CH 46, 49

The nurse is performing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. What is the most appropriate nursing assessment in this case? A. reactivity of pupils B. Doll's head maneuver C. oculovestibular response D. Funduscopic examination to identify papilledema

A. reactivity of pupils Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. Doll's head maneuver should not be performed if there is a cervical spine injury. Oculovestibular response is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness. pg 1356

The nurse is discussing long-term care with the parents of a child who has ventriculoperitoneal shunt to correct hydrocephalus. In the discussion, what should the nurse include? A. Parental protection is essential until the child reaches adulthood B. Cognitive impairment is to be expected with hydrocephalus C. Shunt malfunction or infection requires immediate treatment D. Most childhood activities must be restricted.

C. Shunt malfunction or infection requires immediate treatment Because the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the developmental age of the child. Cognitive impairment depends on the extent of damage before the shunt was placed. Except for contact sports, the child will have few restrictions. pg 1388

What aspects should the parents keep in mind when buying a wheelchair for their child with tetraplegia? Select all that apply. A. The child's preference B. The child's functional capacity C. Where the wheelchair is be used D. Weather conditions of the location E. The color and design of the wheelchair

B, C The child with tetraplegia needs a wheelchair for mobility. There are different types of costly wheelchairs available. However, to get the best wheelchair, it should be selected in relation to the child's functional capacity and where it will be used. The child's preference is inappropriate because it may not fit the child's functional capacity. The designs or color makes no difference in how quickly the child can adapt to the chair and freely move on it. Additionally, most wheelchairs usually last for several years, so it is not necessary to buy one based on weather conditions. pg 14850

Which type of skull fracture occurs when the bone is broken locally into several irregular fragments and results in a pressure on the brain? A. Linear B. Depressed C. Comminuted D. Basilar

B. Depressed Depressed fracture is suspected when the child's head looks misshapen. The bone is broken locally into several irregular fragments that are pushed inward, resulting in a pressure on the brain. Linear fracture is a single fracture line that does not cross suture lines. Comminuted fracture is caused by intense impact resulting in multiple associated linear fractures. Basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bones. pg 1366

What action does the nurse take when caring for a child who is have a tonic-clonic seizure? A. Administers oxygen B. Administers sedatives C. Monitors Temperature D. Places child on the side

D. Places child on the side When a child is having a tonic-clonic seizure, the nurse places the child on the side to facilitate drainage and help maintain a patent airway. Oxygen is administered to the child who is at risk for hypoxia. Sedatives are not usually administered, because the child is integrated into the environment as soon as possible pg 1383

Cerebral palsy may result from a variety of causes. It is now known that what is the most common cause of cerebral palsy? A. Birth asphyxia B. Neonatal Disease C. Cerebral trauma D. Prenatal brain abnormalities

D. Prenatal brain abnormalities Cerebral palsy results from existing brain abnormalities during the prenatal period. Birth asphyxia, neonatal diseases, and cerebral trauma previously were thought to be factors. pg 1455

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider? A. Paralysis is progressive with little hope for recovery b. muscle function will gradually return, and recovery is possible in most children c. disease results from an apparently toxic reaction to certain medications d. disease is inherited as an autosomal, sex-linked, recessive gene.

b. muscle function will gradually return, and recovery is possible in most children Supportive nursing care is essential. Most patients regain full muscle strength. The return of function is in reverse order of onset. The paralysis is progressive, but most children have full recovery. It is an immune-mediated disease associated with viral and bacterial infections. pg 1472-1473

Which questions does the nurse ask the parents in an effort to identify the possible causes of cerebral dysfunction in a child? SATA A. "What was the child's Apgar score at Birth?" B. "Was the child attacked by animals or insects?" C. "How often do you smoke near or around the child?" D. "Which neurologic disorders are present in the family?" E. "How often did you consume alcohol during pregnancy?"

A, B, D, E The nurse asks about neurologic disorders in the child's family members to identify the possibility of genetic influences. The child's Apgar score helps the nurse understand any complications present at the time of birth that may have resulted in cerebral dysfunction. The nurse also assesses for any infections caused by animal or insect encounters. The nurse assesses prenatal influences on the child by asking about alcohol consumption patterns during pregnancy. The nurse assesses the smoking habits of the parents in case the child is at risk for bronchial diseases. pg 1356

Which constituents of the cranium should remain the same at all times to maintain a constant intracranial pressure (ICP)? SATA A. Brain B. Meninges C. Cerebrospinal fluid D. Blood E. Dura Mater

A, C, D The total volume of the cranium consists of brain (80%), cerebrospinal fluid (10%), and intracranial blood (10%). This volume must remain the same at all times to maintain a constant or stable ICP. A change in the volume of one constituent results in a compensatory change in another. Meninges are the three tissue layers that cover the organs of the central nervous system. Dura mater is the outermost of the three layers of the meninges. pg 1355

Which is an ideal medication or treatment to prevent cerebral edema in a comatose child? A. Sedatives B. Osmotherapy C. Corticosteroids D. Barbiturates

B. Osmotherapy Osmotherapy involves administering osmotically active substances to the child to prevent cerebral edema. Sedatives are administered to reduce intracranial pressure. Corticosteroids are used for inflammatory conditions. Barbiturates are used for reducing intracranial pressure when other medications fail. pg 1363

The nurse instructs the parents of the child with cerebral palsy to perform routine stretching exercises with the child after administration of oral pain medication. What is the most appropriate reason for this instruction that the nurse provides to the parents? A. "It is an outlet for frustration related to chronic pain experience." B. "It prevents aspiration and helps the child mobilize the food." C. "It promotes self-care in the child and decreases muscle spasticity." D. "It manages pain impulses. It is done for 60 minutes for oral medicines."

D. "It manages pain impulses. It is done for 60 minutes for oral medicines." Stretching exercises are usually done for 60 minutes immediately after oral pain medication is administered to help manage the child's pain. This does not act as an outlet for frustration for the chronic pain experience. The child is encouraged to verbalize the effects of pain in an attempt to release frustration. Stretching exercises are also not part of the promotion of the self-care and the solution to decrease muscle spasticity. Self-care is taught to promote self-dependence in the child. There are separate exercises to decrease muscle spasticity. Parents are taught how to use jaw control movement in the child to prevent aspiration and mobilize the food. pg1459

Which neurologic condition is indicated if a child's pupils are fixed bilaterally for more than 5 minutes? A. Seizures B. Eye trauma C. Hypothermia D. Brainstem damage

D. Brainstem damage If a child's pupils are fixed bilaterally for more than 5 minutes, further tests are prescribed for brainstem damage. After seizures, the child usually has widely dilated and reactive pupils. Dilated pupils are seen in the child as a result of eye trauma. Dilated and nonreactive pupils are seen in hypothermia. pg 1358

Why are infants particularly vulnerable to acceleration-deceleration head injuries? A. The anterior fontanel is not yet closed B. The nervous tissue is not well developed C. the scalp of the head has extensive vascularity D. Musculoskeletal support of head is insufficient

D. Musculoskeletal support of head is insufficient The relatively large head size coupled with insufficient musculoskeletal support increases the risk to the infant. The anterior fontanel not being closed does not have an effect on this type of injury. The nervous tissue not being well developed does not have an effect on this type of injury. The scalp having extensive vascularity does not have an effect on this type of injury. pg 1365

An examination reveals that an infant has spina bifida (SB). What in particular should the nurse be careful about while monitoring this infant? A. Avoid measuring rectal temperatures B. Assess the level of neurologic involvement C. Assess anal reflex for sensory impairment D. Observe behavior in conjunction with stimuli

Rectal temperatures are not measured in infants with spina bifida because bowel sphincter function is often affected, and the thermometer can cause irritation and rectal prolapse. Ideally, the patient's level of neurologic involvement and anal reflex for sensory impairment are assessed. In addition, nurses observe the infant's behavior in conjunction with stimuli. pg 1465

The health care provider has ordered both tetanus immunoglobulin (TIG) and tetanus toxoid for a child suffering from tetanus. Which is the most accurate method of administration? A. orally or intravenously at two different time by the nurse b. intramuscularly using separate syringes at separate sites c. intramuscularly using the same syringe at different times d. in the same syringe at a single site via the intramuscular route

b. intramuscularly using separate syringes at separate sites TIG and tetanus toxoid are administered via the intramuscular route in separate syringes and at separate sites. TIG is responsible for treatment of the condition, and tetanus toxoid provides immunization and protection against future attacks of the C. tatani bacteria. The route of administration is intramuscular. Intravenous route is an incorrect method of administration. Similarly, it is not necessary to administer the medicines separately at two different times, because this does not have any effect on the functions. The medicines are never administered in the same syringe at a single site. pg 1474

A parent brings her 8-month-old infant to the clinic for a well-child visit. The parent reports that the infant has not yet rolled over, has poor head control, and is using only one side of the body when trying to crawl. During the assessment, the nurse notes the infant also has stiff arms and scissoring of the legs. What diagnosis does the nurse expect the health care provider to give to the parents? a. tetanus b. spina bifida (SB) c. cerebral palsy (CP) d. duchenne muscular dystrophy (DMD)

c. cerebral palsy (CP) The infant's failure to meet the developmental milestones, such as the inability to roll over, poor head control, and use of only one side of the body, are all early warning signs of CP. Early symptoms of tetanus include progressive stiffness in neck and jaw muscles, along with difficulty in opening the mouth. SB is a condition in which abnormalities occur in the neural tube. DMD is a form of progressive muscle disease. Children with DMD typically reach their appropriate developmental milestones. pg 1455

Which posttraumatic syndromes does the nurse assess for in a child after a head injury? SATA A. Postconcussion syndrome B. Posttraumatic seizures C. Neuroblastomas D. Hydrocephalus E. Bacterial meningitis

A, B, D Postconcussion syndrome may occur within hours to days after a mild head injury and may result in loss of consciousness. Posttraumatic seizures may occur within the first few days after a severe head injury. Hydrocephalus is a structural complication that may occur as a result of head injuries. Neuroblastomas are tumors that do not occur as a result of any head trauma or injury; they originate from embryonic neural crest cells. Bacterial meningitis is an acute inflammation of the meninges caused by bacteria. pg 1369

Which diagnostic tests does the nurse evaluate to confirm cerebral dysfunction in a child with increased intracranial pressure (ICP)? SATA A. Electroencephalogram (EEG) B. Lumbar puncture C. Visual evoked potentials D. Computed tomography (CT) E. Magnetic Resonance imaging (MRI)

A, C, D, E EEG provides important information about the brain, such as suppressed cortical function, hematoma, or brain death. Visual evoked potentials are helpful to evaluate visual abnormalities from the retina to the visual cortex. A CT scan and MRI scans are used to visualize the soft tissues and solid matter and help to diagnose the disease. Lumbar puncture is usually avoided in children with increased ICP because of its potential for tentorial herniation. pg. 1359

A 2-month-old infant is showing slow, twisting movements of the trunk and abnormal posture. The health care provider detects the condition as dystonic cerebral palsy (CP). What statement would confirm the diagnosis of CP? A. "The child has CP in which upper motor neuron muscular weakness occurs." B. "The child has CP in which altered skeletal muscle performance occurs." C. "The child shows disintegration of movements of the upper extremities." D. "The child has CP in which combination of spastic and dyskinetic CP symptoms occur."

