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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.
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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.
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.
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.
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition?
- A. Posturing
- B. Vital signs
- C. Focal neurologic signs
- D. Level of consciousness
Correct Answer: D
Rationale: Level of consciousness is the earliest and most sensitive indicator of worsening neurologic status post-head injury. Posturing and focal signs appear later, and vital sign changes are less immediate or specific in children with head injuries.
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.