Child with Neuromuscular Dysfunction

Chapter 35: The Child with Neuromuscular or Muscular
Dysfunction
MULTIPLE CHOICE
1. What is the most common cause of cerebral palsy (CP)?
a
. Central nervous system (CNS) diseases
b
. Birth asphyxia
c
. Cerebral trauma
d
. Neonatal encephalopathy
ANS: D
Approximately 80% of CP is caused by unknown prenatal causes.
Neonatal encephalopathy in term and preterm infants is believed to
play a significant role in the development of CP. CNS diseases such
as meningitis or encephalitis can result in CP. Birth asphyxia does
contribute to some cases of CP. Cerebral trauma, including shaken
baby syndrome, can result in CP.
DIF: Cognitive Level: Understanding REF: p. 1632
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. Spastic cerebral palsy (CP) is characterized by which clinical
manifestations?
a
. Athetosis, dystonic movements
b
. Tremors, lack of active movement
c Hypertonicity; poor control of posture, balance, and
. coordinated motion
d Wide-based gait; poor performance of rapid, repetitive
. movements
ANS: C
Hypertonicity and poor control of posture, balance, and coordinated
motion are part of the classification of spastic CP. Athetosis and
dystonic movements are part of the classification of dyskinetic or
athetoid CP. Tremors and lack of active movement may indicate
other neurologic disorders. A wide-based gait and poor performance
of rapid, repetitive movements are part of the classification of ataxic
CP.
3. What type of cerebral palsy (CP) is the most common type?
a
. Ataxic
b
. Spastic
c
. Dyskinetic
d
. Mixed type
ANS: B
Spastic CP is the most common clinical type. Early manifestations
are usually generalized hypotonia, or decreased tone that lasts for a
few weeks or may extend for months or as long as 1 year. It is
replaced by increased stretch reflexes, increased muscle tone, and
weakness. Ataxic, dyskinetic, and mixed type are less common
forms of CP.
4. The parents of an infant with cerebral palsy (CP) ask the nurse if
their child will have cognitive impairment. The nurses response
should be based on which knowledge?
a Affected children have some degree of cognitive

. impairment.
b Around 20% of affected children have normal
. intelligence.
c About 45% of affected children have normal
.
intelligence.
d Cognitive impairment is expected if motor and sensory
. deficits are severe.
ANS: C
Children with CP have a wide range of intelligence, and 40% to 50%
are within normal limits. A large percentage of children with CP do
not have mental impairment. Many individuals who have severely
limiting physical impairment have the least amount of intellectual
compromise.
DIF: Cognitive Level: Applying REF: p. 1620
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
5. Gingivitis is a common problem in children with cerebral palsy
(CP). What preventive measure should be included in the plan of
care?
a
. High-carbohydrate diet
b
. Meticulous dental hygiene
c
. Minimum use of fluoride
d
. Avoidance of medications that contribute to gingivitis
ANS: B
Meticulous oral hygiene is essential. Many children with CP have
congenital enamel defects, high-carbohydrate diets, poor nutritional
intake, and difficulty closing their mouths. These, coupled with the
childs spasticity or clonic movements, make oral hygiene difficult.
Children with CP have high carbohydrate intake and retention, which
contribute to dental caries. Use of fluoride should be encouraged
through fluoridated water or supplements and toothpaste. Certain
medications such as phenytoin do contribute to gingival hyperplasia.
If that is the drug of choice, then meticulous oral hygiene must be
used.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological
Integrity
6. What is a major goal of therapy for children with cerebral palsy
(CP)?
a
. Cure the underlying defect causing the disorder.
b Reverse the degenerative processes that have
. occurred.
c Prevent the spread to individuals in close contact with
. the child.
d Recognize the disorder early and promote optimum
. development.
ANS: D
The goals of therapy include early recognition and promotion of an
optimum developmental course to enable affected children to attain
their potential within the limits of their dysfunction. The disorder is
permanent, and therapy is chiefly symptomatic and preventive. It is
not possible at this time to reverse the degenerative processes. CP
is not contagious.
Integrity
7. The parents of a child with spastic cerebral palsy (CP) state that
their child seems to have significant pain. In addition to systemic
pharmacologic management, the nurse includes which teaching?
a
. Patterning
b
. Positions to reduce spasticity
c
. Stretching exercises after meals
d
. Topical analgesics for muscle spasms
ANS: B
Parents and children are taught positions to assume while sitting
and recumbent that reduce spasticity. The American Academy of
Pediatrics has stated that patterning should not be used for
neurologically disabled children. Patterning attempts to alter
abnormal tone and posture and elicit desired movements through
positional manipulation or other means of modifying or augmenting
sensory output. Stretching should be done after appropriate
analgesic medication has been given and is effective. Topical
analgesia is not effective for the muscle spasms of spastic CP.
8. A child, age 3 years, has cerebral palsy (CP) and is hospitalized for
orthopedic surgery. His mother says he has difficulty swallowing and
cannot hold a utensil to feed himself. He is slightly underweight for
his height. What is the most appropriate nursing action related to
feeding this child?
a Bottle or tube feed him a specialized formula until he

