Nokea
A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, which should the next priority assessment be?
- A. Swallowing ability
- B. Parental involvement
- C. Level of consciousness
- D. Antecedent viral infections
Correct Answer: A
Rationale: Assessing swallowing ability is critical in GBS due to potential pharyngeal and respiratory involvement, risking aspiration or the need for ventilatory support. Parental involvement, consciousness, and viral history are secondary to immediate physiologic risks.
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The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurses response should be based on which knowledge?
- A. Affected children have some degree of cognitive impairment.
- B. Around 20% of affected children have normal intelligence.
- C. About 45% of affected children have normal intelligence.
- D. Cognitive impairment is expected if motor and sensory deficits are severe.
Correct Answer: C
Rationale: Approximately 40% to 50% of children with CP have normal intelligence, with a wide range of cognitive outcomes. Severe physical impairment does not necessarily correlate with cognitive deficits, and many have minimal intellectual compromise.
What type of cerebral palsy (CP) is the most common type?
- A. Ataxic
- B. Spastic
- C. Dyskinetic
- D. Mixed type
Correct Answer: B
Rationale: Spastic CP, marked by initial hypotonia transitioning to hypertonicity, is the most common type. Ataxic, dyskinetic, and mixed types are less frequent, with spastic CP showing increased stretch reflexes and weakness.
What functional ability should the nurse expect in a child with a spinal cord lesion at C7?
- A. Complete respiratory paralysis
- B. No voluntary function of upper extremities
- C. Inability to roll over or attain sitting position
- D. Almost complete independence within limitations of wheelchair
Correct Answer: D
Rationale: A C7 spinal cord lesion allows significant independence with wheelchair use, with some assistance for transfers and dressing. Respiratory paralysis occurs at C3 or higher, upper extremity function is preserved, and rolling over or sitting is possible.
What statement best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)?
- A. It has an autosomal dominant inheritance pattern.
- B. Onset occurs in later childhood and adolescence.
- C. It is characterized by presence of Gower sign, a waddling gait, and lordosis.
- D. Disease stabilizes during adolescence, allowing for life expectancy to approximately age 40 years.
Correct Answer: C
Rationale: DMD features Gower sign, waddling gait, and lordosis due to progressive muscle weakness starting at ages 3-5. It?s X-linked recessive, not autosomal dominant, and relentlessly progresses, leading to death by respiratory or cardiac failure, not stabilization.
An adolescent with a spinal cord injury is admitted to a rehabilitation center. Her parents describe her as being angry, hostile, and uncooperative. The nurse should recognize that this is suggestive of which psychosocial state?
- A. Normal phase of adolescent development
- B. Severe depression that will require long-term counseling
- C. Normal response to her situation that can be redirected in a healthy way
- D. Denial response to her situation that makes rehabilitative efforts more difficult
Correct Answer: C
Rationale: Anger, hostility, and uncooperativeness in a spinal cord injury adolescent reflect a normal response to disrupted independence, which can be redirected positively during rehabilitation. This isn?t typical adolescent behavior, severe depression, or denial, but an adaptive phase.