A. "The child has CP in which upper motor neuron muscular weakness occurs." There are different types of CP. The dystonic CP is a condition in which involuntary muscle contractures and abnormal posture occurs in the child. This spastic CP represents an upper motor neuron muscular weakness. Athetoid and dystonic CP are non-spastic CP. Therefore, the nurse should not describe the condition as one in which altered skeletal muscle performance occurs. Disintegration of movements of the upper extremities is noted during ataxic CP. In such a condition the common symptoms are wide-based gait and rapid, repetitive movement. Again, the child does not have mixed CP. In mixed CP, symptoms of spastic and dyskinetic CP are observed. pg 1456

The nurse is performing an assessment of a 14-month-old infant with meningitis. The nurse finds that the baby cannot extend the knee more than 135 degrees and cries when in the supine position with the hip and knee flexed at 90 degrees. What is an appropriate interpretation by the nurse? A. Kernig Sign B. Babinksi Reflex C. Chvostek sign D. Cremasteric reflex

A. Kernig Sign A Positive Kernig sign is indicative of meningitis. If the patient cannot extend the knee more than 135 degrees in the supine position, with the hip and knee flexed at 90 degrees, a Kernig sign is said to be present. Pain is also felt in the hamstrings. A positive Babinski reflex is a dorsiflexion and fanning of the toes resulting from stroking the sole of the foot; adults with neuromuscular impairment and healthy infants exhibit this sign. Chvostek sign is elicited by tapping on the facial nerve in the region of the parotid gland; spasm indicates tetany and hypocalcemia. In a male, the cremasteric reflex is elicited by stroking on the inner thigh causing the testes to retract into the scrotal sac. pg 1373

Which measurement scale does the nurse use to assess the level of consciousness (LOC) in a child? A. glascow coma scale (GCS) B. Doll's head maneuver C. Caloric test D. Oculovestibular response

A. glascow coma scale (GCS) The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values are assigned to the levels of responses in each part. The sum of the numeric values provides an objective measurement of the child's LOC. Doll's head maneuver is used for assessing the movement of the eyes, which may help confirm dysfunction in the brainstem. Caloric test is used to assess eye movements in comatose children. Oculovestibular response is another name for caloric test. pg 1355-1356

The nurse who is concerned about increased intracranial pressure in an infant should assess for what? A. irritability B. Photophobia C. Pulsating anterior fontanel D. Vomiting and Diarrhea

A. irritability Irritability is one of the changes that may indicate increased intracranial pressure. Photophobia does not indicate increased intracranial pressure in infants. Frequently pulsations are visible in the anterior fontanel. They are not an indication of increased intracranial pressure. Vomiting is one of the signs in children but, when present with diarrhea, indicates a gastrointestinal disturbance. pg. 1356

What pattern on an electroencephalogram (EEG) indicates the presence of absence seizure in a child? A. High-voltage spike discharges B. A three-per-second spike and wave pattern C. absence of electrical activity in an area D. Abnormal patterns in the discharge intervals

B. A three-per-second spike and wave pattern An EEG is used to evaluate a seizure disorder. Various seizure types produce characteristic EEG patterns. A three-per-second spike and wave pattern on EEG indicates an absence seizure. High-voltage spike discharges indicate tonic-clonic seizures. Absence of electrical activity in an area indicates a large lesion such as an abscess or subdural collection of fluid. Abnormal patterns in the discharge intervals indicate tonic-clonic seizures. pg 1381

Which signs of lethargy does the nurse note when assessing a child for increased intracranial pressure (ICP)? SATA A. Impaired decision making B. Confusion regarding time C. Sluggish speech D. Falling asleep quickly E. limited spontaneous movement

C, D, E The nurse assesses the level of consciousness in a child to evaluate for increased ICP. Lethargy in the child is indicated by sluggish way of speaking, falling asleep quickly, and limited spontaneous movement. Impaired decision making indicates confusion, not lethargy. Confusion about time and place indicates disorientation. pg 1355

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is the priority nursing care? A. Initiate isolation precautions as soon as the diagnosis is confirmed B. Initiate isolation precautions as soon as the causative agent is identified C. Administer antibiotic therapy as soon as it is ordered D. administer sedatives/analgesics on a preventive schedule to manage pain

C. Administer antibiotic therapy as soon as it is ordered Antibiotics are begun as soon as possible to prevent death and avoid resultant disabilities. Isolation should be instituted as soon as diagnosis is anticipated. Antibiotics are the priority function; pain should be managed if it occurs. pg 1372

Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy? A.It is inherited as an autosomal dominant disorder. B. It is characterized by weakness of proximal muscles of both pelvic and shoulder girdles. C. It is characterized by muscle weakness usually beginning about 3 years old. D. Onset occurs in later childhood and adolescence.

C. It is characterized by muscle weakness usually beginning about 3 years old.

A 12-month-old child presents with symptoms of bacterial meningitis. The child undergoes lumbar puncture and the nurse notes that the cerebrospinal fluid is cloudy. How does the nurse interpret this finding? A. the cerebrospinal fluid is healthy B. The glucose level has increased C. The white blood cell count has risen D. The count of red blood cells has risen

C. The white blood cell count has risen An increase in white blood cell count causes cerebrospinal fluid to appear cloudy and possibly milky white. It is a sign of infection. Healthy cerebrospinal fluid is clear. Elevated glucose levels do not affect the color of the spinal fluid. Red blood cells make the spinal fluid appear sanguineous, not cloudy. pg 1376

The child is admitted to the intensive care unit after suffering a spinal cord injury. The primary health care provider prescribes an assessment of neurologic function. The report suggests level D according to the American Spinal Injury Association Impairment Scale. What explanation does the nurse expect the primary health care provider to give to the parents? A. "The neural and motor functions are normal in all segments." B. "The sensory function is preserved in the sacral segments S4-S5." C. "The motor function is not preserved below the neurologic level." D. "The motor functions are preserved in at least half of the key muscles."

D. "The motor functions are preserved in at least half of the key muscles." The American Spinal Injury Association Impairment Scale has five levels. Level D means that the motor function is preserved below the neurologic level and at least half or more of the key muscles below the neurologic level are functional. If the grade is A, then it suggests that there is no motor or sensory function preserved in the sacral segments S4-S5. In level E, the neural and motor functions are normal in all the segments, and often the primary health care provider identifies the presence of prior deficits. If the sensory functions are preserved, but the motor functions are not, it denotes level B: sensory incomplete.

A 3-year-old male child has cerebral palsy and is currently hospitalized for orthopedic surgery. His mother says that 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 one hand (either from a front or side position) to facilitate swallowing c. place him in a well-supported, semi reclining position to make use of gravity flow. d. place him in a sitting position with his neck hyperextended to make use of gravity flow.

b. stabilize his jaw with one hand (either from a front or side position) to facilitate swallowing The neuromuscular compromise of the jaw interferes with the child's ability to eat. Because the jaw is compromised, more normal control can be achieved if the feeder provides stability. Manual jaw control assists with head control, correction of neck and trunk hyperextension, and jaw stabilization. Age 3 is too old for bottle-feeding. The child should be sitting up for meals. For swallowing, the neck should not be hyperextended. pg 1460

The parents of a child with cerebral palsy (CP) report that the child frequently chokes and aspirates during feedings. What advice does the nurse provide to the parents? Select all that apply. A. "Assess the child's chewing and swallowing ability." B. "Use jaw support, and control the jaw during feedings." C. "Use baclofen (Lioresal) therapy with an implanted pump." D. "Position your child on the cradle of your arm during feedings." E. "Position your child in a semiupright position during and after feedings."

A, B, E The nurse asks the parents to assess the child's chewing and swallowing abilities to prevent the chances of aspiration. The parents should support the child's jaw by placing the middle finger of the nonfeeding hand posterior to the bony portion of the chin. The index finger is placed on the chin below the lower lip, and the thumb is placed obliquely across the cheek. The nurse should advise the parents to position the child in a semi-upright position during and after feedings to prevent choking. Baclofen (Lioresal) therapy with an implanted pump is not used in this case. Baclofen (Lioresal) is a medicine administered in a severely spastic child. It is a neurosurgical and pharmacologic approach to relieve the spasticity associated with CP. The child should not be placed in the cradle of the parent's arm during feeding because it may cause the child to choke. p

Which diagnostic tests does the nurse evaluate to confirm the presence of bacterial meningitis in a child who shows symptoms of infection such as headache, photophobia, and nuchal rigidity? SATA A. Lumbar Puncture B. Magnetic resonance imaging (MRI) C. Blood cell count D. Cerebospinal fluid (CSF) glucose E. Computed tomography (CT) scan

A, C, D Lumbar puncture helps to diagnose bacterial meningitis in a child by indicating an elevation in the spinal fluid pressure. The child's white blood cell count is also elevated. CSF glucose level is reduced as a result of bacterial consumption of glucose. MRI is used to detect tumors or cerebral edema. CT scan is used to assess the severity of injuries to the brain or skull. pg 1359

An acutely ill child with tetanus condition is admitted to the intensive care unit. What measures does the nurse take when caring for this child? Select all that apply. A. Provides adequate stimuli and communication about care B. Creates a quiet environment to reduce external stimuli C. Ensures an adequate airway and fluid and electrolyte balance D. Ensures adequate caloric intake and pain management E. Provides constant adjustment of diazepam (Valium) dosage administration

B, C, D An acutely ill child is best treated in an intensive care unit with proper equipment and close observation. It is necessary to provide the child with a quiet environment where there is absence of any external stimuli, because this helps prevent muscle spasms. The nurse should also ensure the child has adequate electrolyte and fluid balance and a free airway. Pain management and caloric intake observation are also provided. Communication may be difficult, because the patient may have a heavy amount of muscle relaxants in the body. The primary health care provider adjusts the diazepam (Valium) dosage, not the nurse.

