Chapter 46: Neurologic Disorders

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. When performing a neurologic exam to assess for meningeal signs in an infant, the primary
care pediatric nurse practitioner will attempt to elicit the Kernig sign by implementing what
action?
a. bending the infant at the waist to touch fingers to toes.
b. extending the leg at the knee with the infant supine.
c. flexing the infant’s neck to touch chin to chest.
d. turning the infant’s head from side to side.
ANS: B
In an infant, the Kernig sign is elicited by extending the leg at the knee with the infant in a
supine position while observing for facial grimacing. Older children can bend at the waist to
touch the toes to elicit the Kernig sign. The Brudzinski sign is elicited by passively flexing the
neck to cause the patient to spontaneously flex the hip and knees. Turning the infant’s head
from side to side is not done to elicit either sign.

2. To evaluate brain tissue disorders in infants, which test is useful?

a. Computerized tomography
b. Head radiographs
c. Magnetic resonance imaging
d. Ultrasonography
ANS: D
Ultrasonography is used to evaluate brain tissue in infants. CT scans expose patients to high
levels of radiation, so they are not used unless indicated. Radiographs have relatively
diagnostic value for the neurologic system. Magnetic resonance imaging is useful but is
expensive and usually requires sedation.

3. A female infant who was developing normally stops meeting developmental milestones at age
12 months and then begins losing previously acquired skills. What will the primary care
pediatric nurse practitioner expect to tell the parents about this child’s prognosis?
a. Cognitive development will be normal but motor skills will be lost.
b. Physical and speech therapy will help the infant regain lost skills.
c. The child’s intellectual development will not progress further.
d. This is a temporary condition with full recovery expected.
ANS: C
This child has symptoms of Rett syndrome, which affects females more than males and is
characterized by a plateau of development with eventual loss of milestones. Intellectual
development remains at the level of plateau. Physical therapy, occupational therapy, and
speech therapy help to preserve functional abilities but do not improve skills. The condition is
progressive, with variable life expectancy.
4. A 14-year-old child has a headache, unilateral weakness, and blurred vision preceded by fever
and nausea. The child’s parent reports a similar episode several months prior. The primary
care pediatric nurse practitioner will consult with a pediatric neurologist to order what
diagnostic test?
a. a lumbar puncture.
b. an electroencephalogram (EEG).
c. neuroimaging with magnetic resonance imaging (MRI).
d. positron emission tomography (PET) scan.
ANS: C
Children who have MS exhibit the symptoms described above and are usually diagnosed with
a gadolinium enhanced MRI. Lumbar puncture may be performed later to identify oligoclonal
bands. An EEG is used to diagnose seizure activity. PET scans are used to detect tumors.

5. The pediatric nurse practitioner provides primary care for a 5-year-old child diagnosed with
cerebral palsy who exhibits athetosis and poor weight gain in spite of receiving high-calorie
formula to supplement intake. The child has had several episodes of pneumonia in the past
year. Which specialty consultation is a priority for this child?
a. Feeding clinic to manage caloric intake
b. Neurology to assess medication needs
c. Pulmonology for possible tracheotomy
d. Surgery for possible fundoplication and gastrostomy
ANS: D
Children with CP who have athetosis often have increased calorie needs up to 50% to 100%
higher than others. This child is unable to gain adequate weight in spite of receiving extra
calories. The child also has possible aspiration pneumonia, probably due to difficulty
swallowing or GERD. A fundoplication and gastrostomy can help to prevent GERD and to
provide nutrition that doesn’t involve swallowing. The feeding clinic would increase calories
and nutrients but, without a gastrostomy, cannot increase actual intake. The child is not having
seizures or drooling that contribute to this problem, so medications aren’t necessary. Unless
there is an airway problem, tracheotomy is not indicated.

6. Because of their inability to ambulate, children with cerebral palsy should be evaluated for
which nutrients?
a. Calcium and vitamin D
b. Fat-soluble vitamins
c. Iron and zinc
d. Sodium and potassium
ANS: A
Children who do not place weight on their bones are at risk for osteopenia and should have
vitamin D and calcium levels monitored and supplemented if indicated.

7. A child with a recent history of URI reports tingling and pain in one ear followed by sagging
of one side of the face. The primary care pediatric nurse practitioner observes that the child
cannot close the eye or mouth on the affected side but does not elicit limb weakness on that
side. What will the nurse practitioner do?
a. Initiate a short course of antibiotic therapy.
b. Perform diagnostic testing to rule out serious causes.
c. Prepare the parents for lifelong complications.
 d. Prescribe oral prednisone 1 mg/kg/day initially.
ANS: D
This child has symptoms and a history consistent with Bell’s palsy. Oral prednisone is given to
reduce inflammation causing paralysis for 1 week with a 1 week taper. Antibiotics are not
indicated, since a viral illness often precipitates symptoms. Diagnostic testing is not indicated
unless symptoms persist longer than 6 weeks or if other neurologic symptoms occur.
Approximately 85% of children recover completely without facial weakness.

