The Child with Neurologic Health Problems 285
72. Two months after an adolescent’s thoracic 76. When making rounds on the pediatric
spinal cord injury, he complains of a pounding
headache. The nurse notes that the client’s arms and
face are flushed and he is diaphoretic. What should
the nurse do next?
■ 1. Check the patency of the urinary catheter.
■ 2. Lower the adolescent’s head below his
knees.
■ 3. Place the adolescent flat on his back.
■ 4. Prepare to administer epinephrine
subcutaneously.
Managing Care Quality
and Safety
73. The nurse is admitting a child who has been
diagnosed with bacterial meningitis to the pediatric
unit. The nurse should implement which type of
isolation?
■ 1. Standard precautions.
■ 2. Contact precautions.
■ 3. Airborne precautions.
■ 4. Droplet precautions.
74. The nurse manager on a pediatric floor is
reviewing national sentinel event alerts and prepar-
ing recommendations for the unit. Which strategy
would help reduce pediatric medication errors?
Select all that apply.
■ 1. Eliminate the pediatric satellite pharmacy.
■ 2. Increase the steps in the medication adminis-
tration procedure.
■ 3. Utilize only oral syringes to administer oral
medication.
■ 4. Limit the size of I.V. fluid bags that can be
hung on small children.
■ 5. Reduce the available concentrations or dose
strengths of high alert medications to the
minimum.
75. The physician orders carbamazapine
extended release (Tegretol-XR) for a client with
a cerebral palsy who also has a seizure disorder.
The client has a gastrostomy feeding tube, and
carbamazapine is on the hospital’s “no crush” list.
In order to administer the medication, the nurse
should:
■ 1. Cut the medication into four pieces that can
be placed in the feeding tube.
■ 2. Dissolve the medication in 30 mL’s of juice.
■ 3. Ask the pharmacist for an oral suspension.
■ 4. Contact the primary care provider to change
the order.
Billings_Part 2_Chap 2_Test 7.indd 285
neurology unit, the nurse manager notes that when
giving I.V. medications many of the staff nurses are
disconnecting the flush syringe first and then clamp-
ing the intermittent infusion device. The nurse is
concerned that the nurses do not understand the
benefits of positive pressure technique and turbu-
lence flow flush in preventing clots. After discussing
the problem with the staff educator which interven-
tion would be the most effective way to improve the
nursing practice?
■ 1. Create a poster presentation on the topic with
a required post test.
■ 2. Send a group email discussing the importance
of clamping the device first.
■ 3. Ask each nurse if they are aware that their
practice is not current.
■ 4. Post an evidence-based article on the unit.
Answers, Rationales, and Test
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question.
Use these keys to further develop your test-taking
skills. For additional information about test-taking
skills and strategies for answering questions, refer to
pages 10–21, and pages 25–26 in Part 1 of this book.
The Client with Myelomeningocele
1. 2, 3, 4, 5. Common shunt complications are
obstruction, infection, and disconnection of the
tubing. The signs presented by the child indicate
increased intracranial pressure from a shunt malfor-
mation, which could be caused by an infection, such
as peritonitis or meningitis. By listening to bowel
sounds, the nurse will note if peritonitis might be
a possibility. Palpating the fontanel would indicate
increased intracranial pressure if it were bulging and
taut. Obtaining vital signs would assess for signs of
infection, such as elevated temperature or, possibly,
Cushing’s triad (elevated blood pressure, slow pulse,
and depressed respirations). A high-pitched cry is
a sign of increased intracranial pressure. Weighing
the child at this time would not be a priority, nor
would it add to identifying the cause of the signs
and symptoms.
CN: Physiological adaptation;
CL: Synthesize
8/7/2010 10:04:36 AM
 286 The Nursing Care of Children
2. 3. Before surgery, the infant is kept flat in the
prone position to decrease tension on the sac. This
allows for optimal positioning of the hips, knees,
and feet because orthopedic problems are com-
mon. The supine position is unacceptable because
it causes pressure on the defect. Flexing the knees
when side lying will increase tension on the sac, as
will placing the infant in semi-Fowler’s position,
even though the chest and abdomen are elevated.
CN: Physiological adaptation;
CL: Synthesize
3. 2, 3, 4. Prevention of urinary tract infections
includes adequate fluid intake, urine acidification,
frequent emptying of the bladder including the
use of the Crede’s maneuver if needed. While the
nurse should keep the skin clean and dry, this will
not prevent urinary tract infections. Keeping urine
close to the meatus with a tight-fitting diaper would
increase the risk for infection.
CN: Reduction of risk potential;
CL: Create
4. 2. A Chiari malformation obstructs the flow of
cerebral spinal fluid resulting in hydrocephalus. This
is a common problem in infants with myelomenin-
gocele and will require surgical intervention with a
shunt. A high-pitched cry is one sign of increased
intracranial pressure that may indicate the presence
of a Chiari malformation and requires further evalu-
ation. Minimal movement of the lower extremities
is an expected finding associated with spinal cord
damage. Overflow voiding comes from a neurogenic
bladder, not increased intracranial pressure. It is
normal for the fontanel to bulge with crying.
CN: Physiological adaptation;
CL: Analyze
5. 1. The parents should see the neonate as
soon as possible, because the longer they must wait
to see the neonate, the more anxiety they will feel.
Because the parents are acutely aware of the deficit,
the nurse should emphasize the neonate’s normal
and positive features during the visit. All parents,
but especially those with a child who has a dis-
ability or defect, need to hear positive comments
and comments that reflect how the infant is normal.
Although the parents need to discuss their fears and
concerns, the priority on the first visit is to empha-
size the neonate’s normal and positive features.