Which is a priority nursing intervention for a child, who is administered IV lorazepam (ativan) for the treatment of status epilepticus? A. monitoring fluid and electrolyte balance B. monitoring infusion of midazolam (dormicum) C. Monitoring of alterations in vital signs D. Monitoring hematocrit frequently

C. Monitoring of alterations in vital signs The nurse monitors for alterations in vital signs to be alert for respiratory depression. The nurse monitors fluid and electrolyte balance in a child who is at risk for dehydration. the child is provided with continuous infusion of midazolam if lorazepam is ineffective to stop the seizures.. it does not require any special monitoring. the child who has subdural taps frequently needs hematocrit monitoring because there is blood loss from the procedure. pg 1382

What areas of initial care does the nurse provide for a newborn with spina bifida (SB)? Select all that apply A. Prevention of infection B. Dental care techniques C. Neurologic assessment D. Impact of the anomaly on the family E. Tetanus immunoglobulin F. Anomalies of spinal bifida

A, C, D, F The initial care of the newborn includes prevention of infection, neurologic assessment, learning about associated anomalies of SB, and dealing with the impact of the anomaly on the family. It is not necessary to know about the techniques of dental care. SB is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. This condition does not hamper dental health. Tetanus immunoglobulin is necessary only if the child suffers a wound with C. tetani bacteria pg 1464

Which test is used to understand the staging criteria for Reye's syndrome in a child? A. Magnetic Resonance imaging (MRI) B. Computed tomography (CT) scan C. Liver biopsy D. Electroencephalogram (EEG)

C. Liver biopsy Reye's syndrome causes fatty changes of the liver and liver dysfunction. Hence, liver biopsy is used to understand the staging criteria for Reye's syndrome in a child. MRI is used to detect tumors or cerebral edema. CT scan is used to assess the injuries of the brain or skull. EEG provides important information about the brain, such as suppressed cortical function, hematoma, or brain death. pg 1377

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.

C. Some degree of fecal continence can usually be achieved With diet modification and regular toilet habits to prevent constipation and impaction, some degree of fecal continence can be achieved. Although a lengthy process, continence can be achieved with modification of diet, use of laxatives, and/or enemas. There is no general contraindication. Colostomy usually is not required. pg 1464

The nurse is providing postoperative care for a child with a spinal cord injury. What does the nurse monitor during the recovery phrase? Select all that apply. a. Hormone balance b. Cognitive impairment c. Alterations in muscle tone d. Complications of immobility e. Development of autonomic dysreflexia

D E During the recovery phase, the nurse monitors the patient for complications of immobility, such as deep vein thrombosis and pulmonary embolus. The nurse also monitors the development of autonomic dysreflexia, which requires prompt action to prevent encephalopathy and shock. Insulin administration applies to children with diabetes mellitus. Hormone balance is monitored during endocrine dysfunction-related conditions. Cognitive impairment and alterations in muscle tone are manifestations of cerebral palsy and need not be monitored in a patient recovering from a spinal cord injury. pg 1466

The nurse is caring for a patient with Guillain-Barré syndrome (GBS). The nurse asks the child's parents to communicate with the child and attempt to make eye contact and physical contact. Which statement by the nurse best explains the rationale for this? A.. "This is advised by the primary health care provider." B. "it is a useful motor function stimulus for your child" C. "This will stimulate the sensory functions of your child." D. "Active cognitive abilities allow your child to relate to you."

D. "Active cognitive abilities allow your child to relate to you." Although the child with GBS has paralysis, cognitive functions are unchanged. The nurse asks the parents to attempt to make eye contact and physical contact with the child to reassure the child and soothe any fear and anxiety. The statement related to the primary health care provider is a direct authoritative statement and does not explain the reason for the nurse's request. Communication does not act as a stimulus to the sensory functions and does not stimulate the child's motor abilities.

Which condition will the nurse anticipate in a child who demonstrates fixed and dilated pupils after a head trauma? A. Seizures B. Respiratory arrest C. dehydration D. increased intracranial pressure

B. Respiratory arrest Fixed and dilated pupils after a head trauma indicate high chances of respiratory arrest. After seizures, the child usually has widely dilated and reactive pupils. Fluid imbalance indicates dehydration in the child. Dilated, nonpulsating blood vessels indicate increased intracranial pressure. pg 1368

Which diet does the nurse recommend for a child for management of epilepsy? A. Low-fat diet B. High-fiber diet C. liquid diet D. Ketogenic diet

D. Ketogenic diet The ketogenic diet is a high-fat, low-carbohydrate, and adequate-protein diet that helps to utilize glucose as the primary energy source. This helps develop a state of ketosis and reduce seizures. A low-fat and high-fiber diet is usually recommended to lower cholesterol levels. A liquid diet is usually prescribed for diabetic patients. pg 1381-1382

Which interventions does the nurse implement in the plan of care for a child with bacterial meningitis? SATA A. Ensuring a quiet environment in the room B. Ensuring maximum exposure to sunlight C. Placing the child in a side lying position D. Using a pillow to lift the child's head E. Assessing whether the child is febrile

A, C, E The nurse ensures that the environment is quiet and peaceful, because the child is sensitive to noise. The child is placed in a side-lying position because of nuchal rigidity. The nurse assesses whether the child is febrile, because it indicates infection. The child is sensitive to bright lights, so exposure to sunlight is avoided. The nurse avoids lifting the child's head, because doing so increases pain and discomfort. pg 1372

Which signs and symptoms indicate an increase in intracranial pressure (ICP) in a child? SATA A. Excessive Thirst B. Increased sleeping C. Forceful vomiting D. Seizures

B, C, D increased ICP in a child  is indicated by increased sleeping or an altered level of consciousness such as lethargy, disorientation, and stupor. Forceful vomiting may be caused by abnormalities in the brainstem as a result of increased ICP. Seizures indicate an abnormal electrical discharge in the brain as a result of increased intracranial pressure. Excessive thirst is seen in children with diabetes insipidus, not in children with increased ICP. pg 1355

A 15-year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. What are the most appropriate nursing interventions for this adolescent? Select all that apply A. Monitoring neurologic status B. Administering corticosteroids C. Monitoring for respiratory complications D. Discussing long-term care issues with the family E. Monitoring and maintaining hemodynamic status

A, B, C, E Close monitoring of sensory and motor function is important to prevent further deterioration of neurologic status as a result of spinal cord edema. Corticosteroids are administered to minimize the inflammation associated with the injury. Closely monitor respiratory status for possible need of ventilator support. Remember "A-B-C's" airway, breathing, circulation. Monitoring and maintaining hemodynamic status may require immediate attention related to increased intracranial pressure resulting in hypotension and bradycardia. The discussion of long-term care issues with the family is not appropriate in the acute phase of spinal cord injury. pg 1477

An inadequately immunized 4-year-old child with tetanus is admitted to the pediatric intensive care unit. How should the nurse care for the child? Select all that apply. A. Monitor fluid balance, pain, and keep appropriate emergency equipment handy. B. Evaluate muscle spasms and keep prescribed relaxants, opioids, and sedatives ready. C. Monitor cognitive development and attend to the wound with antiseptic and relaxants. D. Explain to the parents about feeding procedures and cognitive development. E. Monitor intravenous infusions and suction oropharyngeal secretions. F. Carry out surgical debridement and cleansing of the wound immediately.

A, B, E, F A child with tetanus needs aggressive treatment, with particular attention to fluid balance and pain. If respiratory distress occurs, the nurse will need emergency equipment, so it is necessary to keep the appropriate emergency equipment available. It is also necessary to evaluate the extent of muscle spasms and keep prescribed relaxants, opioids, and sedatives ready. The nurse is also responsible for monitoring intravenous infusions over regular intervals. In addition to this, the nurse should also suction oropharyngeal secretions if necessary. One of the most important steps in the treatment includes surgical debridement and wound cleansing. It prevents proliferation of the bacteria. Cognitive development is not impaired in a child with tetanus. Since the complications of tetanus can lead to seizures and respiratory distress, the child is not left under the parents' supervision. Thus, the nurse does not explain feeding procedures and cognitive development to them. pg 1474

A 4-month-old child shows signs of being infected with Clostridium botulinum, such as mild constipation, loss of neurologic function, and respiratory failure. The nurse asks the senior nurse about the child's care. What are the appropriate responses by the senior nurse? Select all that apply. A. "Observe and report signs of poor feeding, constipation, and muscle impairment." B. "Change the dosage of intravenous botulism immune globulin to control jaw rigidity." C. "Educate the parents about stool softeners, fatigue after recovery, and feeding." D. "Roll the child from time to time to prevent lacerations caused by the condition." E. "Provide assisted mobility and stool softener for abnormal bowel activity."

A, C The nurse must observe and report the signs of poor feeding, constipation, and muscle impairment to the primary health care provider. This will help prevent and treat the condition properly. The nurse must also educate the parents about stool softeners, fatigue after recovery, and feeding. Bowel activity is usually abnormal during recovery. It is also noted that the child will fatigue easily. Hence, if the parent knows about it they will be able to provide the child controlled and timed feeding. Any changes in medication dosage will be prescribed by the primary health care provider. It is not done by the nurse. Lacerations are not observed in this condition, so it is not necessary to roll the child from time to time. Additional assisted mobility is not necessary for a child with botulism. After treatment, a child who has botulism is able to move freely.

A child with cerebral palsy (CP) is experiencing repeated muscle contractures. What advice does the nurse convey to the family to prevent this condition? Select all that apply. "Perform stretching exercises on the affected muscles of the child." "Teach activities of daily living (ADLs) and encourage self-help skills." "Use assistive devices, such as wrist splits and ankle-foot orthoses." "Use jaw control during and after feeding, and remove thick carpeting. "Avoid throw rugs and thick carpeting, and use padded furniture.