. gains sufficient weight.
b Stabilize his jaw with caregivers hand (either from a
. front or side position) to facilitate swallowing.
c
. Place him in a well-supported, semireclining position.
d Place him in a sitting position with his neck
. hyperextended to make use of gravity flow.
ANS: B
Jaw control is compromised in many children with CP. More normal
control is achieved if the feeder stabilizes the oral mechanisms from
the front or side of the face. Bottle or tube feeding will not improve
feeding without jaw support. The semireclining position and
hyperextended neck position increase the chances of aspiration.
Integrity
9. An 8-year-old girl with moderate cerebral palsy (CP) recently
began joining a regular classroom for part of the day. Her mother
asks the school nurse about joining the after-school Girl Scout troop.
The nurses response should be based on which knowledge?
a Most activities such as Girl Scouts cannot be adapted

. for children with CP.
b After-school activities usually result in extreme fatigue
. for children with CP.
c Trying to participate in activities such as Girl Scouts
. leads to lowered self-esteem in children with CP.
d Recreational activities often provide children with CP
. with opportunities for socialization and recreation.
ANS: D
After-school and recreational activities serve to stimulate childrens
interest and curiosity. They help the children adjust to their
disability, improve their functional ability, and build self-esteem.
Increasing numbers of programs are adapted for children with
physical limitations. Almost all activities can be adapted. The child
should participate to her level of energy. Self-esteem increases as a
result of the positive feedback the child receives from participation.
MSC: Client Needs: Psychosocial Integrity
10. A 4-month-old with significant head lag meets the criteria for
floppy infant syndrome. A diagnosis of progressive infantile spinal
muscular atrophy (Werdnig-Hoffmann disease) is made. What should
be included in the nursing care for this child?
a
. Infant stimulation program
b
. Stretching exercises to decrease contractures
c
. Limited physical contact to minimize seizures
d
. Encouraging parents to have additional children
ANS: A
Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the
most common paralytic form of floppy infant syndrome (congenital
hypotonia). An infant stimulation program is essential. Frequent
position changes, including changes in environment, provide the
child with more physical contacts. Verbal, tactile, and auditory
stimulation are also included. Contractures do not occur because of
muscular atrophy. Sensation is normal in children with this disorder.
Frequent touch is necessary as part of the stimulation. Werdnig-
Hoffmann disease is inherited as an autosomal recessive trait.
Parents should be referred for genetic counseling.
DIF: Cognitive Level: Applying REF: p. 1641 TOP: Nursing Process: Planning
11. An 8-year-old child is hospitalized with infectious polyneuritis
(Guillain-Barr syndrome [GBS]). When explaining this disease
process to the parents, what should the nurse consider?
a
. Paralysis is progressive with little hope for recovery.
b Disease is inherited as an autosomal, sex-linked,
. recessive gene.
c Disease results from an apparently toxic reaction to
. certain medications.
d Muscle strength slowly returns, and most children
. recover.
ANS: D
Recovery usually begins within 2 to 3 weeks, and most patients
regain full muscle strength. The paralysis is progressive with
proximal muscle weakness occurring before distal weakness. The
recovery of muscle strength occurs in the reverse order of onset of
paralysis. Most individuals regain full muscle strength. Better
outcomes are associated with younger ages. GBS is an immune-
mediated disease often associated with a number of viral or
bacterial infections or the administration of vaccines.
12. A 12-year-old child with Guillain-Barr syndrome (GBS) is admitted
to the pediatric intensive care unit. She tells you that yesterday her
legs were weak and that this morning she was unable to walk. After
the nurse determines the current level of paralysis, which should the
next priority assessment be?
a
. Swallowing ability
b
. Parental involvement
c
. Level of consciousness
d
. Antecedent viral infections
ANS: A
Assessment of swallowing is essential. Both pharyngeal involvement
and respiratory function are usually involved at the same time. The
child may require ventilatory support. The inability to swallow also
contributes to aspiration pneumonia. Parental involvement is
important after the physiologic assessment is complete. The child is
answering questions and describing the onset of the illness, which
demonstrates she is alert and oriented. Information regarding
antecedent viral infections can be obtained after the child is
assessed and stabilized.
13. What statement is most accurate in describing tetanus?
a Inflammatory disease that causes extreme, localized

. muscle spasm.
b Disease affecting the salivary gland with resultant
. stiffness of the jaw.
Acute infectious disease caused by an exotoxin
c produced by an anaerobic spore-forming, gram-positive
. bacillus.
d Acute infection that causes meningeal inflammation
. resulting in symptoms of generalized muscle spasm.
ANS: C
Tetanus results from an infection by the anaerobic spore-forming,
gram-positive bacillusClostridium tetani. The organism forms two
exotoxins that affect the central nervous system to produce the
clinical manifestations of the disease. Tetanus is not an
inflammatory process. The toxin acts at the neuromuscular junction
to produce muscular stiffness and to lower the threshold for reflex
excitability. It is usually a systemic disease. Initial symptoms are
usually a progressive stiffness and tenderness of the muscles of the
neck and jaw. The sustained contraction of the jaw-closing muscles
provides the name lockjaw. Meningeal inflammation is not the cause
of the muscle spasms.
14. An adolescent whose leg was crushed when she fell off a horse is
admitted to the emergency department. She has completed the
tetanus immunization series, receiving the last tetanus toxoid
booster 8 years ago. What care is necessary for therapeutic
management of this adolescent to prevent tetanus?
a Tetanus toxoid booster is needed because of the type of