8. A child who has had a single non-febrile seizure has a normal neurologic exam. Which
diagnostic test is indicated?
a. Computerized tomography (CT)
b. Electroencephalogram (EEG)
c. Magnetic resonance imaging (MRI)
d. Polysomnography
ANS: B
An EEG is standard for all children after a first non-febrile seizure. CT is not routinely used
because of radiation exposure. MRI is used if cognitive changes or postictal focal dysfunction
persists, if the seizure lasts longer than 15 minutes, if the child is younger than 6 months of
age, and if any new onset of focal neurologic deficit has occurred. Polysomnography is used
to assess nocturnal seizures.

9. The parents of an 18-month-old child bring the child to the clinic after observing a brief
seizure of less than 2 minutes in their child. In the clinic, the child has a temperature of
103.1°F, and the primary care pediatric nurse practitioner notes a left otitis media. The child is
alert and responding normally. What will the nurse practitioner do?
a. Order a lumbar puncture, complete blood count, and urinalysis.
b. Prescribe an antibiotic for the ear infection and reassure the parents.
c. Refer to a pediatric neurologist for anticonvulsant and antipyretic prophylaxis.
d. Send the child to the emergency department for EEG and possible MRI.
ANS: B
This child has symptoms of a simple febrile seizure with a focal site of infection and an
otherwise normal exam. While this is very frightening to the family, the PNP should treat the
infection and provide reassurance to the parents. Lumbar puncture may be performed in
infants younger than 12 months. Prophylactic medications aren’t indicated for febrile seizures.
Antipyretics aren’t useful, since most seizures occur when the temperature is either rising or
falling. EEG and MRI are not indicated when focal neurological signs are not present.

10. An adolescent female reports unilateral headache pain associated with abdominal pain and
nausea occurring just prior to periods each month. The adolescent has been using naproxen
sodium for 6 months but reports little relief from symptoms. What will the primary care
pediatric nurse practitioner do?
a. Add acetaminophen and ondansetron to the naproxen regimen.
b. Consider prophylactic therapy with a beta-blocker or anticonvulsant drug.
c. Prescribe sumatriptan nasal spray at the onset of headache and every 2 hours.
d. Refer the adolescent to a pediatric neurologist for neuroimaging studies.
ANS: C
 When there is no response from analgesics, sumatriptan can be started as abortive therapy
using the nasal spray formulation. Adding acetaminophen and ondansetron is not indicated;
ondansetron is given when vomiting or severe nausea occurs. Prophylactic therapy is
indicated for unpredictable or frequent headaches or headaches severe enough to cause a child
to miss school. Neuroimaging studies are not used unless the history suggests increased
intracranial pressure.

11. A child who has sustained a head injury after falling on the playground is brought to the
clinic. The parents report that the child cried immediately and was able to walk around after
falling. The primary care pediatric nurse practitioner notes slight slurring of the child’s speech
and the child has vomited twice in the exam room. Which course of action is warranted?
a. Admit the child to the hospital for a neurology consult.
b. Observe the child in the clinic for several hours.
c. Order a head CT and observe the child at home.
d. Send the child home with instructions for follow-up.
ANS: A
Children with certain symptoms, such as vomiting or slurred speech after a head injury, should
be admitted to the hospital for neurologic consultation. If the child had not exhibited these
symptoms, any of the other options would be acceptable.

12. The primary care pediatric nurse practitioner performs a well baby exam on a term 4-month-
old infant and observes flattening of the left occiput, bossing of the right occiput, and anterior
displacement of the left ear. The parents report performing various positioning maneuvers, but
say that the baby’s head shape has worsened. What will the nurse practitioner recommend to
correct this finding?
a. Allow the infant to sleep on the tummy when the parents are in the room.
b. Lay the infant in the “back to sleep” position, alternating the left and right occiput.
c. Order a head CT to evaluate the infant for craniosynostosis.
d. Refer the infant for orthotic cranial molding helmet therapy.
ANS: D
This infant was term and likely has positional plagiocephaly, which has not responded to
repositioning efforts, so a referral should be made for an orthotic helmet. Tummy time is
performed when the infant is awake and the parents are present. The “back to sleep” position
with alternation of left and right is a repositioning maneuver. Craniosynostosis is
characterized by bossing and deformity that follow cranial suture lines.

13. A 4-year-old child who has previously met developmental milestones is not toiled trained. The
primary care pediatric nurse practitioner notes decreased reflexes in the lower extremities and
observe a dimple above the gluteal cleft. Which diagnosis may be considered for this child?
a. Arnold-Chiari malformation
b. Reye syndrome
c. Spina bifida cystica
d. Tethered cord
ANS: D
Tethered cord occurs when the caudal end of the spinal cord, causing abnormal stretching and
damage to nerve cells, fibers, and blood vessels. This can cause symptoms of neurologic
deterioration such as incontinence of bladder and bowel and loss of reflexes and sensation in
the legs. Arnold-Chiari malformation involves a downward herniation of the caudal end of the
cerebellar vermis, which can cause brainstem and upper cervical cord compression. Reye
syndrome involves swelling in the brain and signs of increased intracranial pressure. Spina
bifida cystica is a myelomeningocele, with symptoms present at birth.