A, C The family members of the child and the child's parents should be well aware of the different stretching exercises for the affected muscles. It ensures that the child does not have muscle contractures. Assistive devices, such as wrist splints and ankle-foot orthoses, are excellent to prevent muscle contracture. However, it is essential that such devices be used according to the specification of the primary health care provider and at a safety level appropriate for the child's age. ADLs and self-help skills should be promoted so the child becomes self-dependent. This is not done to prevent muscle contracture. The technique of jaw control during and after feeding is used to prevent choking, and it assists in the mobilization of the food. The family of the child is advised to remove thick carpeting to prevent injuries during mobilization in home. pg 1457

The primary health care provider has prescribed blood polymerase chain reaction (PCR) for the dystrophin gene mutation. The newly graduated nurse is inexperienced and asks the senior nurse to explain. What is the most appropriate response? A. "Duchenne muscular dystrophy (DMD) is diagnosed by PCR test." B. "Tetanus condition is diagnosed by PCR for the dystrophin gene mutation." C. "Myelomeningocele is diagnosed by PCR for the dystrophin gene mutation." D. "Cerebral palsy (CP) is diagnosed by PCR for the dystrophin gene mutation."

A. "Duchenne muscular dystrophy (DMD) is diagnosed by PCR test. The diagnosis of DMD is primarily established by PCR for the dystrophin gene mutation. This mutation of the gene, which encodes dystrophin, prevents the synthesis of a protein product in skeletal muscle. The protein product leads to the onset of the symptoms of DMD. Tetanus condition, myelomeningocele, or CP cannot be diagnosed with this test. Tetanus condition is characterized by a prolonged contraction of skeletal muscles, and it usually happens if someone has bacterial contamination of C. tetani in the wound. Examination of the meningeal sac is done as a diagnostic evaluation for myelomeningocele. Neuroimaging of the child is done for the diagnosis of CP. pg 1471

A child has been diagnosed with Guillain-Barre syndrome (GBS). Which is the <b>most</b> appropriate explanation of this condition? A. "GBS is a rare, acute immune-mediated disease with a progressive ascending flaccid paralysis." B. "GBS is a congenital condition with gradual degeneration of muscles and increasing disability." C. "GBS is a congenital condition leading to the failure of the closure of the neural tube in infants." D. "GBS is a nonprogressive permanent disorder leading to an underdeveloped brain in the child."

A. "GBS is a rare, acute immune-mediated disease with a progressive ascending flaccid paralysis." GBS is an immune-mediated disease often associated with a number of viral or bacterial infections or the administration of certain vaccines. The hallmark of GBS is acute peripheral motor weakness and ascending flaccid paralysis. Muscular dystrophy (MD) is a congenital condition in which there is a gradual degeneration of the muscle fibers with increasing disability. Spina bifida (SB) is characterized by the failure of the neural tube to close in infants. Both MD and SB are congenital diseases, but GBS is not a congenital condition. The cerebral palsy condition is a nonprogressive permanent disorder. This condition leads to an underdeveloped brain in the child. In GBS the development of the brain is normal. Pathologic changes in the spinal and cranial nerves with inflammation and edema are noticed. pg 1472

The pediatric clinic nurse completes an assessment on a 4-month-old infant brought in because the parents are concerned that something is "just not right" with their baby. To which assessment findings should the nurse alert the health care provider? Select all that apply. A. Inability to sit up without support B. Poor head control and clenched fists C. Inability to crawl D. Failure to smile E. Extreme irritability

B, D, E The infant would not be expected to sit up without support until 6 or 7 months old. Crawling would not be an expected finding in a 4-month-old infant. Early signs of cerebral palsy include failure to meet any developmental milestones such as rolling over, raising head, sitting up, crawling; persistent primitive reflexes such as Moro, asymmetric tonic neck reflex; poor head control (head lag) and clenched fists after 3 months old; stiff or rigid arms or legs; scissoring legs; pushing away or arching back; stiff posture; floppy or limp body posture, especially while sleeping; inability to sit up without support by 8 months; using only one side of the body or only the arms to crawl; feeding difficulties; persistent gagging or choking when fed; after 6 months old, tongue pushing soft food out of the mouth; extreme irritability or crying; failure to smile by 3 months old; and lack of interest in surroundings. pg 1457

The nurse is caring for an infant with myelomeningocele and needs to keep the infant in the prone position. Which is the <b>most</b> appropriate way to keep the infant in the prone position while minimizing tension in the sac? A. Hips extended with the legs in abduction and the child lying with back down B. Hips kept slightly flexed with the legs in abduction and the child lying chest down C. Legs kept well separated, thighs acutely flexed on the abdomen, and the child lying on the back D. Child lying on the left side with the left thigh slightly flexed and the right thigh acutely flexed on the abdomen

B. Hips kept slightly flexed with the legs in abduction and the child lying chest down In the prone position the child lies face down with hips slightly flexed and supported to reduce tension on the myelomeningocele sac. The legs are maintained in abduction with a pad between the knees to counteract hip subluxation. A small roll is placed under the ankles to maintain a neutral foot position. The child's back is kept upright. When the chest is kept in upright position, it creates a problem because there is a risk of trauma of the myelomeningocele sac. The child also cannot lie on the back with the legs well separated and thighs acutely flexed on the abdomen. Moreover, this position is known as lithotomy. The risks of trauma are also high if the child is kept on the left side-lying position with the left thigh slightly flexed and the right thigh acutely flexed on the abdomen. If the child tilts, it can injure the myelomeningocele sac. pg. 1466

The nurse is admitting a 12-year-old female patient with severe muscle weakness and a differential diagnosis of Guillain-Barré. Upon interviewing the mother regarding the child's recent injuries and illnesses, which finding would be most important? A. A significant fall from her bicycle B. A family trip to the Caribbean C. Contact with a classmate who has chickenpox D. A flu-like illness

D. A flu-like illness GBS (infectious polyneuritis) is an uncommon disease of the peripheral nervous system, caused by a malfunction in the body's own immune system. A significant finding with Guillain-Barré syndrome is the onset of symptoms, which occurs days or even weeks after a flu-like illness. Inflammatory changes cause the myelin sheath to deteriorate, which in turn impairs nerve conduction. Muscle weakness and paralysis initially affect the lower limbs and in advanced cases may involve the thorax. This latter involvement is likely to result in respiratory distress and is potentially life-threatening. A significant fall from her bike, a family trip to the Caribbean, or contact with a classmate who has chickenpox are not associated with Guillain-Barré syndrome. pg 1472

A child has been recently diagnosed with rachischisis. The parents ask the nurse for an explanation of this condition. What is the most appropriate response from the nurse? a. The brain is totally exposed through an associated skull defect in the head region b. there's a skull defect through which various tissues are protruding out of the child c. there's herniation of brain and meninges through the skill producing a fluid-filled sac d. there's a fissure in the spinal column that leaves the meninges and spinal cord exposed

d. there's a fissure in the spinal column that leaves the meninges and spinal cord exposed Rachischisis, or spina bifida (SB), is a neural tube defect in which there is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Exencephaly is a condition in which the brain is totally exposed through an associated skull defect. Cranioschisis is a skull defect through which various tissues protrude. Encephalocele is herniation of the brain and meninges through a defect in the skull, producing a fluid-filled sac. pg 1461

The nurse is planning the discharge of a child with myelomeningocele. The child's parents are ready and successfully coping with the condition. The nurse needs to involve the parents so that they can continue the care at home. What areas of complication should the nurse cover when teaching them home care? Select all that apply. A Urinary B. Neurologic C. Orthopedic D. Psychological E. Reproductive

A B C The life expectancy of a child with myelomeningocele is well into adulthood. The parents usually need assistance if there are complications. Hence, knowing about these complications is a necessary step for home care. Generally these complications are neurologic or orthopedic, and sometimes they are related to the urinary system. Otherwise, the child is healthy, and there is no complication in his or her psychological or reproductive behavior. In fact, children with myelomeningocele after surgery can receive educational training, live independently, have a mate, have sexual relations, and bear children. pg 1466

A child with spina bifida presents with a rash and is also sneezing and coughing continuously. Which are the most appropriate questions to confirm whether the child has a latex allergy? SATA a. "Does your child have a history of allergic reaction to anything?" b. "Did your child come in contact with any rubber product recently?" c. "Did you watch your child undergoing the surgery?" d. "Has your child ever had any allergy testing at a certified clinic?" e. "Did you recently visit any clinic for counseling assistance of your child?" f. "Has your child ever had an allergic reaction during surgery?"

A, B, D, F Latex allergy is a serious health hazard for a child with spina bifida. The most common symptoms of latex allergy are sneezing, coughing, and developing rashes. To know whether the child has come in contact with rubber, the nurse should find out about the child's history of allergic reactions. Sometimes food or other products can cause allergic reactions. If the child has come in contact with rubber, then the child should be immediately taken to a primary health care provider. Allergy testing and allergic reaction during surgery can also confirm latex allergy. However, inquiring about the presence of the parents during a surgery or their visit to a clinic for counseling is not appropriate to determine whether the child has latex allergy. pg 1467

A child with Duchenne muscular dystrophy (DMD) is also suffering from obesity. What advice does the nurse give the parents so that they can manage the child's weight more appropriately? SATA A. "Obesity can lead to premature loss of ambulation and functional independence." B. "Family members should try to feed the child whenever possible to keep the child busy" C. "It is important to increase the physical and recreational activities in your child's life." D. "The child's IQ is 20 points, and thus it is best not to involve the child in learning" E. "Proper dietary intake and a diversified recreational program help reduce the likelihood of obesity."