. injury.
b Human tetanus immunoglobulin is indicated for
. immediate prophylaxis.
c Concurrent administration of both tetanus
. immunoglobulin and tetanus antitoxin is needed.
d No additional tetanus prophylaxis is indicated. The
. tetanus toxoid booster is protective for 10 years.
ANS: A
Protective levels of antibody are maintained for at least 10 years.
Children with serious tetanus-prone wounds, including
contaminated, crush, puncture, or burn wounds, should receive a
tetanus toxoid booster prophylactically as soon as possible. This
adolescent has circulating antibodies. The immunoglobulin is not
indicated.
Integrity
15. During a well-child visit, the mother tells the nurse that her 4-
month-old infant is constipated, is less active than usual, and has a
weak-sounding cry. The nurse suspects botulism and questions the
mother about the childs diet. What factor should support this
diagnosis?
a
. Breastfeeding
b
. Commercial formula
c
. Infant cereal with honey
d
. Improperly sterilized bottles
ANS: C
Ingestion of honey is a risk factor for infant botulism in the United
States. Honey should not be given to children younger than the age
of 1 year. Botulism is not found with the use of commercial infant
cereals. Although there is a slight increase in botulism in breastfed
infants when compared with formula-fed infants, there is not
sufficient evidence to support formula feeding as prevention.
Thoroughly cleaning bottles used for formula feeding is sufficient for
botulism prevention. Inadequate sterilization of home-canned foods
can contribute to botulism.
DIF: Cognitive Level: Analyzing REF: p. 1647
TOP: Integrated Process: Assessment MSC: Client Needs: Physiological
Integrity
16. An adolescent has just been brought to the emergency
department with a spinal cord injury and paralysis from a diving
accident. The parents keep asking the nurse, How bad is it? The
nurses response should be based on which knowledge?
a Families adjust better to life-threatening injuries when

. information is given over time.
b Immediate loss of function is indicative of the long-term
. consequences of the injury.
c Extent and severity of damage cannot be determined
. for several weeks or even months.
d Numerous diagnostic tests will be done immediately to
. determine extent and severity of damage.
ANS: C
The extent and severity of damage cannot be determined initially.
The immediate loss of function is caused by anatomic and impaired
physiologic function, and improvement may not be evident for
weeks or months. It is essential to provide information about the
adolescents status to the parents. Immediate treatment information
should be provided. Long-term rehabilitation and prognosis can be
addressed after the child is stabilized. During the immediate
postinjury period, physiologic responses to the injury make an
accurate assessment of damage difficult.
17. A 14-year-old girl is in the intensive care unit after a spinal cord
injury 2 days ago. What nursing intervention is a priority for this
child?
a
. Minimizing environmental stimuli
b
. Administering immunoglobulin
c
. Monitoring and maintaining systemic blood pressure
d
. Discussing long-term care issues with the family
ANS: C
Spinal cord injury patients are physiologically labile, and close
monitoring is required. They may be unstable for the first few weeks
after the injury. Increased blood pressure may be an indication of
autonomic dysreflexia. It is not necessary to minimize environmental
stimuli for this type of injury. Spinal cord injury is not an infectious
process. Immunoglobulin is not indicated. Discussing long-term care
issues with the family is inappropriate. The family is focusing on the
recovery of their child. It will not be known until the rehabilitation
period how much function the child may recover.
Integrity
18. What functional ability should the nurse expect in a child with a
spinal cord lesion at C7?
a
. Complete respiratory paralysis
b
. No voluntary function of upper extremities
c
. Inability to roll over or attain sitting position
d Almost complete independence within limitations of
. wheelchair
ANS: D
Individuals who sustain injuries at the C7 level are able to achieve a
significant level of independence. Some assistance is needed with
transfers and lower extremity dressing. Patients are able to roll over
in bed and to sit and eat independently. Patients with injuries at C3
or higher have complete respiratory paralysis. Those with injuries at
C4 or higher do not have voluntary function of higher extremities.
Injuries at C5 or higher prevent rolling over or sitting.
19. An adolescent with a spinal cord injury is admitted to a
rehabilitation center. Her parents describe her as being angry,
hostile, and uncooperative. The nurse should recognize that this is
suggestive of which psychosocial state?
a
. Normal phase of adolescent development
b
. Severe depression that will require long-term counseling
c Normal response to her situation that can be redirected
. in a healthy way
d Denial response to her situation that makes
. rehabilitative efforts more difficult
ANS: C
During the rehabilitation phase, it is desirable for adolescents to
begin to express negative feelings toward the situation. The
rehabilitation team can redirect the negative energy toward learning
a new way of life. The injury has interrupted the normal adolescent
process of achieving independence, triggering these negative
behaviors. Severe depression can occur, but it indicates that the
child is no longer in denial. Long-term therapy is not indicated. Being
angry, hostile, and uncooperative are behaviors that are indications
that the adolescent understands the severity of the injury and need
for rehabilitation.
20. What statement best describes Duchenne (pseudohypertrophic)
muscular dystrophy (DMD)?
a
. It has an autosomal dominant inheritance pattern.
b
. Onset occurs in later childhood and adolescence.
c It is characterized by presence of Gower sign, a
. waddling gait, and lordosis.
d Disease stabilizes during adolescence, allowing for life
. expectancy to approximately age 40 years.
ANS: C
DMD is characterized by a waddling gait and lordosis. Gower sign is
a characteristic way of rising from a squatting or sitting position on
the floor. DMD is inherited as an X-linked recessive gene. Genetic
counseling is recommended for parents, female siblings, maternal
aunts, and their female offspring. Onset occurs usually between
ages 3 and 5 years. DMD has a progressive and relentless loss of
muscle function until death by respiratory or cardiac failure.
21. The nurse is preparing a staff education in-service session for a
group of new graduate nurses who will be working in a long-term
care facility for children; many of the children have cerebral palsy
(CP). What statement should the nurse include in the training?
a Children with dyskinetic CP have a wide-based gait and