Reinforcing the doctor’s explanation of the defect
may be necessary later. Reinforcing the explanation
at this initial visit emphasizes the defect, not the
child. The parents should spend time with or care
for the neonate after birth because parent-infant
contact is necessary for attachment. The parents
cannot feed the neonate before the defect is repaired
because the repair typically occurs within 24 hours.
The infant will be prone in an isolette or warmed
Billings_Part 2_Chap 2_Test 7.indd 286
and watched closely. However, the parents can
fondle and stroke the neonate.
CN: Psychosocial adaptation;
CL: Synthesize
6. 1. Excessive cerebrospinal fluid in the cranial
cavity, called hydrocephalus, is the most common
anomaly associated with myelomeningocele. Micro-
encephaly, an abnormally small head, is associated
with maternal exposure to rubella or cytomegalovirus.
Anencephaly, a congenital absence of the cranial vault,
is a different type of neural tube defect. Overriding of
the sutures, possibly a normal finding after a vaginal
delivery, is not associated with myelomeningocele.
CN: Physiological adaptation; CL: Apply
7. 1. Approximately one-third of infants diag-
nosed with myelomeningocele are mentally retarded,
but the degree of retardation is variable and it is
difficult to predict intellectual functioning in neo-
nates. The parents are asking for an answer now and
should not be told to talk with the physician later.
CN: Physiological adaptation;
CL: Synthesize
8. 2. The nurse places the neonate with
myelomeningocele in an isolette shortly after
birth to help to maintain the infant’s temperature.
Because of the defect, the neonate cannot be bun-
dled in blankets. Therefore, it may be difficult to
prevent cold stress. The isolette can be maintained
at higher than room temperature, helping to main-
tain the temperature of a neonate who cannot be
dressed or bundled. Body temperature readings, not
arterial oxygen levels, are the best indicator. Typi-
cally, an infant loses 5% to 10% of body weight
before beginning to regain the weight.
CN: Reduction of risk potential;
CL: Analyze
9. 1, 3, 5. Prior to surgery, the neonate with
a myelomeningocele should be placed in a prone
position. The feet can hang over the edge of the
mattress to prevent foot deformities. The neonate
should rest on a soft surface to reduce pressure on
the skin; the nurse can use a fleece pad or foam over
the mattress. The meningeal sac should not be cov-
ered. The hips should be maintained in abduction
using a diaper roll or small pillow.
CN: Basic care and comfort;
CL: Synthesize
10. 2. Because of the potential for hip dislocation,
the neonate’s legs should be slightly abducted, hips
maintained in slight to moderate abduction, and feet
maintained in a neutral position. The infant’s knees
are flexed to help maintain the hips in abduction.
CN: Reduction of risk potential;
CL: Synthesize
8/7/2010 10:04:37 AM

11. 3. In a neonate with open cranial sutures,
increasing head circumference is the predominant
and earliest sign of increased intracranial pressure
and the nurse should report this to the surgeon.
Bulging fontanels also are seen. However, some
neonates may exhibit bulging fontanels without
head enlargement. Seizures and vomiting are associ-
ated with hydrocephalus, but most often these are
seen in an older child with closed cranial sutures.
Shortly after increasing head circumference and
bulging fontanels occur, other signs and symp-
toms, such as frontal bossing or enlargement with
depressed eyes and the sunset sign (sclera visible
above the iris), may develop. Although irritability
is an early sign, a brief, shrill cry is a later sign of
increasing intracranial pressure associated with the
development of hydrocephalus.
CN: Physiological adaptation;
CL: Analyze
12. 4. The most important aspect of the dis-
charge plan is to ensure that the parents understand
what the daily care of their infant involves and to
provide teaching related to carrying out this daily
care. In addition to the routine care required by the
infant, care also may include physical therapy to
the lower extremities. Providing a list of available
hospital services may be helpful to the parents, but
it is not the most important aspect to include in the
discharge plan. Usually, home health care is not
needed because the parents are able to care for their
child. A referral for counseling is initiated whenever
the need arises, not just at discharge.
CN: Reduction of risk potential;
CL: Synthesize
13. 3. Children with a myelomeningocele are
prone to urinary tract infections (UTI) and foul
smelling urine is one symptom of a UTI. Because
of the level of defect, the child may be insensitive
to pressure or heat. Using a heating pad may lead
to thermal injury because the child may not be able
to sense if the pad is too hot. Keeping the child
away from other children is unnecessary and can
retard social development. Using pillows as props
increases the risk of sudden infant death syndrome.
CN: Safety and infection control;
CL: Evaluate
14. 3. Children with myelomeningocele are at
high risk for development of latex allergy because of
repeated exposure to latex products during surgery
and bladder catheterizations. Cross-reactions to
food items such as bananas, kiwi, milk products,
chestnuts, and avocados also occur. These allergic
reactions vary in severity ranging from mild (such
as sneezing) to severe anaphylaxis. While the child
could have allergies to medications that caused
the wheezing, the latex and food allergies are more
Billings_Part 2_Chap 2_Test 7.indd 287
The Child with Neurologic Health Problems 287
common. Asking about the skin rash is not a priority
when a child is wheezing. Who brought the child to
the emergency department is irrelevant at this time.
CN: Reduction of risk potential;
CL: Analyze
The Client with Hydrocephalus
15. 2. An infant with hydrocephalus is difficult
to feed because of poor sucking, lethargy, and vomit-
ing, which are associated with increased intracranial
pressure. Small, frequent feedings given at times
when the infant is relaxed and calm are tolerated
best. Feeding an infant before any procedure is inap-
propriate because the stress of the procedure may
lead to vomiting. Ideally, the infant should be held
in a slightly vertical position when feeding to pre-
vent backflow of formula into the eustachian tubes
and subsequent development of ear infections. Most
infants are fed on demand every 3 to 4 hours.