A, C, E Obesity is a common complication in children with DMD. Obesity can lead to the premature loss of ambulation and functional independence. The nurse should recommend that the parents involve the child in different recreational and physical activities. Proper dietary intake and a diversified recreational program help reduce the likelihood of obesity and enable children to maintain ambulation and functional independence for a longer time. Overfeeding by well-meaning family and friends should be avoided, because this contributes to obesity. Additionally, the child with DMD should be involved in early learning programs and eventually moved into regular classrooms, even if their IQ is 20 points. This helps promote self-confidence and independence. pg 1469-1471

Which action does the nurse take when there is reduced urinary output in a comatose child? A. Evaluates tests for syndrome of inappropriate antidiuretic hormone secretion (SIADH) B. obtains a prescription from the primary health care provider to increase fluids C. obtains a prescription to increase the child's feedings using bolus feedings D. Positions the child in a side-lying position and elevates the bed slightly

A. Evaluates tests for syndrome of inappropriate antidiuretic hormone secretion (SIADH) There is reduced urinary output when the child acquires SIADH. It indicates overhydration, hyponatremia, and hypoosmolality in the child. The nurse does not obtain a prescription to increase fluids because these are immediately restricted to treat SIADH. The nurse does not increase the child's feedings because it may cause vomiting. The child is placed in a side-lying position and the bed is elevated to facilitate venous drainage and avoid jugular compression. pg 1363

Why would the use of lower-extremity bracing be recommended for a child with a spinal cord injury (SCI)? A. it is necessary for ambulation b. it assists the child with use of the wheelchair c. it is necessary during feeding d. it is necessary to ease breathing

A. it is necessary for ambulation A variety of orthoses are used by children who have SCIs. Lower-extremity bracing in a child with SCI is used for ambulation. The bracing is ineffective in the wheelchair and has no impact during feeding or breathing. pg1480

The parents find that their son has X-linked Duchenne muscular dystrophy (DMD). They also have a daughter and are concerned about their daughter's well-being. Neither parent has muscular dystrophy. Their daughter has not shown any symptoms. Which are the most appropriate statements to address their concerns? SATA A. "Your daughter is surely a carrier of the disease" B. "It can be a new mutation, and the mother need not be a carrier." C. "Your daughter may be a carrier and could develop cardiomyopathy." D. "It is a genetic disease caused by mutation of the gene that encodes dystrophin." E. "Your son has inherited the disease from both parents

B, C, D DMD is a genetic disease. It can be a new mutation that appears in any generation, and the mother need not be a carrier. In some cases, the daughter is a carrier and can later develop cardiomyopathy. In this mutation, the gene that encodes dystrophin is unable to produce the necessary protein. This condition follows an X-linked recessive inheritance pattern. When the father is unaffected and the mother is a carrier, there is a 50% chance that a son will be affected and a 50% chance that a daughter will be a carrier. Therefore, the daughter is not necessarily a carrier of the disease. The son cannot inherit the disease from the father if the latter is not showing signs of muscular dystrophy. pg 1469

The nurse is caring for an infant who sustained a head injury during a fall. The infant presents with signs of increased intracranial pressure (ICP). What is an appropriate nursing action in this context? A. Weighing the infant daily before feeding B. Elevating the infant's head higher than the hips C. Checking the infant's reflexes every 15 minutes D. Providing stimulation to check the level of consciousness

B. Elevating the infant's head higher than the hips Elevation of the head helps decrease intracranial pressure by promoting venous return through gravity. The child is usually placed with the head of the bed elevated slightly and the child's head in midline position. Weighing daily is done routinely for many ill infants because it is an accurate measure of hydration status, but this is not specific to increased ICP. Checking reflexes frequently may be disturbing to the infant and impair the ability to rest. Frequent stimulation may further irritate an already traumatized central nervous system. pg 1355

What is frequently associated with infant botulism? A. contaminated soil B. honey and corn syrup c. commercial infant cereal d. improperly sterilized bottles

B. honey and corn syrup Unlike adult botulism, infant botulism is caused by ingesting spores of C. botulinum and the resultant release of toxin. The bacterium has been found in honey and corn syrup that was fed to affected infants. Contaminated soil, commercial infant cereals, and improperly sterilized bottles usually are not associated with infants who are affected. pg 1476

A child in the hospital complains about difficulty raising the arms over the head, lack of facial mobility, and a forward slope of the shoulders. The primary health care provider identifies facioscapulohumeral condition in the child. Which response from the nurse is most appropriate in explaining the condition to the child's parents? A. "It is a disorder in which mobility is lost within 8 to 9 years after the onset" B. "It will eventually lead to death as a result of respiratory failure by 2 years of age" C. "It is a disorder in which life span varies from 7 months to 7 years in most children" D. "It is an autosomal dominant disorder, with slow progression and unaffected life span"

D. "It is an autosomal dominant disorder, with slow progression and unaffected life span" Facioscapulohumeral condition is an inherited autosomal dominant disorder. The progression of this disease is slow, and the life span is usually unaffected. Spinal muscular atrophy (SMA) type 3 is a condition in which the child loses the ability to walk within 8 to 9 years after the onset of symptoms. Hence, this is an incorrect explanation. Facioscapulohumeral condition does not lead to respiratory failure and death by 2 years of age. Rather, this can occur for those with SMA type 1. In facioscapulohumeral condition there is difficulty raising the arms over the head, lack of facial mobility, and a forward slope of the shoulders. In SMA type 2 the life span varies from 7 months to 7 years, and sometimes even more. pg 1469

Which nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? A. Suctioning child frequently B. Providing environmental stimulation C. Turning head side to side every hour D. Avoiding activities that cause pain or crying

D. Avoiding activities that cause pain or crying Nursing interventions should focus on assessment and interventions to minimize pain. These activities can cause the intracranial pressure to increase. Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase ICP. Environmental stimulation should be minimized. The child's head should not be turned side to side. If the jugular vein is compressed, ICP can rise. pg 1364

A newly hired nurse caring for an infant who has myelomeningocele asks the senior nurse for assistance. The senior nurse tells the new nurse to focus on what areas? Select all that apply. A. Neurologic and behavioral development and measurement of the head circumference and fontanels B. Meningeal sac protection and intervention plans to optimize the child's development c. Constraint-induced movement therapy to induce the weaker extremities to function D. Infection and skin breakdown occurrence and signs of urologic and bowel complications E. Changes in hemodynamic status, joint contractures, disuse atrophy, and obesity

A B D The nurse caring for an infant who has myelomeningocele should assess for neurologic and behavioral development. The nurse should also measure the head circumference and assess the fontanels from time to time. For a child with myelomeningocele, it is important to protect the meningeal sac and plan appropriate interventions to optimize the child's development. It is also important for the nurse to prevent infection and skin breakdown and observe for signs of urologic and bowel complications. Constraint-induced movement therapy is not used to treat myelomeningocele. The nurse should monitor hemodynamic status, joint contractures, disuse atrophy, and obesity in case the child has Duchenne muscular dystrophy. However, monitoring is not done if the child has myelomeningocele. pg 1465

What are the areas of nursing care for a child with Guillain-Barre syndrome (GBS)? Select all that apply A. Monitor paralysis and prevent aspiration and ventilator-associated pneumonia (VAP). B. Prevent atelectasis, deep vein thrombosis (DVT), and autonomic dysfunction C. Apply dressing and prescribe intravenous administration of immunoglobulin (IVIG). D. Prescribe and administer a low-molecular-weight heparin and other medicines. E. Manage fear and neuropathic pain in the child as well as monitor the respiratory function.

A B E The emphasis of the nursing care for the child with GBS is on close observation and assessment of the extent of paralysis. It is also important to know about the different measures of prevention of aspiration and VAP. Often the child suffers from atelectasis, DVT, fear, autonomic dysfunction, and pain. The nurse should work with the health care provider to manage the child's pain. The primary health care provider prescribes IVIG and low-molecular-weight heparin. pg 1472

A child with cerebral palsy has postural instability and difficulty during meals. The nurse teaches the parent the preferred way to facilitate eating. The most important areas the nurse should advise the parent to be careful about are what? Select all that apply. A. Position of the child after feeding B. Jaw control during feeding C. Bowel activity during feeding D. Respiratory action during feeding E. Chewing and swallowing during feeding

A B E The nurse must advise the parent to keep the child in a semi-upright position after feeding. It is also important to encourage the parent to use jaw control while feeding by carefully assessing the child's ability to manage oral feeding. To do this, the parent must assess the child's chewing and swallowing capability. It is not necessary to assess bowel activity or monitor respiratory action during feeding. pg 1460

The nurse is explaining to the parents of a child with myelomeningocele that some degree of fecal continence can be achieved with diet modification. What steps does the nurse cover in the teaching? Select all that apply. A. Dietary fiber supplements B. Regular exercises and stretching routines C. Diet modification and regular toilet habits D. Limitation of fat to 30% of the total diet calories E. Administration of laxatives, suppositories, or enemas

A C E Dietary fiber supplements help in achieving fecal continence. The amount recommended is calculated based on the age of the child in years + 5 = g/day of fiber. Some degree of fecal continence can be achieved through diet modification, regular bathroom habits, and prevention of constipation and impaction with laxatives, suppositories, or enemas. It can be a lengthy process. Limiting fat to 30% of the total diet calories does not provide the assurance of fecal continence. Fecal continence does not have any relation to stretching routines and regular exercises. pg 1464-1465

Which interventions does the nurse implement while feeding a comatose child? SATA A. Carefully monitors the intravenous fluid infusions B. Regularly examines the skin and the mucous membrane C. Evaluates the child's pituitary function tests D. Provides same amount of fluids that the child took when healthy E. Monitors feeding when a nasogastric tube is used

A, B, C, E The nurse carefully monitors intravenous fluid infusions to prevent dehydration or overhydration. The nurse examines the child's skin and mucous membranes for signs of dehydration. The child's pituitary function tests are evaluated to assess the fluid balance. The nurse monitors feedings when a nasogastric tube is used for preventing overfeeding, which may cause vomiting or risk for aspiration. A comatose child cannot tolerate the same amount of fluids that the child took when healthy. Therefore the nurse monitors for overhydration to prevent cerebral edema. pg. 1363

Which cerebral complications is a child at risk for after a head trauma? SATA A. Hemorrhage B. Edema C. Brain Tumors D. Infection E. Brain herniation

A, B, D, E After a head trauma, the child is at risk for epidural and subdural hemorrhage. An epidural hemorrhage is bleeding between the dura and the skull. A subdural hemorrhage is bleeding between the dura and the arachnoid membrane. The child may be at risk for edema resulting from direct cellular injury that leads to intracellular swelling or vascular injury. The child is at risk for infection resulting from open injuries. Head trauma also poses a risk for brain herniation through the brainstem. Brain tumors are not caused by head trauma but arise from any cell within the brain. pg 1365-1368

A child with cerebral palsy needs multidisciplinary care and coordination. The child's parents ask the nurse for help. What areas should the nurse include in the teaching? Select all that apply. A. Proper handling and adapting to the home environment B. Medication administration and the changing role of parents and siblings C. Techniques for immobilizing the child to preserve muscle tone and prevent joint contractures d. Special medicine administration to prevent the child from gagging during meals e. Devising and modifying equipment and activities per the child's ability

