Nokea
What test is never performed on a child who is awake?
- A. Dolls head maneuver
- B. Oculovestibular response
- C. Assessment of pyramidal tract lesions
- D. Funduscopic examination for papilledema
Correct Answer: B
Rationale: The oculovestibular response (caloric test) uses painful ice water instillation, performed only in comatose children. Dolls head maneuver, pyramidal tract assessment, and funduscopic exams are non-painful and can be done on awake children.
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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.
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 term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?
- A. Coma
- B. Stupor
- C. Obtundation
- D. Persistent vegetative state
Correct Answer: B
Rationale: Stupor describes a deep sleep state requiring vigorous, repeated stimulation to respond. Coma involves no response to painful stimuli, obtundation allows arousal with less stimulation, and persistent vegetative state indicates permanent cerebral cortex loss.
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.
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.