CN: Basic care and comfort;
CL: Synthesize
16. 4. For at least the first 24 hours after insertion
of a ventriculoperitoneal shunt, the child is posi-
tioned supine with the head of the bed flat to prevent
too rapid a decrease in cerebrospinal fluid pressure.
Although elevating the head increases cerebrospinal
fluid drainage and reduces intracranial pressure,
a rapid reduction in the size of the ventricles can
cause subdural hematoma. Positioning on the opera-
tive or right side is avoided because it places pres-
sure on the shunt valve, possibly blocking desired
drainage of the cerebrospinal fluid. Elevating the
foot of the bed could increase intracranial pressure.
With continued increased intracranial pressure, the
child would be positioned with the head of the bed
elevated to allow gravity to aid drainage. The child
should be kept off the nonoperative side (side oppo-
site the shunt), or the left side, to help prevent rapid
decompression leading to a cerebral hematoma.
CN: Reduction of risk potential;
CL: Synthesize
17. 3. Monitoring the temperature allows the
nurse to assess for infection, the most common and
most hazardous postoperative complication after
ventroperitoneal shunt placement. Typically, pain
after insertion of a ventriculoperitoneal shunt is mild,
requiring the use of mild analgesics. Usually narcot-
ics are not administered because they alter the level
of consciousness, making assessment of cerebral
function difficult. Neither proteinuria nor glycosuria
is associated with shunt placement. Cerebrospinal
fluid leakage commonly occurs with head injury. It is
not usually associated with shunt placement.
CN: Reduction of risk potential;
CL: Synthesize
8/7/2010 10:04:37 AM
 288 The Nursing Care of Children
18. 4. In a school-age child, irritability, lethargy,
vomiting, difficulty with eating, and decreased level
of consciousness are signs of increased intracranial
pressure caused by a blocked shunt. Decreased
urine output with stable fluid intake indicates fluid
loss from a source other than the kidneys. A tense
fontanel and increased head circumference would
be signs of a blocked shunt in an infant. Elevated
temperature and redness around incisions might
suggest an infection.
CN: Reduction of risk potential;
CL: Evaluate
The Client with Down Syndrome
19. 1, 2, 3. The definition of mental retardation
includes deficits in intellectual functioning and
behavior. The child’s IQ will be 70 or less and he
will have difficult learning. The client cannot adapt
to situations in a manner consistent with children
with higher IQs. The client does not have a normal
intellectual capacity to learn and develop from his
experiences. The client may have behavioral prob-
lems but these are not considered a result of mental
retardation.
CN: Health promotion and maintenance;
CL: Evaluate
20. 1. Watching the child relate to his teacher
and school work is the best indication of how he
is progressing. School involves interacting with a
person who is not a relative and in a situation that is
not totally familiar. Observing the client in situa-
tions with family and friends shows social relation-
ships but does not indicate how the child is learning
new intellectual skills.
CN: Health promotion and maintenance;
CL: Evaluate
21. 1. The goal in working with mentally
retarded children is to train them to be as indepen-
dent as possible, focusing on developmental skills.
The child may not be capable of learning something
new every day but needs to repeat what has been
taught previously. Rather than encouraging more
lenient behavior limits, the parents need to be strict
and consistent when setting limits for the child.
Most children with Down syndrome are unable to
achieve age-appropriate social skills due to their
mental retardation. Rather, they are taught socially
appropriate behaviors.
CN: Health promotion and maintenance;
CL: Synthesize
22. 4. Nonthreatening experiences that are
stimulating and interesting to the child have been
observed to help raise IQ. Practices such as serving
Billings_Part 2_Chap 2_Test 7.indd 288
nutritious meals or letting the child play with more
able children have not been supported by research
as beneficial in increasing intelligence. Vasodila-
tor medications act to increase oxygenation to the
tissues, including the brain. However, these medica-
tions do not increase the child’s IQ.
CN: Health promotion and maintenance;
CL: Synthesize
23. 4. When teaching the parents of a child with
Down syndrome, activities should focus on increas-
ing the parents’ confidence in their ability to care for
the child. The parents must continue to work daily
with their child. Most parents feel affection and a
sense of responsibility for their child regardless of
the child’s limitations. Parents usually understand
the child’s disability on the cognitive level but
have difficulty accepting it on the emotional level.
As the parents’ confidence in their caring abilities
increases, their understanding of the child’s disabil-
ity also increases on all levels.
CN: Psychosocial adaptation; CL: Create
24. 4. When responding to a mother who
becomes angry when someone calls her child
mentally retarded instead of exceptional, the nurse
should give the mother a chance to explore her feel-
ings on the subject. Because the mother obviously
has difficulty with the term “retarded,” stressing the
use of this term would cause further angry feelings.
Apologizing, trying to use logic, and defending
the comment are not effective ways to handle the
situation because the mother’s feelings need to be
addressed.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with a Seizure Disorder
25.
1. Note the time.
3. Ease the child to the floor.
2. Clear the area of potentially harmful objects
and pad the head.
4. Roll the child to the side.
The nurse should very quickly check the time the
seizure begins to be able to determine its length. Sei-
zure duration will determine the need for immediate
additional interventions. Anyone who is standing
or sitting needs to be lowered to the floor to prevent
a fall injury. The next step is to prevent potential
8/7/2010 10:04:38 AM

bodily harm by removing any item in the immediate
area that might present a danger and pad the head.
Finally, the child should be rolled to the side, if pos-
sible, to protect the airway.
CN: Reduction of risk potential;
CL: Synthesize
26. 2. Diphenylhydantoin (Dilantin) can cause
gingival hyperplasia. Children taking Dilantin should
brush their teeth after every meal and at bedtime,
and visit their dentist on a regular basis. Drinking
plenty of fluids is not required while taking Dilantin.