A, B, E Parents of children with cerebral palsy need to know about proper handling and how to adapt the home environment per the child's mobility requirement. This will allow the child to move freely and become self-dependent. Medication administration process is a major concern for parents. The child with cerebral palsy would need help and routine administration of different medicine. The parents need to have proper knowledge about it. The parents and siblings of the child should also be informed about their changing role as a caregiver. In addition, the parents need to know how to devise and modify equipment and activities per the child's requirement. This will allow the child to become self-dependent. It is not necessary for the parents to know how to immobilize the child. Most children with cerebral palsy do not need special medicine to avoid gagging during meals. However, special techniques are used to prevent problems during eating. These include providing jaw support and jaw control during feeding. When feeding, the child is kept in a semi-upright position. pg 1457-1458

The nurse is caring for an infant who has recently undergone surgery to correct myelomeningocele. What should be the nurse's basic focus during postoperative care? SATA A. monitor vital signs, nourishment, signs of infection, and. manage pain B. care for the operative site and monitor signs of cerebrospinal fluid leakage C. Educate the parents on hydrocephalus and developing cognitive skills D. Practice stretches and exercises to minimize muscle contractures and deformity E. educate parents on positioning, feeding, skin care, and exercise

A, B, E Postoperative care for a child who has undergone a surgery to correct myelomeningocele includes monitoring vital signs, nourishment, signs of infection, and managing pain. It is also important to take adequate steps in caring for the operative site and monitoring signs of cerebrospinal fluid leakage. The nurse also needs to educate the parents on positioning, feeding, skin care, and range-of-motion exercises after the child returns home. Parents are not taught about hydrocephalus or cognitive skill development. Similarly, they are not taught about stretches and exercises to minimize the muscle contractures and deformity. pg 1466

The nurse is caring for a newborn who has a sac containing meninges, spinal fluid, and a portion of the spinal cord with its nerves at the lower back. What would be included as the most appropriate nursing care steps for the infant? Select all that apply A. Place the infant in an incubator. B. Apply sterile, moist, and nonadherent dressing. C. Roll over the child every 2 to 3 hours. D. Involve the parents in the nursing care. E. Change dressings frequently. F. Closely inspect for infections and irritations.

A, B, E, F The infant is always placed in an incubator so that the temperature can be maintained without clothing or covers that irritate the spinal lesion. The myelomeningocele is prevented from drying through the application of a sterile, moist, and nonadherent dressing over the sac. Dressings are changed frequently, and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The child is in a delicate condition. Hence, the child is not moved. If the child is rolled over every 2 to 3 hours, the risk of rupturing the myelomeningocele sac increases. Moreover, involving the parent in the nursing care is not advised. It is best if a certified nurse and primary health care provider take care of the infant. pg 1465

The child with spinal cord injury needs special skin care. What are included in the key areas of assessment and management for the nurse? SATA A. use pressure mattresses B. apply antiseptic ointment C. Evaluate skin breakdown risks D. Use air cushions on the wheelchair E. inject tetanus immunoglobulin (TIG) and tetanus toxoid

A, C, D The child with reduced mobility and sensation needs frequent assessment and careful management of skin breakdown. The nurse should evaluate the skin at least once a day to assess for skin breakdown. One of the best measures is to use an alternating-pressure mattress underneath the child. There are also air cushions available to prevent skin breakdown, which may be useful for the child confined to a wheelchair. Antiseptic ointment is not necessary to prevent skin breakdown. It is used if there are minor bruises and burns. TIG and tetanus toxoid is the treatment to prevent tetanus. pg 1479

Which instructions does the nurse give to the parents of an infant or child to prevent submersion injuries? SATA A. "Avoid reading by the pool" B. :Leave the child alone with a flotation device." C. "Use water-entry alarms at home pools." D. "Learn Cardiopulmonary resuscitation" E. "Do not teach swimming skills at a young age"

A, C, D The nurse instructs the parents to avoid engaging in any distracting activities such as reading or talking on the phone when the child is in the pool to prevent submersion injuries. Setting water-entry alarms at home will help the parents monitor their child's activity. The nurse advises the parents to learn cardiopulmonary resuscitation so that it could be used in emergency situations. The child is never left alone in the pool, even with a flotation device, because an accident could occur during a momentary lapse of supervision. The nurse advises the parents to teach the child swimming skills at a young age to prevent any submersion events. pg 1372

Which interventions does the nurse implement to prevent the elevation of intracranial pressure (ICP) in an unconscious child? SATA A. Provides dim lights in the room B. Asks many relatives to visit C. prevents sudden movements in the child D. Administers prescribed pain medications E. Monitors the child's temperature frequently

A, C, D, E The nurse provides dim lights in the room because the child is sensitive to bright lights. The nurse also prevents sudden jarring movements in the child, such as head banging, because it may result in an increase in ICP. The nurse administers the prescribed pain medications for pain because unrelieved pain causes stress and increases ICP. The nurse also monitors the child's temperature every 2 to 4 hours because brainstem disorders affect the child's thermoregulation. The nurse provides a quiet environment in the child's room by limiting the visitors. pg 1355

Which conditions can occur from infection in the nervous system? SATA A. Rabies B. Seizures C. meningitis D. hydrocephalus E. Reye's syndrome

A, C, E Meningitis is caused by a bacterial infection that causes acute inflammation of the meninges. Rabies is an acute infection of the nervous system caused by a virus. Reye's syndrome causes impaired consciousness and disordered hepatic function, which usually follows viral illness, such as influenza or varicella. Hydrocephalus causes enlargement of the skull and dilation of the ventricles. Seizures are not caused by infections in the nervous system. They are a neurologic disorder, which results in abnormal electrical activity in the brain. pg 1372-1377

A child has been recently diagnosed with cerebral palsy (CP), and the nurse is explaining how to care for the child to the child's parents. What major areas should the nurse focus on when speaking with the parents? SATA A. Reinforce the therapeutic plan and activities necessary for the child. B. Reinforce genetic counseling and family planning in group meetings C. Provide guidance on devising and modifying equipment and activities D. Provide guidance on the immunization procedure and insulin treatment E. Reinforce correct handling, home care, and role change from parent to caregiver.

A, C, E The nurse should reinforce the therapeutic plan and activities necessary for the child. The nurse should also assist the family in devising and modifying equipment and activities to continue the therapy program at home. All family members should be trained on proper handling, home care, and change of role from parent to caregiver. This is done so that the change of role can be properly melded with the already established relationship between the child and the family members. Genetic counseling is recommended for mothers who have borne a child with neural tube defect. It is not necessary to provide guidance on the immunization procedure and insulin treatment. A child with CP receives immunizations like a healthy child. pg 1457-1460

A 3-week-old infant is receiving treatment for meningitis. The nurse is assessing the infant for complications. What observation made by the nurse suggests a complication? A. A Tense and nonpulsatile anterior fontanel on the head B. a lack of coordination between eye and muscle movement C. A larger head circumference than chest circumference D. An inability to support the head in the prone position

A. A Tense and nonpulsatile anterior fontanel on the head A Tense or bulging fontanel is indicative of increased intracranial pressure, which is caused by the fluid accumulation associated with hydrocephalus. Conjugate gaze does not occur until 3 to 4 months of age when eye muscles are mature. The head is the largest part of the body at this age; the head circumference should be about 1 inch larger than the chest. An infant cannot support the head before 1 to 1½ months of age, so an inability to do so by a 3-week-old infant does not suggest a complication. pg 1373

The nurse is planning therapeutic management for optimal development of a child with cerebral palsy (CP). What key areas of prevention and normalization should the nurse focus on during the therapy? SATA a. Establish optimal mobility, communication, and self-help skills. b. prevent hydrocephalus condition and duchenne muscular dystrophy (DMD) c. Provide educational opportunities tailored to the child's needs and abilities. d. Provide genetic counseling and aggressive supportive care of immunizations e. Promote socialization experiences with other affected and unaffected children.

A, C, E They should focus on establishing optimal mobility, communication, and self-help skills. To attain normalization it is also important to focus on providing educational opportunities adapted to the child's needs and capabilities. Additionally, there is a need to improve the child's socialization experiences with other affected and unaffected children, instead of keeping the child alone at home. Hydrocephalus is a frequently associated anomaly in 80% to 90% of children with spina bifida (SB). DMD is applicable to children with spinal muscular atrophy (SMA). There is no need to provide aggressive supportive care of immunizations to the child with CP. The immunization approach would be the same as for any healthy child. pg 1457

The nursing instructor is explaining Duchenne muscular dystrophy (DMD) to parents. Which statements does the nurse include in the explanation? Select all that apply. A. "It is inherited as an X-linked recessive trait, and it is a single-gene defect." B. "It is an autosomal recessive, autosomal dominant, or X-linked recessive trait." C. "The female carriers are completely healthy without any symptoms of the illness." D. "About 10% of female carriers develop cardiomyopathy with elevated creatine kinase." E. "In about 30% of cases it is a new mutation, and in 65% of cases it is a positive family history."

A, D, E DMD is inherited as an X-linked recessive trait, and the single-gene defect is located on the short arm of the X chromosome. Female carriers have an elevated serum creatine kinase, and about 10% develop cardiomyopathy. Although this condition has a positive family history in about 65% of the cases, in about 30% of the cases it is a new mutation. These are common facts about DMD that nurses need to know and often have to convey to the families. DMD is not an autosomal recessive or autosomal dominant trait. Even though this condition is a recessive trait, it is not that the female carriers are entirely normal. Female carriers do suffer from mild cardiomyopathy and an elevated serum creatine kinase condition in a few cases. pg 1469

The nurse is reviewing a child's medical reports and notes that the child has suffered a spinal cord injury and has tetraplegia. What does the nurse expect the health care provider to tell the parents about the child's condition? A. "The child will have loss of functional use of the four extremities" B. "the child will have complete or partial paralysis of the lower extremities" C. "The child will have diaphragm paralysis that requires mechanical ventilation" D. The child will have temporary neural dysfunction without damage to the cord"

A. "The child will have loss of functional use of the four extremities" A higher damage without any functional use of the four extremities is called tetraplegia. The complete or partial paralysis of the lower extremities of the body is known as paraplegia. The child requires mechanical ventilation when diaphragm paralysis is present. This is due to cervical cord injury that affects the phrenic nerve. A mild form of spinal cord trauma or spinal cord compression is when the child has temporary neural dysfunction without visible damage to the cord. pg 1478

Which statement by the nurse is most effective in alleviating the feelings of guilt in the parents of a child who has sustained a submersion injury? A. "We are doing out best to help you and your child." B. "You should have been careful; your child is very young." C, "we must accept what is destined for us." D. "This is very common during childhood."