. repetitive movements.
b Children with spastic pyramidal CP have a positive
. Babinski sign and ankle clonus.
c Children with hemiplegia CP have mouth muscles and
. one lower limb affected.
d Children with ataxic CP have involvement of pharyngeal
. and oral muscles with dysarthria.
ANS: B
CP has a variety of clinical classifications. Spastic pyramidal CP
includes manifestations such as a positive Babinski sign and ankle
clonus; ataxic CP has a wide-based gait and repetitive movements;
hemiplegia CP is characterized by motor dysfunction on one side of
the body with upper extremity more affected than lower limbs; and
dyskinetic CP involves the pharyngeal and oral muscles, causing
drooling and dysarthria.
22. The nurse should suspect a child has cerebral palsy (CP) if the
parent says what?
a
. My 6-month-old baby is rolling from back to prone now.
b
. My 4-month-old doesnt lift his head when on his tummy.
c
. My 8-month-old can sit without support.
d
. My 10-month-old is not walking.
ANS: B
Delayed gross motor development is a universal manifestation of CP.
The child shows a delay in all motor accomplishments, and the
discrepancy between motor ability and expected achievement tends
to increase with successive developmental milestones as growth
advances. The infant who does not lift his head when on the tummy
is showing a gross motor delay, as that is seen at 0 to 3 months. The
other statements are within normal growth and development
expectations.
DIF: Cognitive Level: Analyzing REF: p. 1619 TOP: Nursing Process: Evaluation
23. The nurse is caring for a 4-year-old child with cerebral palsy (CP).
The child, developmentally, is at an infant stage. Appropriate
developmental stimulation for this child should be what?
a
. Playing pat-a-cake with the child
b
. None so the child does not become overstimulated
c
. Putting a colorful mobile with music on the bed
d
. Giving the child a coloring book and crayons
ANS: C
Incorporating play into the therapeutic program for a child with CP
often requires great ingenuity and inventiveness from those
involved in the childs care. Objects and toys are chosen for the
childs developmental stage to provide needed sensory input using a
variety of shapes, forms, and textures. Nurses can help parents
integrate therapy into play activities in natural ways.
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion
and Maintenance
24. A recommendation to prevent neural tube defects (NTDs) is the
supplementation of what?
a
. Vitamin A throughout pregnancy
b
. Folic acid for all women of childbearing age
c Folic acid during the first and second trimesters of
. pregnancy
d Multivitamin preparations as soon as pregnancy is
. suspected
ANS: B
The widespread use of folic acid among women of childbearing age
has decreased the incidence NTDs. In the United States, the rates of
NTDs have declined from 1.3 per 1000 births in 1990 to 0.3 per
1000 after the introduction of mandatory folic acid supplementation
in food in 1998. Vitamin A is not related to the prevention of NTDs.
Folic acid supplementation is recommended for the preconceptual
period, as well as during the pregnancy. The NTD is a failure of
neural tube closure during early development, the first 3 to 5 weeks.
Integrity
25. The nurse is caring for a family whose infant was just born with
anencephaly. What is the most important nursing intervention?
a Implement measures to facilitate the attachment

