ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 27 : The Child with Cerebral Dysfunction Questions
Question 1 of 5
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?
Correct Answer: C
Rationale: After ensuring airway, breathing, and circulation, stabilizing the neck and spine prevents further trauma in a suspected head or spinal injury. Positioning, blood pressure checks, or bleeding assessments follow to avoid exacerbating potential spinal injuries.
Question 2 of 5
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?
Correct Answer: C
Rationale: Consulting a practitioner ensures safe analgesia administration to manage pain and reduce ICP from anxiety, while monitoring neurologic status. Analgesia is not contraindicated, past pain history is secondary, and pain relief is necessary despite reduced consciousness.
Question 3 of 5
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?
Correct Answer: D
Rationale: Level of consciousness is the earliest and most sensitive indicator of worsening neurologic status post-head injury. Posturing and focal signs appear later, and vital sign changes are less immediate or specific in children with head injuries.
Question 4 of 5
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?
Correct Answer: C
Rationale: Behavioral changes, such as irritability or sleep disturbances, are expected in postconcussion syndrome and typically don?t require medical attention. Vomiting, blurred vision, or loss of consciousness warrant evaluation for complications like increased ICP.
Question 5 of 5
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?
Correct Answer: A
Rationale: Hypoxia is the primary problem in drowning, causing rapid global cell damage, especially to neurons, within 4-6 minutes. Aspiration leads to pulmonary complications, hypothermia occurs but is secondary, and electrolyte imbalances are not the primary cause of morbidity.