ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 27 Questions
Question 1 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.
Question 2 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 3 of 5
What term is used to describe a childs level of consciousness when the child is arousable with stimulation?
Correct Answer: C
Rationale: Obtundation describes a child arousable with stimulation but with reduced alertness. Stupor requires vigorous stimulation, confusion involves impaired decision-making, and disorientation pertains to time and place confusion.
Question 4 of 5
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?
Correct Answer: D
Rationale: A sudden fixed and dilated pupil in an unconscious child signals a neurosurgical emergency, often due to increased intracranial pressure or unilateral brain damage. Eye trauma is less likely, brain death involves bilateral fixed pupils, and pinpoint pupils suggest brainstem damage.
Question 5 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.