The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes are:
Symptomatic of decorticate posturing
Symptomatic of decerebrate posturing
Indicators of severe brain damage
Normal Findings
The Correct Answer is D
Reflexes play a crucial role in evaluating the neurological status of infants.
Moro reflex: Also known as the startle reflex, the Moro reflex is a normal response in infants. It occurs when an infant is startled by a sudden noise or movement. The baby responds by extending their arms and legs, followed by a quick contraction. This reflex usually disappears around 4-6 months of age.
Tonic neck reflex (fencer's reflex): This reflex involves turning an infant's head to one side, causing the arm on that side to extend and the opposite arm to flex. It's a normal reflex that typically disappears around 4-6 months of age.
Withdrawal reflex: The withdrawal reflex is a normal response to a stimulus, such as touching a baby's foot with a cold object. The baby will pull their leg away in response to the stimulus.
Symptomatic of decorticate or decerebrate posturing (options A and B):
Decorticate and decerebrate posturing are abnormal postures seen in individuals with severe brain damage or injury. Decorticate posturing involves the arms being flexed and held close to the body, while decerebrate posturing involves the arms being extended and the wrists being pronated. These reflexes are typically indicative of significant neurological dysfunction and are not expected in a 2-month-old infant after a car accident.
Indicators of severe brain damage (option C):
The reflexes described (Moro, tonic neck, and withdrawal reflexes) are not indicative of severe brain damage in a 2-month-old infant. These reflexes are normal for an infant of this age and are part of their typical neurological development.
Normal findings (option D):
The reflexes described are normal findings in a 2-month-old infant and are expected as part of their developmental milestones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistentBlood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms likefrequent urination, thirst, blurry vision, or fatigue) are concerning. The clientshould have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
Correct Answer is A
Explanation
A. Replacement therapy may require daily subcutaneous injections.
Explanation: Growth hormone deficiency (hypopituitarism) often requires treatment with growth hormone therapy. One common method of administering growth hormone is through daily subcutaneous injections. Subcutaneous injections involve injecting the medication under the skin into the fatty tissue. This is a routine part of growth hormone therapy, and nursing considerations would include educating the child and their family about proper injection techniques, site rotation, and adherence to the treatment schedule.
Explanation for the other choices:
B. Lifelong replacement therapy will be required:
This statement is generally true. Growth hormone deficiency often requires long-term treatment, which may extend throughout childhood and adolescence. However, in some cases, the need for growth hormone therapy might change based on the individual's response to treatment and growth patterns.
C. Treatment is most successful if started during adolescence:
The optimal timing for starting growth hormone therapy can vary depending on the specific circumstances and the underlying cause of growth hormone deficiency. While treatment during adolescence can be effective, growth hormone therapy can also be successful if started earlier in childhood or later in adolescence. The key is identifying and treating the deficiency as soon as possible to promote healthy growth.
D. Treatment is considered successful if children attain full stature by adulthood:
While growth hormone therapy aims to support growth, achieving "full stature" might not always be possible. The goal of treatment is to help the child reach a more typical height based on their genetic potential and individual response to therapy. The success of treatment is determined by improvements in growth velocity and height, rather than necessarily achieving "full stature," which can vary greatly among individuals.
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