A. "We are doing out best to help you and your child" The parents of a child who has sustained a submersion injury may feel anxious, because they do not know the final outcome. Hence, it is important that the nurse support the parents by telling them that he or she and the staff are doing their best to help them during the crisis. This helps reduce guilt and loneliness in the parents. Telling the parents that they should have been more careful will increase the feelings of guilt. The nurse does not say that the parents should accept what is destined, because it may make the parents more anxious and lonely. Telling the parents that submersion injury is common is an unsympathetic statement and will make the family feel distant. pg 1371-1372

Which statement is most accurate in describing tetanus? A. Acute infectious disease caused by an exotoxin produced by an anaerobic gram-positive bacillus B. inflammatory disease that causes extreme, localized muscle spasm C. acute infection that causes meningeal inflammation resulting in symptoms of generalized muscle spasm D. disease affecting the salivary gland with resultant stiffness of the jaw

A. Acute infectious disease caused by an exotoxin produced by an anaerobic gram-positive bacillus Tetanus is an acute, preventable disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus, Clostridium tetani. Muscle spasms and stiffness of the jaw are symptoms caused by the effect of the toxins becoming fixed on nerve cells. pg 1474

A 12-month-old infant has been prescribed lumbar puncture to confirm the diagnosis of meningitis. The nurse is teaching the parents of the child about the rationale behind the procedure. The nurse incorporates in the teaching that a lumbar puncture is used to do what? A. Determine the causative agent B. Identify the presence of blood C. Reduce the intracranial pressure D. Measure the glucose level

A. Determine the causative agent Organisms that cause meningitis are often harbored in the cerebrospinal fluid. The lumbar puncture helps determine if meningitis is present and if the causative agent is bacterial or viral. Although some blood may be found in the spinal fluid, its presence is not a finding that confirms the diagnosis of meningitis. More conservative measures, such as medications or positioning, are used to reduce intracranial pressure. Although testing for cerebrospinal fluid glucose levels may be done if infection or bleeding is suspected, it does not determine the causative agent. pg 1369

The nurse is planning care for a school-age child with bacterial meningitis. What should the plan include? A. Keeping environmental stimuli at a minimum B. Avoiding giving pain medications that could dull sensorium C. Measuring head circumference to assess developing complications D. Having child move head side to side at lease every 2 hours

A. Keeping environmental stimuli at a minimum Children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nurse should keep the room as quiet as possible, with a minimum of external stimuli. After consultation with the practitioner, pain medications can be used if necessary. A school-age child will have closed sutures. Head circumference should not change. The child is placed in side-lying position with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that would increase discomfort. pg 1372

Which is a priority nursing action while providing care for a child who undergoes repeated subdural taps? A. Monitor the child's hematocrit B. Monitor for dehydration C. Administer opioids for pain D. Evaluate the child's gag reflexes

A. Monitor the child's hematocrit The nurse monitors the child's hematocrit to detect excessive blood loss from the procedure. The nurse monitors the child for dehydration if the child is unconscious and fluids are supplied intravenously. Opioids are not administered to children for pain; however, pain control is not an immediate concern in this case. The nurse evaluates the gag reflexes in a child to assess the level of consciousness. pg 1360-1361

The nurse is caring for a 10-year-old child with a head injury. The nurse finds that the child does not exhibit the usual signs of a head injury, other than a headache, even though 10 hours have passed since the child sustained the injury. What is a priority nursing action in this context? A. Monitor the level of consciousness for 2 hours B. Promote rest by creating a quiet environment C. Seek information about what happened to cause the injury D. Administer an opioid to provide relief from the headache.

A. Monitor the level of consciousness for 2 hours Unlike an epidural hemorrhage, which develops inwardly against the less resistant brain tissue, a subdural hemorrhage tends to develop more slowly and spreads thinly and widely until it is limited by the dural barriers. Evidence of a subdural hemorrhage may take hours or days to develop. A decreasing level of consciousness is an early indication of neurologic damage. Therefore, assessing the child's level of consciousness at least every 2 hours is imperative. Although promoting rest is important, early recognition of neurologic damage is the priority. Taking a history at this time is not appropriate nor is it a priority. Administering an opioid is contraindicated because it may mask the signs and symptoms of increasing neurologic injury. pg 1368

The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. What should the nurse recognize that these reflexes suggest? A. Neurologic health B. severe brain damage C. decorticate posturing D. Decerebrate posturing

A. Neurologic health The Moro, tonic neck, and withdrawing reflexes are usually present in infants younger than 3 to 4 months of age. Therefore, the presence of these reflexes indicates neurologic health. Decorticate posturing indicates severe dysfunction of the cerebral cortex. Decerebrate posturing indicates dysfunction at the level of the midbrain. pg 1355

The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and pupils are unequal and sluggish. What is the most appropriate nursing action? A. Notify the health care provider immediately B. Document level of consciousness C. Observe closely for signs of increased intracranial pressure (ICP) D. Administer pain medication and assess for response

A. Notify the health care provider immediately The worsening of symptoms may indicate that the ICP is increasing. The practitioner should be notified immediately. The health care provider should be notified first before documenting. The nurse is already noting signs of potentially increased ICP. Pain medication should not be given. Consultation with the practitioner should occur first. pg 1356

A ventriculoperitoneal (VP) shunt has been placed in an infant with hydrocephalus. What does the nurse include in the assessment to determine if the VP shunt is functioning properly? A. Palpate the anterior fontanel B. Check for periorbital edema C. determine the frequency of voiding D. observe for symmetry of the moro reflex

A. Palpate the anterior fontanel A bulging fontanel is the most significant sign of increased intracranial pressure in an infant because the fontanels do not close until 18 months of age. Periorbital edema is not an indicator of increased intracranial pressure. It is a normal finding in most individuals. The frequency of voiding is not an indicator of increased intracranial pressure. It indicates bowel movements. Symmetry of the Moro reflex is not an indicator of increased intracranial pressure. Moro reflex is a normal reflex found in infants. pg 1388-1389

A 9-month-old infant sustained a head injury during an automobile collision. The infant is quiet and has a prominent hematoma on the right temporal area. What assessment finding is most important for the nurse to report? A. Persistent vomiting B. Temperature of 99.6 ºF C. Positive Babinski reflex D. Heart Rate of 110 beats/min

A. Persistent vomiting Vomiting frequently accompanies a Head injury because of increased intracranial pressure and stimulation of the vomiting reflex. A temperature of 99.6° F is the expected temperature for a 9-month-old infant. A positive Babinski reflex is expected in a 10-month-old infant. A heart rate of 110 beats/per minute is within the expected range for a 10-month-old infant. pg 1356

Which is a priority nursing intervention for a child who is breathing spontaneously after a submersion event? A. Restore oxygen delivery to the cells B. Administer intravenous fluids C. Administer sedatives D. Monitor Temperature

A. Restore oxygen delivery to the cells The nursing priority for a child who is breathing spontaneously after a submersion event is to restore oxygen delivery to the cells to prevent further hypoxia. The child is in need of oxygen, not fluids. Therefore the nurse need not administer fluids. Sedatives are administered to manage seizure activity, not after a submersion injury. The child's temperature is not a concern at this stage because the child is hypoxic and needs oxygen first. pg 1371

Which is an appropriate position to place a child who is unconscious for a long period? A. Side-lying B. Supine C. Prone D. Dorsal recumbent

A. Side-lying The side-lying position in an unconscious child prevents aspiration of saliva, nasogastric secretions, and vomitus. The child is placed in a supine position with an elevated bed after supratentorial craniotomy to prevent hemorrhage. The prone position is not used in an unconscious patient, because it may cause obstruction of the airway. The dorsal recumbent position is used for procedures such as urinary catheterization. pg 1364

A 6-year-old girl born with a myelomeningocele has a neurogenic bladder disorder. Her parents have been performing clean intermittent catheterization. What is the nurse's most appropriate action? A. Teach the child to do self-catherization B. Teach the child appropriate bladder control c. continue having parents do catherization d. encourage the family to consider urinary diversion

A. Teach the child to do self-catherization At 6 years old, this child should be able to perform the intermittent catheterization herself. This will give her more control and mastery over her disability. Bladder control cannot be taught to a child with a neurogenic bladder. This would be a good time to have the child begin caring for herself. A urinary diversion is not necessary. pg 1464

The primary health care provider asks the nurse to watch for signs of developing hydrocephalus in a toddler with spina bifida. The nurse should look for what signs? A. Temperature instability, irritability, and lethargy, and elevated intracranial pressure B. Intactness of the membranous cyst, anal reflex inactivity, and motor or sensory impairment C. Behavioral instability, and inactivity in spinal cord reflex and limb movement with stimuli D. Cognitive impairment, pain, and tension or bulging in any part of the body

A. Temperature instability, irritability, and lethargy, and elevated intracranial pressure Early signs of hydrocephalus include signs of infection, such as temperature instability (axillary), irritability, and lethargy, and elevated intracranial pressure. Children with spina bifida are placed in an incubator so their temperature can be maintained without clothing. Signs of intactness of the membranous cyst, anal reflex inactivity, and motor or sensory impairment leading to immobility are not signs of developing hydrocephalus. Similarly, behavioral instability, impaired limb movement in conjunction with stimuli, and spinal cord reflex inactivity also are not signs of developing hydrocephalus. In addition to this, cognitive impairment, pain, and tension or bulging in any part of the body are also looked for, but these are not signs of developing hydrocephalus. pg 1465

Which site is used for inserting the intraventricular catheter for monitoring intracranial pressure? A. The lateral ventricle B. the subarachnoid space C. the third ventricle D. the space between the dura and the skull

A. The lateral ventricle The lateral ventricle on the non-dominant side is used for inserting the intraventricular catheter. If the catheter cannot be cannulated in the ventricle, then the subarachnoid bolt is placed in the subarachnoid space. The third ventricle is not used to insert the catheter because it is filled with cerebrospinal fluid. The epidural sensor is placed between the dura and the skull for monitoring the intracranial pressure. pg 1360

