Exam 3 Content (Neurological/Genetic/Cognitive Alterations, Musculoskeletal/Neuromuscular)

What is the glascow coma scale?

A neurological assessment tool used to evaluate a person’s level of consciousness after a brain injury or other neurological impairment.

What are the 3 functions the glasgow coma scale assess?

1. eye opening

2. verbal response

3. motor response

What is the condition where ther is excessive amounts of cerebral spinal fluid within the cerebral ventricles?

Hydrocephalus

What condition manifests in infancy with abnormally rapid head growth, bulging fontanels, dilated scalp veins, macewen sign, thinning of skull bones/frontal enlargement, sunsetting eyes, irritability, lethargy, sluggish pupillary response, lower extremity spasticity, and high-pitched cry?

Hydrocephalus

What is the macewen sign?

percussion on skull over the junction of the frontal, termporal, and parietal bones where a hallow or “cracked pot” sound is heard if there is an increased ICP or fluid accumulation.

what is sunsetting eyes?

downward deviation of the eyes where sclera is visible above the iris.

What condition manifests in an older child as headache on awakening but improves after vomiting or sitting upright, irritability, lethargy, apathy, confusion, change in motor abilities (ataxia, spasticity), papilledema, strabismus, and decrease in visual acuity?

Hydrocephalus

What is papilledema?

swelling of the optic disc due to ICP

How is hydrocephalus diagnosed in infants?

measuring head circumferences daily to see if head rapidly increases

What are the primary tools that are used to diagnose hydrocephalus?

CT scan and MRI

What is the shunt called thats used for hydrocephalus?

Ventriculoperitoneal Shunt

How does a ventriculoperitoneal shunt work?

it is inserted into the ventricle that has the accumulated fluid, and drains the fluid into the peritoneal cavity & naturally removed by the body.

Will VP shunts need changed as the infant grows?

Yes

What is a way to avoid rapid reduction of intracranial fluid ?

Lay patient flat

What diet should the patient be on post op VP shunt and for how long?

NPO for 24 hours

Which seizure is abnormal electrical activity in one hemisphere?

Focal seizure

Which seizure involves both hemispheres?

generalized seizure

What seizures manifest as jerking activity in one extremity, stiffness, may be aware, impaired awareness, or unconscious, buzzing sounds, anxiety, and flashing lights?

Focal seizures

How are seizures diagnosed?

CT, MRI, EEG, and labs (electrolytes, imbalances, infections, toxicity)

What are 3 things you need to know about Phenytoin?

• monitor therapeutic levels

• use an IV filter

• tell patient to use soft bristle toothbrush due to gingival hyperplasia

What are 2 examples of benzodiazepines and what are some side effects?

• lorazepam or diazepam

• drowsiness, fatigue, dizziness, weakness, sedation, respiratory depression,

What are 3 examples of anti-epileptics and what is one important thing to monitor with these meds?

Carbamazapine, valproic acid, phenytoin.

Monitor the therapeutic levels!

What seizure is triggered by high fever?

Febrile Seizures

What is the condition where the meninges of the brain and spinal cord is infected?

Meningitis

What disease is this?

Pathophysiology: the pathogen acts as a toxin, creating meningeal inflammation with release of purulent exudate. Vascular congestion and inflammation lead to cerebral edema, which may produce increased ICP. Necrosis of brain cells can cause permanent damage and death.

meningitis

What condition manifests as headhache, photophobia, malaise, irritability, chills, fever, nuchal rigidity, kernig’s sign, brudzinski’s sign, vomiting, possible seizures, decreasing LOC, possible back pain, bulging fontanel, petechial/pupuric rashes, and chronically draining ears?

Meningitis

What are 3 signs of meningeal irritation?

• Nuchal rigidity

• kernig’s sign

• Brudzinski’s sign

Contraction or pain in the hamstring muscle when attempting to extend the leg when the hip is flexed?

Kernig’s Sign

When child is lying supine and their head is flexed, and that causes pain or causes knees and hips to flex involuntarily

Brudzinski’s sign

How is meningitis diagnosed?

• lumbar puncture

• blood cultures

• throat culture

• urine culture

• nasal swab

• CBC

• lytes

• glucose

Should the family be careful around the child with meningitis?

yes! have prophylactic antibiotics for family

True or False:

Large doses of broad-spectrum IV antibiotics is used for bacterial meningitis.

