lying .in .the .opisthotonic .position. .Which .of .the .following
.interventions .should .the .nurse .take .initially?
Palpate .the .child's .fontanels.
Educate .the .family .about .preventing .bacterial .meningitis.
Encourage .the .mother .to .hold .and .comfort .the .infant.
Institute .droplet .precautions .in .addition .to .standard .precautions. .- .CORRECT
.ANSWER-Institute .droplet .precautions .in .addition .to .standard
.precautions.Bacterial .meningitis .is .a .medical .emergency. .The .child .must .be
.placed .on .droplet .precautions .until .24 .hours .of .antibiotics .have .been .given.
Palpating .the .fontanels .is .used .to .assess .for .hydrocephalus.Educating .the
.family .about .preventing .bacterial .meningitis .would .be .appropriate .later .on .once
.the .initial .infection .has .been .controlled.Encouraging .the .mother .to .hold .and
.comfort .the .child .is .an .intervention .but . not .the .priority .one: .the .focus .is .to .get
, the .infant .the .appropriate .medications .to .fight .the .infection .and .to .prevent .its
.
spread.
.
The .nurse .is .providing .education .to .the .parents .of .a .2-year-old .boy .with
.hydrocephalus .who . has .just .had .a .ventriculoperitoneal .shunt .placed. .Which
.information .is .most .important .for .the .parents .to .be .taught?
"Always .keep .his .head .raised .30 .degrees."
"Limit .the .amount .of .television .he .watches."
"Watch .for .changes .in .his .behavior .or .eating .patterns."
"Call .the .doctor .if .he .gets .a .headache." .- .CORRECT .ANSWER-"Watch .for
.changes .in .his .behavior .or .eating .patterns."Changes .in .behavior .or .in .eating
.patterns .can .suggest .a .problem .with .his .shunt, .such .as .infection .or .blockage.
.Irritability, .lack .of .appetite, .increased .crying, .or .inability .to .settle .down .may
.indicate .increased .intracranial .pressure.
A .child .is .diagnosed .with .aseptic .meningitis. .The .child's .mother .states, ."I .don't
.know .where .she .would .have .picked .this .up." .The .nurse .prepares .to .respond .to
.the .mother, .based .on .the .understanding .that .this .disorder .is .most .likely .caused
.by .which .of .the .following?
Haemophilus .influenza .type .B
Enterovirus
Escherichia .coli
Streptococcus .group .B .- .CORRECT .ANSWER-Enterovirus
Aseptic .meningitis .is .the .most .common .type .of .meningitis, .and .if .a .causative
.organism .can .be .identified, .it .is .usually .a . virus .such .as .enterovirus.
H. .influenza .type .B .is .a .cause .of .bacterial .meningitis.
E. .coli .is .a .cause .of .bacterial .meningitis.
Streptococcus .group .B .is .a .cause .of .bacterial .meningitis.
During .the .physical .assessment .of .a .2r-month-old .infant, .the .nurse .suspects .the
.child .may . have . hydrocephalus. .Which .of .the .following .signs .or .symptoms .was
.observed?
Dramatic .increase .in .head .circumference
Pupil .of .one .eye .dilated .and .reactive
Posterior .fontanel .is .closed
Vertical .nystagmus .- .CORRECT .ANSWER-Dramatic .increase .in .head
.circumference
A .dramatic .increase .in .head .circumference .is .a .symptom .of .hydrocephalus,
.suggesting .that .there .is .a .build-up .of .fluid .in .the .brain.
The .nurse .knows .that .the .heads .of .infants .and .toddlers .are .large .in .proportion
.to .their .bodies, .placing .them .at .risk .for .which .of .the .following?
Closed .head .injury
Intracranial .hemorrhaging
Congenital .hydrocephalus
Positional .plagiocephaly .- .CORRECT .ANSWER-Closed .head .injury