. process.
b Help the family cope with the birth of an infant with a
. fatal defect.
c Prepare the family for extensive surgical procedures
. that will be needed.
d Provide emotional support so the family can adjust to
. the birth of an infant with problems.
ANS: B
Anencephaly is the most serious neural tube defect. The infants
have an intact brainstem and, if born alive, may be able to maintain
vital functions for a few hours to several weeks. The family requires
emotional support and counseling to cope with the birth of an infant
with a fatal defect. The parents should be encouraged to hold their
infant and provide comfort measures. This facilitates the grieving
process because the infant has a limited life expectancy. Infants with
anencephaly do not have cerebral hemispheres. There is no surgical
correction available for this defect. Emotional support is needed as
the family adjusts to the birth of a child who has a fatal defect.
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial
Integrity
26. What refers to a hernial protrusion of a saclike cyst of meninges,
spinal fluid, and a portion of the spinal cord with its nerves through a
defect in the vertebral column?
a
. Rachischisis
b
. Meningocele
c
. Encephalocele
d
. Myelomeningocele
ANS: D
A myelomeningocele has a visible defect with an external saclike
protrusion, containing meninges, spinal fluid, and nerves.
Rachischisis is a fissure in the spinal column that leaves the
meninges and the spinal cord exposed. Meningocele is a hernial
protrusion of a saclike cyst of meninges with spinal fluid but no
neural elements. Encephalocele is a herniation of brain and
meninges through a defect in the skull, producing a fluid-filled sac.
27. A woman who is 6 weeks pregnant tells the nurse that she is
worried that, even though she is taking folic acid supplements, the
baby might have spina bifida because of a family history. The nurses
response should be based on what?
a
. Prenatal detection is not possible yet.
b
. There is no genetic basis for the defect.
c Chromosome studies done on amniotic fluid can
. diagnose the defect prenatally.
d Open neural tube defects (NTDs) result in elevated
. concentrations of a-fetoprotein in amniotic fluid.
ANS: D
Ultrasound scanning and measurement of a-fetoprotein may
indicate the presence of anencephaly or myelomeningocele. The
optimum time for performing this analyzing is between 16 and 18
weeks. Prenatal diagnosis is possible through amniocentesis. A
multifactorial origin is suspected, including drugs, radiation,
maternal malnutrition, chemicals, and possibly a genetic mutation.
Chromosome abnormalities are not present in NTDs.
28. The most important nursing intervention when caring for an
infant with myelomeningocele in the preoperative stage is which?
a
. Take vital signs every hour.
b Place the infant on the side to decrease pressure on the
. spinal sac.
c Watch for signs that might indicate developing
. hydrocephalus.
d Apply a heat lamp to facilitate drying and toughening of
. the sac.
ANS: B
The spinal sac is protected from damage until surgery is performed.
Early surgical closure is recommended to prevent local trauma and
infection. Monitoring vital signs and watching for signs that might
indicate developing hydrocephalus are important interventions, but
preventing trauma to the sac is a priority. The sac is kept moist until
surgical intervention is done.
29. Neuropathic bladder disorders are common among children with
which disorder?
a
. Plagiocephaly
b
. Meningocele
c Craniosynostosis
.
d
. Myelomeningocele
ANS: D
Myelomeningocele is one of the most common causes of
neuropathic bladder dysfunction among children. Plagiocephaly is
the flattening of a side of the childs head. This is not associated with
neuropathic bladder. Children with meningocele usually do not have
neuropathic bladder. Craniosynostosis is the premature closure of
one or more cranial sutures. It is not associated with neuropathic
bladder.
DIF: Cognitive Level: Understanding REF: p. 1635 TOP: Nursing Process:
Planning
30. What most accurately describes bowel function in children born
with a myelomeningocele?
a
. Incontinence cannot be prevented.
b
. Enemas and laxatives are contraindicated.
c Some degree of fecal continence can usually be
. achieved.
d Colostomy is usually required by the time the child
. reaches adolescence.
ANS: C
With a combination of dietary modification, regular toilet habits, and
prevention of constipation and impaction, some degree of fecal
continence can usually be achieved. Incontinence can be minimized
with the development of a regular bowel training program. A
surgical intervention can assist with continence. Enemas and
laxatives are part of a bowel training program. Colostomies are not
indicated in children with myelomeningocele.
DIF: Cognitive Level: Understanding REF: p. 1637 TOP: Nursing Process:
Planning
31. The nurse is caring for a neonate born with a myelomeningocele.
Surgery to repair the defect is scheduled the next day. What is the
most appropriate way to position and feed this neonate?
a
. Prone with the head turned to the side
b
. On the side
c
. Supine in an infant carrier
d
. Supine, with defect supported with rolled blankets
ANS: A
The prone position with the head turned to the side for feeding is
the optimum position for the infant. It protects the spinal sac and
allows the infant to be fed without trauma. The side-lying position is
avoided preoperatively. It can place tension on the sac and affect hip
dysplasia if present. The infant should not be placed in a supine
position.
32. A goal for children with spina bifida is to reduce the chance of
allergy development. What is a priority nursing intervention?
a
. Recommend allergy testing.
b
. Provide a latex-free environment.
c
. Use only powder-free latex gloves.
d
. Limit use of latex products as much as possible.
ANS: B
A latex-free environment is the goal. This includes eliminating the
use of latex gloves and other medical devices containing latex.
Allergy testing would provide information about whether the allergy
has developed. It will not reduce the chances of developing the
allergy. Although powder-free latex gloves are less allergenic, latex
should not be used. Limiting the use of latex products is one
component of providing a latex-free environment, but latex products
should not be used.
33. When a child develops latex allergy, which food may also cause
an allergic reaction?
a
. Yeast
b
. Wheat
c
. Peanuts
d
. Bananas
ANS: D
There are cross-reactions between allergies to latex and to a number
of foods such as bananas, avocados, kiwi, and chestnuts. Although
yeast, wheat, and peanuts are potential allergens, currently they are
not known to cross-react with latex allergy.
DIF: Cognitive Level: Analyzing REF: p. 1640 TOP: Nursing Process: Planning
34. The clinic nurse is assessing infant reflexes. What assessment
indicates a persistence of primitive reflexes?
a
. Tonic neck reflex at 8 months of age
b
. Palmar grasp at 4 months of age
c
. Plantar grasp at 9 months of age
d Rooting reflex at 3 months of age
.
ANS: A
Persistence of primitive reflexes is one of the earliest clues to CP
(e.g., obligatory tonic neck reflex at any age or nonobligatory
persistence beyond 6 months of age and the persistence or even
hyperactivity of the Moro, plantar, and palmar grasp reflexes). The
palmar grasp disappears by 6 months, the plantar grasp disappears
by 12 months, and the rooting reflex disappears at 4 months, so
these are normal findings.
35. A toddler with spastic cerebral palsy needs to be transported to
the radiology department. What transportation method should the
nurse use to take the toddler to the radiology department?
a
. A stretcher
b
. A wheelchair
c
. A wagon with pillows
d
. Carried in the nurses arms
ANS: C
A wagon with pillows would support the child with spastic cerebral
palsy better than a stretcher or wheelchair. A wagon would give the
child a wheelchair experience, so the nurse should not carry the
child.
Integrity
36. What is the rationale for orthopedic surgery for a child with
cerebral palsy?
a To cure spasticity
.
b
. To improve function
c
. For cosmetic purposes
d
. To prevent the need of physical therapy
ANS: B
Orthopedic surgery is used primarily to improve function rather than
for cosmetic purposes and is followed by physical therapy. It will not
cure spasticity.
37. A feeding technique the nurse can teach to parents of a child
with cerebral palsy to improve use of the lips and the tongue to
facilitate speech is which?
a
. Feeding pureed foods
b
. Placing food on the tongue
c
. Placing food at the side of the tongue
d
. Placing food directly into the mouth with a spoon
ANS: C
Feeding techniques such as forcing the child to use the lips and
tongue in eating facilitate speech. An example of this technique is
placing food at the side of the tongue, first one side and then the
other, and making the child use the lips to take food from a spoon
rather than placing it directly on the tongue. Feeding pureed foods
would not encourage use of the lips and tongue.
MSC: Client Needs: Health Promotion and Maintenance
38. The nurse is teaching the family of an infant with cerebral palsy
how to administer a diazepam (Valium) pill by gastrostomy tube.
What should the nurse include in the teaching session?
a The pill should be crushed and mixed with a small

