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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?
- A. Neurologic health
- B. Severe brain damage
- C. Decorticate posturing
- D. Decerebrate posturing
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.
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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?
- A. Hypoxia
- B. Aspiration
- C. Hypothermia
- D. Electrolyte imbalance
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.
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?
- A. Place the child on his side.
- B. Take the childs blood pressure.
- C. Stabilize the childs neck and spine.
- D. Check the childs scalp and back for bleeding.
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.
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?
- A. Vomiting
- B. Blurred vision
- C. Behavioral changes
- D. Temporary loss of consciousness
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.
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.
What nursing intervention is appropriate when caring for an unconscious child?
- A. Avoid using narcotics or sedatives to provide comfort and pain relief.
- B. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP).
- C. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
- D. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are contraindicated.
Correct Answer: C
Rationale: Monitoring fluid intake and output prevents overhydration, which can cause cerebral edema in unconscious children. Narcotics and sedatives are used for comfort, frequent repositioning prevents complications, and antipyretics are preferred over sponge baths for fever.