ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 27 : The Child with Cerebral Dysfunction Questions
Question 1 of 5
The nurse is caring for a child with severe head trauma after a car accident. What is an ominous sign that often precedes death?
Correct Answer: D
Rationale: Periodic or irregular breathing indicates brainstem dysfunction, often preceding apnea and death. Delirium reflects confusion, papilledema suggests chronic increased ICP, and flexion posturing indicates cerebral or corticospinal damage, not necessarily imminent death.
Question 2 of 5
What test is never performed on a child who is awake?
Correct Answer: B
Rationale: The oculovestibular response (caloric test) uses painful ice water instillation, performed only in comatose children. Dolls head maneuver, pyramidal tract assessment, and funduscopic exams are non-painful and can be done on awake children.
Question 3 of 5
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?
Correct Answer: A
Rationale: Presence of Moro, tonic neck, and withdrawal reflexes in a 2-month-old indicates normal neurologic function for age. These reflexes are expected and do not suggest brain damage, decorticate, or decerebrate posturing, which involve abnormal motor responses.
Question 4 of 5
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?
Correct Answer: A
Rationale: CT scans are painless, requiring immobilization, and this should be emphasized to reduce anxiety. Pain medication isn?t needed, movement is restricted during the scan, and a caregiver can often stay with the child, depending on facility protocols.
Question 5 of 5
What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child?
Correct Answer: D
Rationale: Avoiding pain or crying prevents ICP increases, as these raise intracranial pressure. Frequent suctioning, head turning, and environmental stimulation can elevate ICP and are contraindicated or require careful management, such as pre-suction hyperventilation.