. amount of water.
b The pill should be crushed and mixed with the infants
. formula.
c After administering the medication, flush the tube with
. air.
d Before administering the medication, check the
. placement of the tube.
ANS: A
Pills may be crushed and mixed with small amounts of water but not
other liquids, such as formula or elixir medications, because these
may act together to form a sludge that can interfere with
gastrostomy tube function. When crushed pills or tablets are
administered, flush the feeding tube with more water after instilling
the dissolved pill in water. The tube should not be flushed with air,
and placement does not need to be checked because it is directly
into the stomach.
39. The nurse is caring for a child with tetanus during the acute
phase. What should the nurse plan in the care for this child?
a
. Playing music on a radio
b
. Giving frequent back rubs
c
. Providing bright lighting in the room
d
. Clustering nursing care to limit distractions
ANS: D
In caring for a child with tetanus during the acute phase, every
effort should be made to control or eliminate stimulation from
sound, light, and touch. Although a darkened room is ideal, sufficient
light is essential so that the child can be carefully observed; light
appears to be less irritating than vibratory or auditory stimuli. The
infant or child is handled as little as possible, and extra effort is
expended to avoid any sudden or loud noise to prevent seizures.
Integrity
40. A mother tells the clinic nurse that she often puts honey on her
infants pacifier to soothe the infant. What response should the nurse
make to the mother?
a
. That is a good way to soothe your baby.
b
. Honey does not have any soothing effects.
c
. There is still a risk for infant botulism from honey.
d
. Honey is OK, but it should not be put on the pacifier.
ANS: C
Although the precise source of Clostridium botulinum spores has not
been identified as originating from honey in many cases of infant
botulism in the United States, it is still recommended that honey not
be given to infants younger than 12 months because the spores
have been found in honey.
41. The nurse is caring for a child with myasthenia gravis (MG). What
health care prescription should the nurse verify before
administering?
a
. Ceftizoxime (Cefizox)
b
. Cefotaxime (Claforan)
c
. Ceftriaxone (Rocephin)
d
. Garamycin (gentamicin)
ANS: D
Avoid aminoglycoside antibiotics such as gentamicin because they
potentiate MG symptoms. Cefizox, Claforan, and Rocephin are
cephalosporin antibiotics.
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. What findings should the nurse expect to observe in a 7-month-
old infant with Werdnig-Hoffman disease? (Select all that apply.)
a
. Noticeable scoliosis
b
. Absent deep tendon reflexes
c
. Abnormal tongue movements
d
. Failure to thrive
e
. Prominent pectus excavatum
f. Significant leg involvement
ANS: B, C, D
Clinical manifestations of Werdnig-Hoffman disease in an infant
include absent deep tendon reflexes, abnormal tongue movements,
and failure to thrive. Scoliosis, prominent pectus excavatum, and
significant leg involvement are findings observed in a child with
intermediate spinal muscular atrophy.
2. The nurse is teaching the family with a child with cerebral palsy
(CP) strategies to prevent constipation. What should the nurse
include in the teaching session? (Select all that apply.)
a
. Increase fluid intake.
b
. Increase fiber in the diet.
c
. Administer stool softeners daily as prescribed.
d
. Increase the amount of dairy products in the diet.
e Allow the child to decide when to try to have a bowel
. movement.
ANS: A, B, C
A variety of factors, including decreased mobility, decreased fluid
intake, a fear of toileting, poor positioning on the toilet, and lack of
fiber intake may be responsible for constipation for a child with CP.
Stool softeners, laxatives, and a bowel management program may
be required to prevent chronic constipation. The child should be
placed on the toilet or encouraged to have a bowel movement at the
same time each day. Dairy products can cause constipation.
3. What functional goal should the nurse expect for a child who has a
C7 spinal cord injury?(Select all that apply.)
a
. Able to drive automobile with hand controls
b Complete independence within limitations of a
. wheelchair
c Can roll over in bed, sit up in bed, and eat
. independently
d Requires some assistance in transfer and lower
. extremity dressing
e Ambulation with bilateral long braces using four-point or
. swing-through crutch gait
ANS: B, C, D
A child with a C7 spinal cord injury can expect to be completely
independent within the limitations of a wheelchair, can roll over in
bed, sit up in bed, and eat independently, and will require some
assistance in transfer and lower extremity dressing. The ability to