A child on Dilantin does not need to be observed
during waking hours because the seizures should
be under control. Infections do not occur with an
increased incidence in clients receiving Dilantin.
CN: Pharmacological and parenteral
therapies; CL: Create
27. 3. During a generalized tonic-clonic seizure,
the first priority is to keep the child safe and pro-
tect the child by removing any nearby objects that
could cause injury. Although obtaining information
about events surrounding the seizure is important,
this information can be obtained later, once the
child’s safety is ensured. During a seizure, the child
should not be moved. Although providing privacy
is important, the child’s safety is the priority. During
a seizure, nothing should be forced into the client’s
mouth because this can cause severe damage to the
teeth and mouth.
CN: Physiological adaptation;
CL: Evaluate
28. 3. Most children who develop seizures after
infancy are intellectually normal. A child with a
seizure disorder needs the same experiences and
opportunities to develop intellectual, emotional,
and social abilities as any other child. Activity limi-
tation is not needed. Learning disabilities are not
associated with seizures. The child is able to attend
public school, and social stigma is a rarity.
CN: Health promotion and maintenance;
CL: Create
29. 1. A child who has generalized seizures
should not participate in activities that are poten-
tially hazardous. Even if accompanied by a respon-
sible adult, the child could be seriously injured
if a seizure were to occur during rock climbing.
Someone also should accompany the child during
activities in the water. At summer camp, hiking and
swimming would occur most commonly as group
activities, so someone should be with the child. Ten-
nis would be considered an appropriate, nonhazard-
ous activity for a child with generalized seizures.
CN: Safety and infection control;
CL: Synthesize
Billings_Part 2_Chap 2_Test 7.indd 289
The Child with Neurologic Health Problems 289
30. 4. Most febrile seizures occur in the presence
of an upper respiratory infection, otitis media, or
tonsillitis. Febrile seizures typically occur during
a temperature rise rather than after prolonged fever.
There appears to be increased susceptibility to
febrile seizures within families. Infrequently, febrile
seizures may lead to respiratory arrest.
CN: Physiological adaptation;
CL: Analyze
31. 2. Shivering, the body’s defense against
rapid temperature decrease, results in an increase
in body temperature. Therefore the parents need to
take measures to stop the shivering (and the result-
ing increase in body temperature) by increasing the
room temperature or the temperature of the child’s
immediate environment (such as with blankets)
until the shivering stops. Then, attempts are made to
lower the temperature more slowly. Shivering does
not necessarily correlate with being cold. Alcohol,
a toxic substance, can be absorbed through the skin.
Its use is to be avoided.
CN: Physiological adaptation;
CL: Evaluate
32. 3. Phenytoin sodium (Dilantin) is a known
teratogenic agent, causing numerous fetal prob-
lems. Therefore the adolescent should be advised
to talk to the doctor about changing the medica-
tion. Additionally, anticonvulsant requirements
usually increase during pregnancy. Seizures can be
controlled but cannot be cured. There is a familial
tendency for seizure disorders. Seizure disorders
and infertility are not related.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
33. 3. A toxic effect of valproic acid (Depakene)
is liver toxicity, which may manifest with jaundice
and abdominal pain. If jaundice occurs, the client
needs to notify the health care provider as soon as
possible. Diarrhea and sore throat are not common
side effects of this drug. Increased appetite is com-
mon with this drug.
CN: Pharmacological and parenteral
therapies; CL: Analyze
The Client with Meningitis
34. 3. The current recommendation is that the
MCV4 vaccine be given at the earliest opportunity
after the age of 11. Therefore, it is quite possible
that the client received the vaccine at a previous
visit and did not remember. On a college campus,
students living in dormitories are at highest risk,
but because it is difficult to target that group col-
leges may elect to require proof of vaccination for
8/7/2010 10:04:39 AM
 290 The Nursing Care of Children
all incoming students. Other risk factors should
also be considered, such as if the student plans to
travel abroad. The vaccination is typically given as
a single injection, but sometimes a second dose is
recommended based on risk factors. The MCV4 is
not a live vaccine. It may be given during pregnancy
if the client is at risk.
CN: Health promotion and maintenance;
CL: Synthesize
35. 2. A child in the acute stage of meningitis is
irritable and hypersensitive to loud noise and light.
Therefore, extraneous noise should be minimized
and bright lights avoided as much as possible. There
is no need to limit conversations with the child.
However, the nurse should speak in a calm, gentle,
reassuring voice. The child needs gentle and calm
bathing. Because of the acuteness of the infection,
sponge baths would be more appropriate than tub
baths. Although treatments need to be completed
as quickly as possible to prevent overstressing the
child, they should be performed carefully and at a
pace that avoids sudden movements to prevent star-
tling the child and subsequently increasing intracra-
nial pressure.
CN: Basic care and comfort;
CL: Synthesize
36. 1. Disseminated intravascular coagulation
is characterized by skin petechiae and a purpuric
skin rash caused by spontaneous bleeding into the
tissues. An abnormal coagulation phenomenon
causes the condition. Heparin therapy is often used
to interrupt the clotting process. Edema would sug-
gest a fluid volume excess. Cyanosis would indicate
decreased tissue oxygenation. Dyspnea on exertion
would suggest respiratory problems, such as pulmo-
nary edema.
CN: Physiological adaptation;
CL: Analyze
37. 2. Organisms that cause bacterial meningitis,
such as pneumococci or meningococci, are com-
monly spread in the body by vascular dissemina-
tion from a middle ear infection. The meningitis
may also be a direct extension from the paranasal
and mastoid sinuses. The causative organism is a
pneumococcus. A chronically draining ear is also
frequently found. Bladder infections commonly are
caused by Escherichia coli, unrelated to the devel-
opment of pneumococcal meningitis. Pneumococ-
cal meningitis is unrelated to a fractured clavicle
or to septic arthritis, which is commonly caused by
Staphylococcus aureus, group A streptococci, or
Haemophilus influenzae.