True

What injury manifests early as photophobia, N/V, headache, vertigo, irritability, lethargy, poor feeding, amnesia/confusion, apnea, altered LOC, and CSF leak?

head injury

What injury manifests late as increased ICP, hydrocephalus, seizures, posturing, unequal/non-reactive pupils, and ecchymosis around eyes or mastoid?

head injury

True or False:

LOC is always an indicator for presence of concussion.

False.

LOC is not accurate indicator for presence of concussion

How can mild head injuries be managed at home? (Education for parents)

• assess patient every 2 hours to make sure they are able to be awake

• they may have nausea, headache.

• use Tylenol for pain.

• soft, light, bland diet

• return to the hospital if there is any change in LOC, difference in pupil size, severe headache, gait abnormalities

What condition/disorder manifests as

• epicanthic folds (small skin folds on inner corners of eyes),

• square hands with a single transverse crease across palm

• large tongue in small mouth

• high arched palate

• muscle weakness and hypotonia

• upward slant to eyes

• small nose and depressed nasal bridge

• wide space between big and second toe

• abnormally aligned teeth

• congenital heart defects

• increased incidence of Hirschsprung, hypothyroidism, leukemia

Trisomy 21 (down syndrome)

A 4-year-old child with Down syndrome is in a pediatric clinic for a routine visit. The nurse knows that which developmental milestone is most likely delayed?

A. Running and jumping
B. Sitting without support
C. Responding to name
D. Smiling at familiar faces

✅ Correct Answer: A – Motor skills like running and jumping are often delayed due to hypotonia and joint laxity.

The nurse is caring for a 9-month-old infant with Down syndrome. Which milestone should the nurse expect the infant to achieve by this age?

A. Pulling to a stand
B. Transferring objects between hands
C. Walking independently
D. Saying two-word phrases

✅ Correct Answer: B – Fine motor skills such as transferring objects between hands develop around 6–9 months, even in children with developmental delays.

A nurse is counseling parents of a 4-year-old child with Down syndrome about social development. Which parental statement indicates a need for further teaching?

A. "We will encourage our child to participate in group play with peers."
B. "Our child may prefer parallel play longer than other children."
C. "We should limit interactions with other children to prevent frustration."
D. "We will use structured routines to help our child feel comfortable in social settings."

✅ Correct Answer: C – Children with Down syndrome benefit from social interactions, and limiting peer exposure can hinder social development. Instead, gradual socialization with support is recommended.

What condition/disorder manifests as

• poor communication/different communication

• unusual forms of play; also typically solitary play

• bizarre body movements

• repetitive actions

• absent eye contact

• aversion to some or all physical contact

• sensitivity to tactile stimuli

• echolalia (repeating last words or words heard)

• unresponsiveness to auditory stimuli

• exaggerated attachments to key possessions

• no stranger anxiety

Autism spectrum disorder

How does an infant present with autism?

They may be a typical infant at first, using language. Then all of a sudden they will lose most of it or all.

What condition is when there is an abnormal gene on the lower end of the long arm of the X chromosome?

Fragile X Syndrome

What condition/disorder manifests as

• long face with prominent jaw

• large protruding ears

• large testes in post-pubertal males

• hypotonia/flexibile joints

• mitral valve prolapse

• behavioral manifestations in pre-pubertal children

Fragile X syndrome

3 medications to help with ADHD and their side effects?

• methylphenidate, dextroampheatime, dexmethylphenidate

• anorexia, weight loss, abdominal pain, H/A, insomnia, tachycardia, and hypertension

What condition/disorder manifests as vocal, motor, simple, and complex tics?

Tourettes

When are tics usually worse?

During stress or excitement

How long to tics have to be present for to be diagnosed with tourettes?

One year

What is the condition where the femoral head has an abnormal relationship to the acetabulum (hip socket)?

Developmental dysplasia of the hip (DDH)

What are some factors that influence someone having DDH?

• relaxin

• frank breech presentation

• twinning

• macrosomia (large infant size)

• swaddling/tightly wrapping infant in blankets

What DDH is the mildest form of DDH, where the acetabular development but femoral head remains in acetabulum?

Acetabular dyplasia

What DDH is where the femoral head remains in contact with the acetabulum, but a stretched capsule and ligament causes the head of the femur to be partially displaced? (most common)

Subluxation

What DDH is where there is complete loss of contact of femoral head with the acetabulum?

Dislocation

What condition manifests as unequal leg length, asymmetry of thigh and gluteal folds, limited abduction on affected side, gait abnormalities, level of pelvis may be unequal, and shortening of one limb?

