CHAPTER 32: NEUROLOGICAL ALTERATIONS

CHAPTER 32: NEUROLOGICAL ALTERATIONS

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse assessing an infant finds the following signs and symptoms: sun setting eyes with sclera seen above the iris, a high-pitched cry, a bulging fontanel, dilated scalp veins, slight alteration in consciousness, and vomiting. The nurse is aware that these signs and symptoms are most consistent with:

a.	increased intracranial pressure	c.	encephalitis caused by a virus
b.	spinal cord trauma	d.	severe hypoxia

 

 

ANS:  A

 

	Feedback
A	Correct. For the child with increased intracranial pressure, the common presenting signs and symptoms may include vomiting, alteration in level of consciousness, sun setting eyes with the sclera seen above the iris, high-pitched cry, bulging fontanel, and dilated scalp veins.
B	Incorrect. These signs and symptoms are not associated with spinal cord trauma.
C	Incorrect. These signs and symptoms are not associated with encephalitis caused by a virus.
D	Incorrect. These signs and symptoms are not associated with severe hypoxia.

 

 

PTS:   1                    REF:   p. 1194 – Seizures

OBJ:   Cognitive Level: Application

 

2. An infant’s brain is what portion of the weight of an adult’s brain?

a.	one-fourth	c.	one-half
b.	one-third	d.	two-thirds

 

 

ANS:  D

 

	Feedback
A	Incorrect. An infant’s brain weight that is one-fourth the weight of an adult’s brain would warrant further evaluation.
B	Incorrect. An infant’s brain weight that is one-third the weight of an adult’s brain would warrant further evaluation.
C	Incorrect. An infant’s brain weight that is one-half the weight of an adult’s brain would warrant further evaluation.
D	Correct. At birth, the infant’s brain weight is approximately two-thirds the weight of an adult’s brain.

 

 

PTS:   1                    REF:   p. 1198 – Seizures

OBJ:   Cognitive Level: Comprehension

 

3. The nurse reporting on duty learns that the nursing unit is using the AVPU scale on one of the nurse’s assigned clients. The nurse recalls that the AVPU scale is used for:

a.	determining the level of pain of an intubated child
b.	measuring the weight of a child who cannot stand
c.	obtaining a measure of the level of consciousness
d.	obtaining a gross measure of intracranial pressure

 

 

ANS:  C

 

	Feedback
A	Incorrect. The AVPU scale is not used for determining pain status.
B	Incorrect. The AVPU scale is not used for determining the weight of the child.
C	Correct. The AVPU scale is used to evaluate the child’s level of consciousness. AVPU is a mnemonic which represents A=alert and awake, V=responsive to verbal stimuli, P=responsive to painful stimuli, U=unresponsive.
D	Incorrect. The AVPU scale is not used in obtaining a gross measure of intracranial pressure.

 

 

PTS:   1                    REF:   p. 1199 – Seizures

OBJ:   Cognitive Level: Comprehension

 

4. You are the nurse reporting on duty. You learn during report that one of the children assigned to your care has been in status epilepticus. You will recall that status epilepticus refers to:

a.	a chronic seizure condition that is not well controlled and usually lasts for years or a lifetime
b.	a prolonged seizure or a series of convulsions there loss of consciousness occurs for at least 30 minutes
c.	an unconscious state induced by medication to keep seizures under control and give the brain a chance to rest
d.	being diagnosed with epilepsy in the past, but not having seizures for 5 or more years

 

 

ANS:  B

 

	Feedback
A	Incorrect. Status epilepticus is not typically referred to as a chronic seizure disorder.
B	Correct. Status epilepticus is a prolonged seizure or series of convulsions there loss of consciousness occurs for at least 30 minutes.
C	Incorrect. Status epilepticus is not characterized as an unconscious state induced by medications.
D	Incorrect. Status epilepticus is not defined as having a history of epilepsy without seizure activity for 5 or more years.

 

 

PTS:   1                    REF:   p. 1201 – Seizures

OBJ:   Cognitive Level: Comprehension

 

5. Refractory seizures last more than how many minutes?

a.	30	c.	50
b.	40	d.	60

 

 

ANS:  D

 

	Feedback
A	Incorrect. Refractory seizures are not characterized by seizures lasting 30 minutes.
B	Incorrect. Refractory seizures are not characterized by seizures lasting 40 minutes.
C	Incorrect. Refractory seizures are not characterized by seizures lasting 50 minutes.
D	Correct. Refractory seizures last longer than 60 minutes.

 

 

PTS:   1                    REF:   p. 1201 – Seizures

OBJ:   Cognitive Level: Comprehension