CN: Physiological adaptation;
CL: Analyze
Billings_Part 2_Chap 2_Test 7.indd 290
38. 3. Preschool-age children worry about having
an intact body and become fearful of any threat to
body integrity. Allowing the child to participate in
required care helps protect her image of an intact
body. Development of trust is the task typically asso-
ciated with infancy. Additionally, allowing the child
to apply a dressing over the intravenous insertion
site is unrelated to the development of trust. Find-
ing diversional activities is not a priority need for a
child in this age group. Separation anxiety is more
common in toddlers than in preschoolers.
CN: Health promotion and maintenance;
CL: Apply
39. 83 mL/hour
1,000 mL ÷ 12 hours = 83 mL/hour
CN: Pharmacological and parenteral
therapies; CL: Apply
40. 3. The child is angry and needs a positive out-
let for expression of feelings. An emotionally tense
child with pent-up hostilities needs a physical activ-
ity that will release energy and frustration. Pounding
on a pegboard offers this opportunity. Listening to a
story does not allow the child to express emotions.
It also places the child in a passive role and does not
allow the child to deal with feelings in a healthy and
positive way. Activities such as painting and stack-
ing a tower of blocks require concentration and fine
movements, which could add to frustration. How-
ever, if the child then knocks the tower over, doing
so may help to dispel some of the anger.
CN: Health promotion and maintenance;
CL: Synthesize
The Client with Near-Drowning
41. 2. Hypoxia is the primary problem because it
results in brain cell damage. Irreversible brain dam-
age occurs after 4 to 6 minutes of submersion. Hypo-
thermia occurs rapidly in infants and children because
of their large body surface area. Hypothermia is more
of a problem when the child is in cold water. Although
fluid aspiration occurs in most drownings and results
in atelectasis and pulmonary edema, further aggravat-
ing hypoxia, hypoxia is the primary problem. Cutane-
ous capillary paralysis is not a problem.
CN: Physiological adaptation;
CL: Analyze
42. 1. Near-drowning victims typically suf-
fer hypoxia and mixed acidosis. The priority is to
restore oxygenation and prevent further hypoxia.
Here, the client has blunted sensorium, but is not
unconscious; therefore, delivery of supplemental
8/7/2010 10:04:40 AM

oxygen with a mask is appropriate. Warming
protocols and fluid resuscitation will most likely be
needed to help correct acidosis, but these interven-
tions are secondary to oxygen administration. Intu-
bation is required if the child is comatose, shows
signs of airway compromise, or does not respond
adequately to more conservative therapies.
CN: Physiological adaptation;
CL: Synthesize
43. 2. Guilt is a common parental response. The
parents need to be allowed to express their feelings
openly in a nonthreatening, nonjudgmental atmo-
sphere. Telling the parents that these things happen
does not allow them to verbalize their feelings. Tell-
ing the parents that they should not have taken their
eyes off the child blames them, possibly further
contributing to their guilt. Telling the parents that
they shouldn’t feel guilty denies the parents’ feel-
ings of guilt and is inappropriate. Telling the parents
that they are lucky that the child will be okay does
not remove the feelings of guilt.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with Guillain-Barré
Syndrome (Infectious Polyneuritis)
44. 1. Most children with sore throat have some
difficulty swallowing, so it is important for the
nurse to determine the extent of difficulty to aid in
determining what action is necessary. Typically a
sore throat precedes the paralysis of this disorder.
Muscle tenderness is an initial symptom. Distal
muscle weakness follows proximal muscle weak-
ness, ultimately progressing to paralysis. Diet his-
tory and difficulty urinating will not contribute to
assessment of the cause of a sore throat or difficulty
swallowing. After determining the extent of diffi-
culty swallowing, the nurse can obtain information
about exposure to illness.
CN: Health promotion and maintenance;
CL: Analyze
45. 2. With Guillain-Barré syndrome, progressive
ascending paralysis occurs. Therefore, the nurse
should assess the child’s muscle strength bilaterally
to determine the extent of involvement and progres-
sion of the illness. Assessing the child’s ability to
follow simple commands evaluates brain function.
Range-of-motion exercises are an important part
of treatment, but they are not a priority initially.
Although the child may need diversional activities
later, they also are not an initial priority.
CN: Physiological adaptation;
CL: Synthesize
Billings_Part 2_Chap 2_Test 7.indd 291
The Child with Neurologic Health Problems 291
46. 3. In a child with Guillain-Barré syndrome,
decreased volume and clarity of speech and
decreased ability to cough voluntarily indicate
ascending progression of neural inflammation, spe-
cifically affecting the cranial nerves. Inflammation
of the larynx and epiglottis is manifested by hoarse-
ness, stridor, and dyspnea. A child with laryngeal
inflammation still retains the ability to cough. Irrita-
bility, behavior changes, headache, and vomiting are
common signs of increased intracranial pressure in
a school-age child. Regression would be manifested
by being more dependent and less able to care for
self.
CN: Physiological adaptation; CL: Apply
47. 2. Ineffective breathing pattern caused by the
ascending paralysis of the disorder interferes with
the child’s ability to maintain an adequate oxygen
supply. Therefore, this nursing diagnosis takes
precedence. Additionally, as the neurologic impair-
ment progresses, it will probably have an effect on
the child’s ability to maintain respirations. Risk for
infection related to an altered immune system is not
involved with Guillain-Barré syndrome. Although
impaired swallowing and incontinence may occur
with the ascending paralysis of this disorder, oxy-
genation is the priority.