drive an automobile with hand controls is a functional goal for a T1
to T10 spinal cord injury. Ambulation with bilateral long braces using
four-point or swing-through crutch gait is a functional goal for a T10
to L2 injury.
4. What functional goal should the nurse expect for a child who has a
T1 to T10 spinal cord injury? (Select all that apply.)
a
. May be braced for standing
b
. Able to drive automobile with hand controls
c
. Can manage adapted public transportation
d
. Some able to use regular public transportation
e Ambulates well, often with short leg braces with or
. without cane
ANS: A, B, C
A child with a T1 to T10 spinal cord injury may be braced for
standing, is able to drive an automobile with hand controls, and can
manage adapted public transportation. The ability to use regular
public transportation and ambulation with bilateral long braces
using four-point or swing-through crutch gait are functional goals for
individuals with a T10 to L2 injury.
5. The nurse is preparing to admit a 7-year-old child with ataxic
cerebral palsy. What clinical manifestations of ataxic cerebral palsy
should the nurse expect to observe? (Select all that apply.)
a
. Wide-based gait
b
. Rapid, repetitive movements performed poorly
c
. Slow, twisting movements of the trunk or extremities
d Hypertonicity with poor control of posture, balance, and
. coordinated motion
e Disintegration of movements of the upper extremities
. when the child reaches for objects
ANS: A, B, E
Clinical manifestations of ataxic cerebral palsy include a wide-based
gait; rapid, repetitive movements performed poorly; and
disintegration of movements of the upper extremities when the child
reaches for objects. Slow, twisting movements of the trunk are seen
with dyskinetic cerebral palsy, and hypertonicity with poor control of
posture, balance, and coordinated motion are seen with spastic
cerebral palsy.
6. What are some of the associated disabilities seen with cerebral
palsy? (Select all that apply.)
a
. Visual impairment
b
. Hearing impairment
c
. Speech difficulties
d Intellectual impairment
.
e
. Associated heart defects
ANS: A, B, C, D
Some of the disabilities associated with CP are visual impairment,
hearing impairment, behavioral problems, communication and
speech difficulties, seizures, and intellectual impairment. Additional
sensory deficits such as hypersensitivity, hyposensitivity, and
balance difficulties may occur in children with CP.
7. The nurse is preparing to admit a 5-year-old with spina bifida
cystica that was below the second lumbar vertebra. What clinical
manifestations of spina bifida cystica below the second lumbar
vertebra should the nurse expect to observe? (Select all that apply.)
a
. No motor impairment
b
. Lack of bowel control
c
. Soft, subcutaneous lipomas
d
. Flaccid, partial paralysis of lower extremities
e
. Overflow incontinence with constant dribbling of urine
ANS: B, D, E
The clinical manifestations of spina bifida cystica below the second
lumbar vertebra include lack of bowel control, flaccid, partial
paralysis of lower extremities, and overflow incontinence with
constant dribbling of urine. No motor impairment occurs with spina
bifida cystica that was below the third lumbar vertebra, and soft,
subcutaneous lipomas occur with spina bifida occulta.
8. The nurse is preparing to admit a 2-year-old child with spina bifida
occulta. What clinical manifestations of spina bifida occulta should
the nurse expect to observe? (Select all that apply.)
a
. Dark tufts of hair
b
. Skin depression or dimple
c
. Port-wine angiomatous nevi
d
. Soft, subcutaneous lipomas
e
. Bladder and sphincter paralysis
ANS: A, B, C, D
Clinical manifestations of spina bifida occulta include dark tufts of
hair; skin depression or dimple; port-wine angiomatous nevi; and
soft, subcutaneous lipomas. Bladder and sphincter paralysis are
present with spina bifida cystica but not occulta.
9. The nurse is preparing to admit a 5-year-old child with a lower
motor neuron syndrome. What clinical manifestations of a lower
motor neuron syndrome should the nurse expect to observe? (Select
all that apply.)
a
. Loss of hair
b
. Babinski reflex present
c
. Skin and tissue changes
d
. Marked atrophy of atonic muscle
e
. Hyperreflexia with tendon reflexes exaggerated
ANS: A, C, D
Clinical manifestations of a lower motor neuron syndrome include
loss of hair, skin and tissue changes, and marked atrophy of atonic
muscle. Babinski reflex present and hyperreflexia with tendon
reflexes exaggerated are manifestations of an upper motor neuron
syndrome.
10. The nurse is preparing to admit a 7-year-old child with an upper
motor neuron syndrome. What clinical manifestations of an upper
motor neuron syndrome should the nurse expect to observe? (Select
all that apply.)
a
. No flexor spasms
b
. Babinski reflex present
c
