The nurse is caring for an 11 year old child with moderate mixed spastic and athetoid Cerebral Palsy. Identify which findings are expected?
writhing movements and spasticity
flat nose with upward slanting eyes
persistent primitive reflexes
increased head circumference and sundown sign
feeding problems
Fever and increased WBC
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
Cerebral palsy is a nonprogressive neurological motor disorder caused by prenatal or perinatal brain injury affecting movement, posture, and muscle coordination. Mixed spastic-athetoid forms present with hypertonia, involuntary movements, persistent primitive reflexes, dysphagia, and impaired motor control.
Rationale:
Writhing movements and spasticity are expected because mixed cerebral palsy combines spastic hypertonia with athetoid involuntary movements resulting from pyramidal and extrapyramidal motor pathway injury causing impaired coordinated movement.
Flat nose with upward slanting eyes is not expected because these are characteristic dysmorphic features associated with chromosomal disorders such as Down syndrome rather than neurological motor dysfunction seen in cerebral palsy.
Persistent primitive reflexes are expected due to impaired cortical inhibition from central nervous system injury, causing persistence of neonatal reflexes beyond the normal developmental period and interfering with voluntary motor control.
Increased head circumference and sundown sign are not expected because these findings indicate hydrocephalus with increased intracranial pressure rather than cerebral palsy, which is a nonprogressive motor disorder without progressive ventricular enlargement.
Feeding problems are expected because impaired oral-motor coordination and bulbar muscle dysfunction commonly produce dysphagia, poor sucking, aspiration risk, and nutritional difficulties in children with cerebral palsy.
Fever and increased WBC are not expected because they indicate systemic infection or inflammatory response rather than chronic neurological impairment associated with cerebral palsy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hydrocephalus is characterized by excess cerebrospinal fluid accumulation within the ventricular system due to impaired absorption, obstruction, or overproduction. In infants, open cranial sutures allow increased intracranial pressure to manifest as progressive head enlargement, bulging fontanelles, and ocular displacement known as “sunset eyes.”
Rationale:
A. Spina bifida is a neural tube defect involving incomplete closure of the spinal column and may coexist with hydrocephalus but is not itself an expected clinical finding associated with increased intracranial pressure in this presentation.
B. Low weight for age reflects failure to thrive or chronic malnutrition. It is not a defining feature of hydrocephalus, which primarily affects cranial volume and neurological status rather than systemic growth parameters.
C. Enlarged head circumference is a classic sign of progressive hydrocephalus in infants due to open sutures allowing skull expansion. This compensatory growth occurs as intracranial pressure increases from cerebrospinal fluid accumulation.
D. Poor skin turgor indicates dehydration, which is unrelated to cerebrospinal fluid accumulation or intracranial pressure changes. It reflects fluid loss rather than intracranial pathology.
Correct Answer is ["A","C","D","E"]
Explanation
Childhood immunization schedules are based on adaptive immune priming, booster dose timing, and age-specific antigen exposure responses. At 4 to 6 years, children receive booster vaccinations to reinforce waning immunity and ensure long-term protection against viral exanthems, bacterial toxins, and poliovirus infection before school entry.
Rationale:
A. MMR is administered as a second booster dose at 4 to 6 years to ensure sustained immunity against measles, mumps, and rubella. This reinforces memory B-cell response and prevents breakthrough infections during school exposure.
B. Hepatitis B series is typically completed in infancy with doses at birth, 1 to 2 months, and 6 to 18 months. No routine booster is required at 5 years unless the child is unimmunized or high-risk exposure.
C. Varicella vaccine requires a second dose at 4 to 6 years to improve seroconversion rates and long-term immunity against varicella-zoster virus, reducing risk of breakthrough chickenpox in school settings.
D. DTaP includes a preschool booster dose at 4 to 6 years to reinforce immunity against diphtheria, tetanus, and pertussis toxins, ensuring continued protection as antibody titers decline after primary series.
E. IPV (inactivated poliovirus vaccine) is given as a final booster dose at 4 to 6 years to maintain immunity against poliovirus and complete the primary immunization series before school entry requirements.
F. Hib vaccine series is completed in early childhood, typically by 15 to 18 months in healthy children. At 5 years, routine administration is not required unless the child has specific high-risk immunocompromised conditions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.