CN: Physiological adaptation;
CL: Analyze
48. 4. Even in the absence of respiratory prob-
lems or distress, the child must be turned frequently
to help prevent the cardiopulmonary complica-
tions associated with immobility, such as atelectasis
and pneumonia. Maintaining the child in a supine
position is unnecessary. Doing so does not pre-
vent unnecessary nerve stimulation. In addition,
maintaining a supine position may lead to stasis
of secretions, placing the child at risk for pneumo-
nia. Transferring the child to a chair will not pre-
vent postural hypotension. However, doing so will
increase vascular tone and help prevent respiratory
and skin complications. During the acute disease
phase, vigorous physiotherapy is contraindicated
because the child may experience muscle pain and
be hypersensitive to touch. Careful and gentle han-
dling is essential.
CN: Physiological adaptation;
CL: Synthesize
49. 3. Developmentally appropriate activities
and therapeutic play should be used as rehabilita-
tion modalities. Taking the child to the pool to
exercise with other children indicates that the child
is participating in exercise as well as engaging with
other children, thus fostering development. Arguing
with the sister does not address the discharge plan.
Inappropriate rewards or threats should not be used
8/7/2010 10:04:40 AM
 292 The Nursing Care of Children
to coerce a child into compliance. Although the
mother is attempting to comply with the discharge
plan, bribery is an inappropriate technique to foster
compliance. Missing therapy sessions delays recov-
ery. The parents need to help set the child’s sched-
ule to ensure that she gets adequate rest to be able to
follow her treatment plan.
CN: Physiological adaptation;
CL: Evaluate
The Client with a Head Injury
50. 2. For the child with serious head trauma, a
nasogastric tube is inserted initially to decompress
the stomach and to prevent vomiting and aspiration.
Medications would be administered intravenously
in the initial period. The tube will not be used to
obtain gastric specimens. Nutrition is not a priority
initially. Later on, the tube may be used to adminis-
ter feedings.
CN: Reduction of risk potential;
CL: Apply
51. 1. Because a basilar skull fracture can involve
the frontal and ethmoid bones, inserting a naso-
gastric tube carries the risk of introducing the tube
into the cranial cavity through the fracture. An oral
gastric tube is preferred for a client with a basilar
skull fracture. The tube would not be placed into the
duodenum. Gastric aspirate is not routinely tested
for blood unless there is an indication to suggest
bleeding, such as a falling hemoglobin or visible
blood in the drainage.
CN: Reduction of risk potential;
CL: Synthesize
52. 3. As a rule, children demonstrate more
rapid and more complete recovery from coma than
do adults. However, it is extremely difficult to
predict a specific outcome. Reassuring the parents
that they will be kept informed helps open lines
of communication and establish trust. Telling the
parents that children do not do well would be
extremely negative, destroying any hope that the
parents might have. Telling the parents that chil-
dren recover rapidly may give the parents false
hopes. Telling the parents to talk to the doctor
ignores the parents’ concerns and interferes with
trust-building.
CN: Physiological adaptation;
CL: Synthesize
53. 2. The level of consciousness (LOC) is the
best indicator of brain function. If the child’s condi-
tion deteriorates, the nurse would notice changes in
LOC before any other changes and should notify the
physician that these changes are occurring. Changes
Billings_Part 2_Chap 2_Test 7.indd 292
in vital signs and pupils typically follow changes
in LOC. Motor strength is primarily assessed as a
voluntary function. With changes in levels of con-
sciousness there may be motor changes.
CN: Physiological adaptation; CL: Apply
54. 2. The unconscious child is positioned to
prevent aspiration of saliva and minimize intrac-
ranial pressure. The head of the bed should be
elevated, and the child should be in either the semi-
prone or the side-lying position. Lying prone with
hips and knees slightly elevated increases intrac-
ranial pressure, as does lying on the back in the
Trendelenburg position. The semi-Fowler’s position
with arms at the side is not the best choice.
CN: Physiological adaptation;
CL: Synthesize
55. 3. Mannitol is an osmotic diuretic used to
reduce intracranial pressure. The use of the drug is
controversial and should be reserved to cases which
do not respond to other treatments or when brain
herniation is likely. Children this sick should be
on intracranial pressure (ICP) monitoring. The best
indicator that the drug has produced the desired
results is a reduction in the ICP. Improved levels of
consciousness should follow reduced ICP. While
the drug will cause increased urine output, that
measurement in and of itself does not indicate suc-
cessful treatment. Because the drug is being used
for head injuries, not to improve urine output in
acute renal failure, the child may not have visible
edema.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
The Client with a Brain Tumor
56. 2. A decreasing level of consciousness, decer-
ebrate positioning, or Cushing’s triad (elevated sys-
tolic blood pressure, decreased pulse, and decreased
respiratory rate) indicates that there is pressure on
the brain stem and the client could require intuba-
tion and cardiac resuscitation unless the physician
can order a medication or surgical procedure to
reduce the intracranial pressure. Raising the head
of the bed could offer some reduction in the intrac-
ranial pressure by increasing venous blood return
from the head, but it is not the priority at this time.
An analgesic administered at this time would mask
the sign of decreasing level of consciousness and
hinder assessment. An oximeter would measure the
oxygen level in the blood, but not necessarily in the
brain.
CN: Physiological adaptation;
CL: Synthesize
8/7/2010 10:04:41 AM

57. 1. This client is experiencing neurological
changes consistent with increasing intracranial
pressure (ICP). The nurse should first notify the
physician. The physician may intubate the child to
ensure a patent airway. The nurse should not lower
the head of the bed as this will cause increased ICP.
The nurse should ensure an adequate fluid balance.
The physician will likely order hypertonic saline to
draw fluid from the brain.