DDH

What are the 2 diagnostic tests used to diagnose DDH and when is it done?

• barlow manuever

• ortolani maneuver

Done in the newborn period (1st-28 days)

What is diagnostic test where the examiner pushes an unstable femoral head out of the acetabulum by use of gentle lateral pressure of the lower trochanter?

Barlow Manuever

What is the diagnostic test where the examiner reduces dislocated femoral head into the acetabulum by gentle abduction and external rotation. A “clunk” is heard and felt as this occurs?

Ortolani manuever

What is used to manage DDH in newborns - 3-6 months?

Pavlik harness

What is used to manage DDH in 6-24 month old patients?

Traction and casting (Closed reduction)

What is used to manage DDH in older children?

operative reduction

How to promote adequate blood flow for an infant wearing a pavlik harness?

Massage

How frequently should the nurse assess the infant for signs of skin irritation or pressure sores under the Pavlik harness?

The nurse should assess the skin under the harness at least twice daily for signs of skin irritation, redness, or pressure sores, particularly in areas where the straps may cause friction (e.g., chest, thighs, and groin). Additional checks should be done if the infant shows signs of discomfort or crying.

What should be done if signs of diaper rash or chafing are noticed under the harness straps?

Gently clean the affected area with mild soap and warm water, and pat dry.

A nurse is teaching the parents of an infant about care for a child wearing a Pavlik harness. Which of the following instructions is most important for the nurse to include?
a) "You can remove the harness whenever you need to change the baby’s diaper or clothing."
b) "Monitor your baby’s skin under the harness at least twice a day for redness or irritation."
c) "The harness can be removed for bathing the baby for a few hours each day."
d) "It’s best to leave the baby in the harness at all times, even while sleeping."

Answer: b) "Monitor your baby’s skin under the harness at least twice a day for redness or irritation."
Rationale: The nurse should emphasize regular monitoring of the skin for any signs of irritation or breakdown, as this is a common issue when using the Pavlik harness. The harness should remain on the baby except for bathing or when directed by the healthcare provider.

What condition manifests as the foot pointing downward/inward, rigid, fixed and difficult to move, shortened achilles tendion, thin/atrtophic calf muscle and small foot?

Talipes equinovarus (Clubfoot)

What is the most common technique used for treating clubfoot?

Ponseti method

How does the ponseti method work?

the foot is manipulated to the correct position and a cast is placed.

How often are casts changed for someone with clubfoot?

every week

What condition manifests as severe bone fragility, multiple fractures, pain, may have deafness, dental deformities, blue sclera, hyperlaxity of ligaments, thin skin, excess diaphoresis, and short stature?

Osteogenesis imperfecta

What supplements are good for OI patients?

calcium - helps with bone formation

Vitamin D - enhances absorption of calcium

Biphosphonates - increases bone density

Vitamin C - collagen synthesis

Magnesium - supports bone mineralization

what condition manifests as unequal shoulder/hip level, prominence of one scapula, curved spinal column, rotation of spine/scapula on one side being more prominent when child bends over, more common thoracic curves, and pain?

Scoliosis

What brace is an underarm prefabricated plastic shell used for curves of the low thoracolumbar and lumbar spine? Also more socially acceptable.

Boston Brace

What brace is used for thoracolumbar curves, which get molded to the individuals body and built like a jacket?

TLSO

What brace is used for high thoracic curves, consisting of plastic and metal with a chin extension?

Milwaukee brace

How often should braces be worn for kids with scoliosis?

16-23 hours of the day

What is the most common procedure for someone with scoliosis with a curve of 40 degrees or more?

posterior spinal fusion with instrumentation and bone grafting

True or False:

You can raise the HOB after surgery for scoliosis?

False

Some nursing considerations to take in for post op surgery for someone with scoliosis?

• log roll - maintains spinal alignment

• do not raise head of the bed

• PCA pump for analgesia

• good skin care

• assessment of neuro status - neurovascular checks

• discuss alternate methods of education during recovery phase

What disease manifests as positive gower sign,enlargement of calves, thighs and upper arms due to fatty infiltration (pseudohypertrophy), profound muscular atrophy (in later stages), mental deficiency, walking becomes impossible (between ages 9-12), muscles for breathing become weak, myocardium deteriorates, and death from respiratory infections or cardiac failure?

Muscular Dystrophy

What is the goal for therapeutic management of muscular dystrophy?