. No wasting of muscle mass
d
. Marked atrophy of atonic muscle
e
. Hyperreflexia with tendon reflexes exaggerated
ANS: B, C, E
Clinical manifestations of an upper motor neuron syndrome include
Babinski reflex present, no wasting of muscle mass, and
hyperreflexia with tendon reflexes exaggerated. No flexor spasms
and marked atrophy of atonic muscle are manifestations of a lower
motor neuron syndrome.
11. The nurse is preparing to admit a 10-year-old child with
Duchenne muscular dystrophy. What clinical features of Duchenne
muscular dystrophy should the nurse recognize? (Select all that
apply.)
a
. Calf muscle hypertrophy
b
. Late onset, usually between 6 and 8 years of age
c Progressive muscular weakness, wasting, and
. contractures
d
. Loss of independent ambulation by 9 to 12 years of age
e Slowly progressive, generalized weakness during
. adolescence
ANS: A, C, D, E
Clinical features of Duchenne muscular dystrophy include calf
muscle hypertrophy; progressive muscular weakness; wasting and
contractures; loss of independent ambulation by 9 to 12 years of
age; and slowly progressive, generalized weakness during
adolescence. The onset is early, not late, usually between 3 and 5
years of age.
COMPLETION
1. The health care provider has prescribed dantrolene sodium
(Dantrium) 0.5 mg/kg PO once a day for a child with cerebral palsy.
The child weighs 55 lb. Calculate the dose the nurse should
administer in milligrams. Record your answer below using one
decimal place.
________
ANS:
12.5
The correct calculation is:
55 lb/2.2 kg = 25 kg
Dose of Dantrium is 0.5 mg/kg given once a day
0.5 mg 25 = 12.5 mg
Integrity
2. The health care provider has prescribed diazepam (Valium) 0.8
mg/kg/day PO divided q 6 hours for a child with cerebral palsy. The
child weighs 110 lb. The nurse is preparing to administer the 1200
dose. Calculate the dose the nurse should administer in milligrams.
Record your answer below in a whole number.
_______
ANS:
10
110 lb/2.2 kg = 50 kg
Dose of Valium is 30 mg/kg/day divided q 6 hours
0.8 mg 50 = 40 mg/day
40 mg/4 = 10 mg for one dose
Integrity
3. The health care provider has prescribed neostigmine (Prostigmin)
0.04 mg/kg/per dose SC q 4 to 6 hrs PRN for a child with myasthenia
gravis. The child weighs 77 lb. The nurse is preparing to administer
a dose. Calculate the dose the nurse should administer in
milligrams. Record your answer below using one decimal place.
________
ANS:
1.4
77 lb/2.2 kg = 35 kg
Dose of Prostigmin is 0.04 mg/kg/dose
0.04 mg 35 = 1.4 mg
Integrity
4. The health care provider has prescribed oxybutynin (Ditropan) 0.2
mg/kg/day divided bid for a child with myelomeningocele. The child
weighs 33 lb. The nurse is preparing to administer the 0900 dose.
Calculate the dose the nurse should administer in milligrams. Record
your answer below using one decimal place.
_______
ANS:
1.5
33 lb/2.2 kg = 15 kg
Dose of Ditropan is 0.2 mg/kg/day divided bid
0.2 mg 15 = 3 mg
3 mg/2 = 1.5 mg
Integrity
5. The health care provider has prescribed gabapentin (Neurontin)
30 mg/kg/day divided q 8 hours for a child with cerebral palsy
having seizures. The child weighs 110 lb. The nurse is preparing to
administer the 1200 dose. Calculate the dose the nurse should
administer in milligrams. Record your answer below in a whole
number.
_________
ANS:
500
110 lb/2.2 kg = 50 kg
Dose of Neurontin is 30 mg/kg/day divided every 8 hours
30 mg 50 = 1500 mg/day
Integrity
6. The health care provider has prescribed valproic acid (Depakene)
30 mg/kg/day divided bid for a child with cerebral palsy having
seizures. The child weighs 22 lb. The nurse is preparing to
number.
__________
ANS:
165
22 lb/2.2 kg = 11 kg
Dose of Depakene is 30 mg/kg/day divided bid
30 mg 11 = 330 mg
Integrity
7. The health care provider has prescribed carbamazepine (Tegretol)
20 mg/kg/day divided bid for a child with cerebral palsy having
seizures. The child weighs 44 lb. The nurse is preparing to
number.
_________
ANS:
200
44 lb/2.2 kg = 20 kg
Dose of Tegretol is 20 mg/kg/day divided bid
20 mg 20 = 400 mg
400 mg/2 = 200 mg
Integrity

Child with Neuromuscular Dysfunction

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Child with Neuromuscular Dysfunction

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Chapter 35: The Child with Neuromuscular or Muscular

a Affected children have some degree of cognitive

a Bottle or tube feed him a specialized formula until he

a Most activities such as Girl Scouts cannot be adapted

a Inflammatory disease that causes extreme, localized

a Tetanus toxoid booster is needed because of the type of

a Families adjust better to life-threatening injuries when

a Children with dyskinetic CP have a wide-based gait and

a Implement measures to facilitate the attachment

a The pill should be crushed and mixed with a small

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