CN: Management of care; CL: Synthesize
58. 3. A child who has symptoms of vomit-
ing, headaches, and problems walking needs to be
evaluated by a health care provider to determine the
cause. Unexplained headaches and vomiting along
with complaints of difficulty walking (e.g., ataxia)
may suggest a brain tumor. Evaluation by an eye
doctor would be appropriate once a complete medi-
cal evaluation has been accomplished. Psychologi-
cal counseling may be indicated for this adolescent,
but only after medical evaluation to determine that
she is physically healthy. Meeting with the child’s
teachers would be appropriate after medical evalua-
tion.
CN: Physiological adaptation;
CL: Synthesize
59. 4. When a brain tumor is suspected, the child
and parents are likely to be very apprehensive and
anxious. It is unrealistic to expect to eliminate their
fears; rather, the nurse’s goal is to decrease them.
Preparing both the child and family during hospital-
ization can help them cope with some of their fears.
Although the nurse may be able to decrease some of
the child’s anxiety, it would be impossible to elimi-
nate it. Children with infratentorial tumors seldom
have seizures, so seizure precautions are not indi-
cated. Although introducing the child to other chil-
dren is a positive action, this action would be more
appropriate once the nurse has decreased some of
the child’s and parents’ anxiety by preparing them.
CN: Psychosocial adaptation;
CL: Synthesize
60. 1. The infant has opisthotonos, an indication
of brain stem herniation; the nurse should notify
the physician immediately and have resuscitation
equipment ready. Stroking the back will not relieve
the herniation or release the arching. Although the
infant may also have a seizure, and padded side
rails will prevent injury, the first action is to notify
the physician. Placing the child in a prone position
will not relieve the herniation or release the arching.
CN: Management of care; CL: Synthesize
61. 1, 2, 4. Head tilt, vomiting, and lethargy are
classic signs assessed in a child with a brain tumor.
Clinical manifestations are the result of location and
size of the tumor. Polydipsia is rare with a brain
Billings_Part 2_Chap 2_Test 7.indd 293
The Child with Neurologic Health Problems 293
tumor. It is more often a sign of diabetes insipidus
following a closed head injury. Increased appetite
occurs during a growth spurt and is not necessarily
a sign of a brain tumor. Increased pulse is a nonspe-
cific sign and can occur with many illnesses, cardiac
anomalies, fever, or exercise.
CN: Physiological adaptation;
CL: Analyze
62. 3. After surgery for an infratentorial tumor,
the child is usually positioned flat on either side,
with the head and neck in midline and the body
slightly extended. Pillows against the back, not
the head, help maintain position. Such a position
helps avoid pressure on the operative site. Placing
the child in a prone or semi-Fowler’s position will
cause pressure on the operative site. The Trende-
lenburg position is usually contraindicated because
keeping the head below the level of the heart
increases intracranial pressure as well as the risk of
hemorrhage.
CN: Physiological adaptation;
CL: Synthesize
63. 1. Hypercapnia, hypoxia, and acidosis are
potent cerebral vasodilating mechanisms that can
cause increased intracranial pressure. Lowering
the carbon dioxide level and increasing the oxygen
level through hyperventilation is the most effective
short-term method of reducing intracranial pressure.
Although ensuring a patent airway is important, this
is not accomplished by manual hyperventilation.
Manual hyperventilation does not lower the arousal
level; in fact, the arousal level may increase. Manual
hyperventilation is used to reduce hypoxia, not pro-
duce it.
CN: Reduction of risk potential;
CL: Evaluate
64. 3. Glucose in this clear, colorless fluid indi-
cates the presence of cerebrospinal fluid. Excessive
fluid leakage should be reported to the physician.
The nurse should not change the dressing of a
postoperative craniotomy client unless instructed
to do so by the surgeon. Ordinarily, the head of the
bed would not be elevated because this would put
pressure on the sutures. The nurse should notify the
physician after testing the fluid for glucose.
CN: Reduction of risk potential;
CL: Synthesize
65. 1. It is not uncommon for a child to be
concerned about a change in appearance when
the entire head or only part of the head has been
shaved. The child should be encouraged to partici-
pate in decisions about her care when possible. Ask-
ing her if she would like to wear a hat is one way to
encourage this participation. Reassuring the child
that her hair will grow back does not address the
8/7/2010 10:04:42 AM
 294 The Nursing Care of Children
immediate change in appearance, and it ignores the
child’s current feelings. Explaining that this type of
reaction is normal does not address the child’s feel-
ings. The child needs to be able to express feelings
and be involved in care as much as possible. Buying
the child a wig as a surprise does not address the
child’s feelings and does not allow her to participate
in decision making. Rather, the parents should ask
the child if she would like a wig and then work with
the child to determine what kind of wig she would
like.
CN: Psychosocial adaptation;
CL: Synthesize
66. 1. Parents of a child who has undergone neu-
rosurgery can easily become overprotective. Yet the
parents must foster independence in the convalesc-
ing child. It is important for the child to resume age-
appropriate activities, and parents play an impor-
tant role in encouraging this. Statements about going
back to school would be expected. Parents want the
child to return to normal activities after a serious ill-
ness or injury as a sign that the child is doing well.
CN: Psychosocial adaptation;
CL: Evaluate
The Client with a Spinal Cord Injury
67. 2. The adolescent’s signs and symptoms sug-
gest a spinal cord injury. A client with suspected
spinal cord injury should not be moved until the
spine has been immobilized. Removing the helmet
could further aggravate a spinal cord injury. The
nurse could assess for abdominal trauma, but only if
it can be done without moving the adolescent.
