PEDS EXAM #3||QUESTIONS AND
CORRECT ANSWERS||DOWNLOAD
NOW||
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 ANSWER 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 ANSWER 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.
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 ANSWER 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 ANSWER 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.
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 ANSWER 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
ANSWER 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.
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 ANSWER 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 ANSWER 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.
Oral care is essential in the unconscious child. Mouth care should be done at least twice
daily to prevent oral infections.
The head of the bed should be elevated, not lowered, in a child with neurologic
involvement.
, The nurse is instructing a group of parents about head injuries in children. The nurse
should explain that infants are particularly vulnerable to acceleration-deceleration head
injuries because the
A. anterior fontanel is not yet closed.
B. nervous tissue is not well developed.
C. scalp of head has extensive vascularity.
D. musculoskeletal support of head is insufficient. -CORRECT ANSWER D.
musculoskeletal support of head is insufficient.
The relatively large head size coupled with insufficient musculoskeletal support
increases the risk to infants of acceleration-deceleration head injuries.
The lack of closure of the anterior fontanel is not relevant to the development of
acceleration-deceleration head injuries in infants.
The lack of well-developed nervous tissue is not relevant to the development of
acceleration-deceleration head injuries in infants.
The vascularity of the scalp is not relevant to the development of acceleration-
deceleration injuries in infants.
The nurse is caring for a toddler who has had surgery for a brain tumor. During an
assessment, the nurse notes that the child is becoming irritable and the pupils are
unequal and sluggish. The most appropriate nursing action is to
A. notify the practitioner immediately.
B. assess for level of consciousness (LOC).
C. observe closely for signs of increased intracranial pressure (ICP).
D. administer pain medication and assess for response. -CORRECT ANSWER A. notify
the practitioner immediately.
The worsening of symptoms may indicate that the ICP is increasing. The practitioner
should be notified immediately because this is considered a medical emergency.
Assessing for the LOC should be done as part of the assessment.
The nurse is noting signs of potentially increased ICP as described; therefore, this has
already been completed.
Pain medication should not be given, because it can often mask the signs of increasing
ICP. The priority nursing intervention is to consult with the practitioner immediately.
The postoperative care of a preschool child who has had a brain tumor removed should
include
A. recording of colorless drainage as normal on the nurse's notes.
B. close supervision of the child while he or she is regaining consciousness.
C. positioning the child on the right side in the Trendelenburg position.
D. no administration of analgesics. -CORRECT ANSWER B. close supervision of the
child while he or she is regaining consciousness
The child needs to be observed closely, with careful and frequent assessment of the
vital signs and monitoring for signs of increasing intracranial pressure. Any changes
should be reported immediately to the practitioner.
Colorless drainage may be leakage of cerebrospinal fluid from the incision site. This
needs to be reported to the practitioner immediately.
The child should not be positioned in the Trendelenburg position postoperatively.
CORRECT ANSWERS||DOWNLOAD
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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 ANSWER 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 ANSWER 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.
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 ANSWER 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 ANSWER 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.
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 ANSWER 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
ANSWER 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.
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 ANSWER 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 ANSWER 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.
Oral care is essential in the unconscious child. Mouth care should be done at least twice
daily to prevent oral infections.
The head of the bed should be elevated, not lowered, in a child with neurologic
involvement.
, The nurse is instructing a group of parents about head injuries in children. The nurse
should explain that infants are particularly vulnerable to acceleration-deceleration head
injuries because the
A. anterior fontanel is not yet closed.
B. nervous tissue is not well developed.
C. scalp of head has extensive vascularity.
D. musculoskeletal support of head is insufficient. -CORRECT ANSWER D.
musculoskeletal support of head is insufficient.
The relatively large head size coupled with insufficient musculoskeletal support
increases the risk to infants of acceleration-deceleration head injuries.
The lack of closure of the anterior fontanel is not relevant to the development of
acceleration-deceleration head injuries in infants.
The lack of well-developed nervous tissue is not relevant to the development of
acceleration-deceleration head injuries in infants.
The vascularity of the scalp is not relevant to the development of acceleration-
deceleration injuries in infants.
The nurse is caring for a toddler who has had surgery for a brain tumor. During an
assessment, the nurse notes that the child is becoming irritable and the pupils are
unequal and sluggish. The most appropriate nursing action is to
A. notify the practitioner immediately.
B. assess for level of consciousness (LOC).
C. observe closely for signs of increased intracranial pressure (ICP).
D. administer pain medication and assess for response. -CORRECT ANSWER A. notify
the practitioner immediately.
The worsening of symptoms may indicate that the ICP is increasing. The practitioner
should be notified immediately because this is considered a medical emergency.
Assessing for the LOC should be done as part of the assessment.
The nurse is noting signs of potentially increased ICP as described; therefore, this has
already been completed.
Pain medication should not be given, because it can often mask the signs of increasing
ICP. The priority nursing intervention is to consult with the practitioner immediately.
The postoperative care of a preschool child who has had a brain tumor removed should
include
A. recording of colorless drainage as normal on the nurse's notes.
B. close supervision of the child while he or she is regaining consciousness.
C. positioning the child on the right side in the Trendelenburg position.
D. no administration of analgesics. -CORRECT ANSWER B. close supervision of the
child while he or she is regaining consciousness
The child needs to be observed closely, with careful and frequent assessment of the
vital signs and monitoring for signs of increasing intracranial pressure. Any changes
should be reported immediately to the practitioner.
Colorless drainage may be leakage of cerebrospinal fluid from the incision site. This
needs to be reported to the practitioner immediately.
The child should not be positioned in the Trendelenburg position postoperatively.
