Nokea
The nurse is caring for a child with severe head trauma after a car accident. What is an ominous sign that often precedes death?
- A. Delirium
- B. Papilledema
- C. Flexion posturing
- D. Periodic or irregular breathing
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.
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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?
- A. Explain that analgesia is contraindicated with a head injury.
- B. Have the parents describe the childs previous experiences with pain.
- C. Consult with a practitioner about what analgesia can be safely administered.
- D. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert.
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.
What statement is descriptive of a concussion?
- A. Petechial hemorrhages cause amnesia.
- B. Visible bruising and tearing of cerebral tissue occur.
- C. It is a transient and reversible neuronal dysfunction.
- D. It is a slight lesion that develops remote from the site of trauma.
Correct Answer: C
Rationale: A concussion is a transient, reversible neuronal dysfunction causing brief loss of awareness post-trauma. Petechial hemorrhages and tissue tearing describe contusions, and remote lesions indicate contrecoup injuries, not concussions.
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the childs younger brother had when he was an infant. The nurse should base a response on which information?
- A. Meningitis rarely occurs during infancy.
- B. Often a genetic predisposition to meningitis is found.
- C. Vaccination to prevent all types of meningitis is now available.
- D. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.
Correct Answer: D
Rationale: Vaccines for pneumococcal and H. influenzae type B meningitis have reduced their incidence, but group B streptococci and E. coli are common neonatal causes. Meningitis is serious in infancy, no genetic predisposition is noted, and vaccines don?t cover all causes.
What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called?
- A. Twitching
- B. Spasticity
- C. Choreiform movements
- D. Associated movements
Correct Answer: C
Rationale: Choreiform movements are quick, jerky, uncoordinated, and irregular, often subsiding with relaxation. Twitching is brief spasms, spasticity involves prolonged muscle contractions, and associated movements are involuntary motions accompanying voluntary ones.
What finding is a clinical manifestation of increased intracranial pressure (ICP) in children?
- A. Low-pitched cry
- B. Sunken fontanel
- C. Diplopia, blurred vision
- D. Increased blood pressure
Correct Answer: C
Rationale: Diplopia and blurred vision are signs of increased ICP in children due to pressure on cranial nerves. High-pitched cry and bulging fontanel are typical, not low-pitched or sunken. Increased blood pressure is less common in children compared to adults.