CN: Reduction of risk potential;
CL: Synthesize
68. 1. In spinal cord injury, temperature regu-
lation is lost below T3. Body temperature must
be maintained by adjusting room temperature or
bed linens, such as covering the client’s legs with
blankets. Coolness of the extremities is an expected
finding. Therefore, it is not necessary to notify the
physician immediately. Repositioning the client’s
legs does not alleviate the temperature regulation
problem and could be harmful, considering the cli-
ent’s diagnosis. Moving the legs before the spine is
stabilized could lead to further cord damage. Laying
the client flat will not increase the warmth to the
legs and feet.
CN: Physiological adaptation;
CL: Synthesize
69. 3. A thoracic spinal cord injury involves
the muscles of the lower extremities, bladder, and
rectum. Paralytic ileus often occurs as a result of
Billings_Part 2_Chap 2_Test 7.indd 294
decreased gastrointestinal muscle innervation. The
nurse evaluates this by auscultating the abdomen.
Because the client has a thoracic spinal cord injury,
the client may not feel abdominal cramping. Addi-
tionally, auscultation would provide no evidence of
cramping. Hyperactive bowel sounds would be evi-
denced with increased peristalsis; peristalsis would
probably be diminished with this injury. Profuse
diarrhea, resulting from increased peristalsis, would
not be an expected finding. Diarrhea would be
more commonly associated with a gastrointestinal
infection.
CN: Physiological adaptation;
CL: Analyze
70. 3. Spinal shock causes a loss of reflex activ-
ity below the level of the injury, resulting in blad-
der atony and flaccid paralysis. When the reflex
arc returns, it tends to be overactive, resulting in
spasticity. The reflexes and bladder becomes hyper-
tonic during this phase of spinal shock resolution;
sensation does not return. A widened pulse pressure
is not associated with resolution of spinal shock.
CN: Physiological adaptation;
CL: Evaluate
71. 1. After a catastrophic injury, individuals
commonly experience grief. Initially, the person
experiences denial, the most common response.
With gradual awareness of the situation, anger com-
monly occurs. The child is demonstrating anger,
not rebellion, as he gradually becomes aware of his
situation. Rebellion is the child’s way to maintain
autonomy and individuality. It is a reaction to rigid
rules. Examples include refusing to follow a treat-
ment protocol when the child had no input and
running away. Sensory overload would cause the
child to be irritable and tired and to have difficulty
sleeping. Too much attention usually would lead to
irritability, difficulty sleeping, and mood swings.
CN: Psychosocial adaptation;
CL: Analyze
72. 1. The adolescent is exhibiting signs of
autonomic dysreflexia, a generalized sympathetic
response usually caused by bladder or bowel dis-
tention. Immediate treatment involves eliminating
the cause. Because bladder distention is a common
cause of this problem, the nurse should immediately
determine the patency of the indwelling (Foley)
catheter. Lowering the head below the knees would
increase the blood pressure and is contraindicated
because of the spinal cord injury. Lying flat will not
decrease blood pressure. Epinephrine is contraindi-
cated because it elevates blood pressure and there-
fore can exacerbate the problem.
CN: Physiological adaptation;
CL: Synthesize
8/7/2010 10:04:43 AM

Managing Care Quality and Safety
73. 4. Bacterial meningitis is caused by one of
three organisms, Haemophilus influenzae type b,
Neisseria meningitidis, or Streptococcus pneu-
moniae. All three organisms may be transmitted
through contact with respiratory droplets. These
droplets are heavy and typically fall within 3 feet of
the client. Droplet precautions require, in addition
to standard precautions, that health care providers
wear masks when coming into close contact with
the client. Standard precautions, previously referred
to as universal precautions, are general measures
used for all clients. Contact precautions are used
when direct or indirect contact with the client
causes disease transmission. Gowns and gloves are
needed but not masks. Airborne precautions differ
from droplet in that the particles are smaller and
may stay suspended in the air for longer periods of
time. These clients require negative pressure rooms
and all heath care workers must wear respirators.
CN: Safety and infection control;
CL: Apply
74. 3, 4, 5. Using only oral syringes to admin-
ister oral medications reduces the chance that the
medication will be given intravenously. The use
of smart pumps alone is not enough to prevent I.V.
fluid administration. An additional measure pedi-
atric floors can institute to prevent accidental fluid
overload is to use smaller I.V. fluid bags, such as
250 mL. Whenever a medication comes in multiple
concentrations and doses, there is risk of adminis-
tering the wrong dose. The use of pediatric satel-
lite pharmacies with pediatric pharmacists greatly
Billings_Part 2_Chap 2_Test 7.indd 295
The Child with Neurologic Health Problems 295
increases the safety of medication administration.
Any time steps are added to the medication admin-
istration process there is one more place where an
error might occur.
CN: Safety and infection control;
CL: Synthesize
75. 4. The coating on an extended release
medication helps assure slow absorption of
the medication. If the nurse crushes the medication,
the medication may enter the client’s system too
quickly and result in toxic levels. The only appropri-
ate action is to contact the prescriber and ask that the
order be changed. Cutting the medication or trying to
dissolve a whole tablet would have similar results as
crushing it. Carbamazapine comes as an oral suspen-
sion, but it is not extended release. Therefore, an
order would be needed to address dosing if switch-
ing to this form.
CN: Safety and infection control;
CL: Synthesize
76. 1. A poster presentation is an eye-catching
way to disseminate information that can be used to
educate nurses on all shifts. The addition of the post
test will verify that the poster information has been
received. Because of the large volume of emails the
typical employee receives, information sent this way
may be overlooked. If several nurses are observed
not using the most current practice, it is quite pos-
sible many more do not understand it. Thus, a larger
scale plan is needed. Posting an article will not
alone assure that the information is read.
CN: Reduction of risk potential;
CL: Create
8/7/2010 10:04:43 AM