Maintaining function in unaffected muscles for as long as possible

What fracture is when theres a break on one side and theres a little bend on the other?

Greenstick

What fracture is where there is a break at the growth plate?

Epiphyseal injury

What fracture is when the bone breaks through the skin, causing a risk for infection?

Compound fracture

What injury manifests as generalized swelling, pain/tendereness, diminished functional use of affected part and possible bruising, severe muscular rigidity, and crepitus?

Fracture

A 6-year-old child in a long arm cast complains of pain, rating it as 8/10 on the FLACC scale. The parent states, "We already gave ibuprofen 1 hour ago, but my child is still in pain." The nurse’s next best action is:

a) Reassure the parent that mild pain is normal after a fracture
b) Apply cold therapy and elevate the arm
c) Administer opioid analgesia as prescribed
d) Check for tightness of the cast and assess neurovascular status

Answer: d) Check for tightness of the cast and assess neurovascular status.
Rationale: Pain that is not relieved by medication can indicate compartment syndrome. The nurse must assess circulation, sensation, and movement (CSM) before administering further pain medication.

A nurse is teaching the parents of a 5-year-old with a fiberglass leg cast about home care. Which parent statement indicates a need for further teaching?

a) "If my child’s toes feel cold and look pale, I will call the doctor."
b) "If my child gets food crumbs inside the cast, I will rinse it with warm water."
c) "I will keep my child’s cast dry and use a plastic covering when bathing."
d) "I will encourage my child to wiggle their toes frequently to keep circulation moving."

Answer: b) "If my child gets food crumbs inside the cast, I will rinse it with warm water."
Rationale: Moisture trapped inside the cast can lead to skin breakdown and infection. Parents should never insert anything into the cast, including water, to clean it.

A 6-year-old child with a forearm cast returns for a follow-up, and the parent reports that the cast feels tighter than before. The nurse notices swelling but the fingers remain pink and warm. What is the best nursing action?

a) Document findings and reassure the parent this is normal
b) Elevate the arm, apply ice, and reassess in 30 minutes
c) Immediately request an order to remove the cast
d) Massage the fingers to promote circulation

Answer: b) Elevate the arm, apply ice, and reassess in 30 minutes.
Rationale: Mild swelling is common in growing children, especially within the first 48 hours of cast application. If symptoms worsen, cast adjustment may be needed.

True or False:

A child should still be in pain 24-48 hours after having a cast put on.

False, pain should not be occuring and talk to provider

Which procedure is a non-surgical procedure where a fractured bone is manipulated manually back into alignment without an incision?

Closed reduction

Which procedure is a surgical procedure where an incision is made to realign fractured bones, often using internal fixation (plates, screws, rods or pins)

Open reduction

What traction is non-invasive, using straps, boots or slings applied to the skin?

Skin traction

Which traction is invasive where pins, wires, or screws are inserted into the bone?

Skeletal traction

What condition results from failure of brain to form correctly or some type of insult causing permanent damage?

Cerebral palsy

What condition causes inability to control muscles and movement as well as sensory functions, perception, cognition, and communication?

Cerebral palsy

How is cerebral palsy acquired? (not congenital)

• meningitis

• head trauma

• other conditions causing cerebral hemorrhage

What cerebral palsy is manifested as very stiff/rigid muscles, difficulty with coordination, decreased muscle tone, and is the most common?

Spastic cerebral palsy

What cerebral palsy manifests as alternating increase and decreased muscle tone, can be slow moving or have quick jerky movements?

Dyskinetic

What cerebral palsy is classified as having difficult with coordination and gait?

Ataxic

When is cerebral palsy diagnosed?

18 months to 2 years

A 2-year-old child with spastic cerebral palsy is being discharged from the hospital after an orthopedic surgery to correct a hip deformity. Which of the following interventions should the nurse prioritize to support the child's needs at home?

a) Encourage the child to walk as soon as possible to improve mobility.
b) Teach the family to provide passive range-of-motion exercises to maintain joint flexibility.
c) Encourage the family to use a restrictive wheelchair to limit movement for safety.
d) Advise the family to allow the child to rest for long periods of time and avoid physical activity.

Answer: b) Teach the family to provide passive range-of-motion exercises to maintain joint flexibility.
Rationale: Passive range-of-motion exercises are important for children with spastic cerebral palsy to maintain joint flexibility, prevent contractures, and improve muscle mobility. Encouraging the child to walk too soon or overly restricting movement may delay development and independence.