A child has been admitted to the emergency department after falling off a horse. The first responders stabilized the child using a rigid cervical collar with supportive blocks on a rigid backboard. What is the most appropriate explanation for the nursing team to give regarding why the child was stabilized in this manner? A." it immobilizes the entire spine" B. "it prevents the spread of infection" C. "It provides psychological reassurance" D. "it promotes cognitive development"

A." it immobilizes the entire spine" Initial care of the child with a spinal cord injury begins at the scene of the accident with proper immobilization of the cervical, thoracic, and lumbar spines. The rigid cervical collar with supportive blocks on a rigid backboard is the ideal support. The device is not used to provide psychological reassurance to the child or to deal with anxiety. Neither cognitive development of the child nor the prevention of infection is enhanced with the rigid cervical collar. pg 1479

What monitoring steps does the nurse follow during the assessment of ABCs of the child with a spinal cord injury (SCI)? Select all that apply A. Neurologic, cognitive, and psychological damage B. Airway and breathing, and if needed, opens the airway C. Cardiovascular instability and optimal cardiac output D. Administration of medications to prevent the spread of infection E. Internal organ damage and potential bleeding

B, C, E The nurse should monitor the airway and breathing to assess the level of distress in the respiration. Based on the analysis it may be necessary to open the airway using the jaw-thrust technique to minimize damage to the cervical spine. The nurse should also monitor for any cardiovascular instability and cardiac output. Oftentimes the child suffers from internal organ damage and potential bleeding. The nurse must also assess the condition and examine for abdominal distention and other signs. A part of the ABCs in a child with SCI does not include neurologic, cognitive, and psychological damage assessment or assessment of infection. Medications are prescribed by the primary health care provider, not by the nurse. pg 1478

A mother is caring for a 7-year-old child who has been diagnosed with a concussion. The nurse instructed the mother to wake up the child every 2 hours to check the child's level of consciousness. The mother tells the nurse, "I am really afraid of letting my child go back to sleep." What is an appropriate response by the nurse? A. "You can bring your child to the hospital before bedtime if you want" B. "That is an understandable concern that you are expressing but you will be there to monitor your child during this period." C. "There is no need to worry becuase your child is past the critical period" D. "Waking up your child throughout the night should alert you to any changes"

B. "That is an understandable concern that you are expressing but you will be there to monitor your child during this period." A decreasing level of consciousness is a sign of neurologic impairment, for which medical attention is required. Telling the mother why she should wake her child during the night reassures her that there is no danger in allowing the child to sleep, as long as responsiveness is periodically evaluated. Because there is no change warranting care by health professionals, hospitalization is unnecessary. Telling the mother not to worry is a false reassurance; a change in the child's condition is possible. Telling the mother that waking the child will alert her to any change does little to reassure the mother in response to her being "really afraid of letting my child go back to sleep." And while this is an appropriate instruction in this situation, the stem of the question should address the "concerns" of the parent. pg 1369

What teaching does the nurse give to the parents about the computed tomography (CT) scan that is prescribed for a child with head trauma? A. "This scan helps detect structural brain abnormalities" B. "This scan helps detect the severity of the trauma" C. "This scan is done to assess cerebral edema" D. "This scan will help identify any seizure activity"

B. "This scan helps detect the severity of the trauma" The severity of an injury is not evident during a clinical examination, but it is detected through a CT scan. . Magnetic resonance imaging (MRI) is used to detect structural brain abnormalities or to assess cerebral edema. Electroencephalogram (EEG) helps identify any seizure activity. pg 1360

The nurse is caring for a 5-year-old child who had a craniotomy. The nurse is assessing the neurologic status of the child. The nurse has checked the level of consciousness, pupillary activity, and reflexes. What else does the nurse assess in the patient? A. Blood pressure B. Motor Function C. Rectal temperature D. Head circumference

B. Motor Function The nurse should observe for motor functions such as spontaneous activity, gait, and response to painful stimuli. This provides clues to the location and extent of cerebral dysfunction, if any. Assessment of motor function is an important component of a neurologic examination. Even subtle movements (e.g., the outward rotation of a hip) should be noted. Blood pressure is not a direct measure of neurologic status. Temperature is not a direct measure of neurologic status. Head circumference provides information as to skeletal development and brain growth, not neurologic data. A change in head circumference as a result of increased intracranial pressure is not expected in a 5-year-old whose cranial bones are fused. pg 1357-1358

The primary health care provider prescribes tetanus immunoglobulin (TIG) and tetanus toxoid and proposes immediate care of the wound. What is the most appropriate step for taking care of such a wound? A. Covering and bandaging the wound B. Performing surgical debridement and cleansing of the wound C. Administering pain medication to the wound D. Administering TIG and Tetanus toxoid to the wound

B. Performing surgical debridement and cleansing of the wound Surgical debridement should be done, and the wound must be cleaned. This ensures reduction in the number of proliferating organisms, which cause tetanus, at the site. Pain medication is not administered to the wound, but it is orally administered or injected to the other sites on the skin. Muscle relaxants and neuromuscular blocking agents are also used. Muscle relaxants are used to prevent muscle spasms. Additionally, the wound is not covered and bandaged without taking out the debris. Otherwise, the tetanus bacteria proliferate, preventing attainment of healthy status. TIG and tetanus toxoid are given at two separate sites and via two separate syringes. They are not administered to the wound but are injected through the intramuscular route to treat the condition and immunize the child. pg 1475

The postoperative care of a preschool child who has had a brain tumor removed should include which information? A. colorless drainage is to be expected B. close supervision is needed while the child is regaining consciousness c. positioning is on the side in the Trendelenburg position D. analgesics are contraindicated because of altered consciousness

B. close supervision is needed while the child is regaining consciousness The child needs to be observed closely. Vital signs must be assessed carefully, and signs of increasing intracranial pressure need to be monitored. Colorless drainage may be leakage of cerebral spinal fluid from the incision site. This needs to be reported as soon as possible. The child should not be positioned in the Trendelenburg position after surgery. Analgesics can be used for postoperative pain. pg 1355

What are the most appropriate nursing interventions when caring for a child experiencing a seizure? SATA A. Restraining the child when a seizure occurs to prevent bodily harm B. Placing a padded tongue between the teeth if they become clenched C. Avoiding the suctioning of the child during the seizure D. Describing and documenting the seizure activity observed E. applying supplemental oxygen after inserting an artificial oral airway

C, D The priority nursing intervention is to observe the child and seizure, document the activity observed, and avoid suctioning the child during the seizure. The child should not be restrained, because this may cause an injury. Nothing should be placed in the child's mouth, because this may cause an injury not only to the child but also to the nurse. To prevent aspiration, the child should be placed on the side if possible to facilitate drainage. pg 1378-1387

The nurse is assessing the level of neurologic involvement in a child with spina bifida (SB). What are the most appropriate areas for assessment? Select all that apply A. Determine cognitive impairment. B. Assess behavioral modification. C. Measure skin response, especially anal reflex. D. Assess the limb movement with stimulus. E. Evaluate urinary retention and bladder distention.

C, D, E An important nursing care approach of infants with SB is assessing the level of neurologic involvement. This is done by measuring the skin response, especially the anal reflex. Moreover, limb movement in conjunction with stimulus is observed. The nurse also assesses for urinary retention and bladder distention. Cognitive development in most of the children with SB is near normal and would not be assessed for neurologic involvement. Any modification in the child's behavior is also uncommon. The most common issues include hydrocephalus, paralysis, orthopedic deformities, meningitis, seizures, and hypoxia, which are due to neurologic impairment. pg 1465

The parents of a child with cerebral palsy ask the nurse about the advantages of ankle-foot orthoses (AFOs). What is the most appropriate response by the nurse? A. "AFOs have custom seats for dependent mobilization" B. "AFOs are useful for independent mobility." C. "AFOs are used to prevent deformity and increase energy efficiency of gait" D. "AFOs provide sitting balance"

C. "AFOs are used to prevent deformity and increase energy efficiency of gait" AFOs (or braces) are used to prevent deformity, increase the energy efficiency of gait, and control alignment. AFOs do not have custom seats for dependent mobilization. It is a supportive device for the ankle or a part of the foot. Custom seats cannot be adjusted within this device. They also do not allow independent mobility or provide sitting balance. It controls the ankle position and compensates for the muscle weakness. pg 1457

The temperature of an adolescent who is unconscious is 105° F. What is the priority nursing action? A. continue to monitor temperature B. initiate a pain assessment C. Apply a hypothermia blanket D. administer acetaminophen or ibuprofen

C. Apply a hypothermia blanket It is extremely important to institute temperature-lowering interventions, such as hypothermia blankets and tepid water baths. The temperature needs to be monitored but it also needs to be lowered. Initiating a pain assessment should be ongoing; lowering the body temperature is the priority action. Brain damage can occur at temperatures this high. Antipyretics are not useful in cases of hyperthermia. pg 1369

Which is the most important nursing intervention while providing care for a child with endotracheal intubation who is in a deep comatose state? A. Ask family members to be always present B. monitor hematocrit often C. Assess Respiratory effectiveness D. Perform suctioning everyday

C. Assess Respiratory effectiveness The nurse assesses the respiratory effectiveness in an unconscious child because secretions tend to pool in the throat and pharynx, which may obstruct the airway. The nurse does not ask the parents to be present at all times because it is not required that they be present. The nurse monitors hematocrit in a child who undergoes repeated subdural taps to detect blood loss from the procedure. Suctioning is performed only when needed to prevent an increase in the intracranial pressure. pg 1362

The nurse is caring for a 10-year-old child with a history of diabetes mellitus who recently had brain surgery. On assessment, the nurse finds that the body temperature has risen to 103° F. What is an appropriate interpretation by the nurse? A. Children with diabetes mellitius usually develop an infection after surgery B. high body temperature is common in children after surgical procedures C. Cerebral edema after brain surgery exerts pressure on teh hypothalamus D. excessive viscid secretions result in inadequate respiratory ventilation

C. Cerebral edema after brain surgery exerts pressure on the hypothalamus Temperature measurement is needed because of hyperthermia caused by surgical intervention in the hypothalamus or brainstem. This also happens as a result of some types of general anesthesia. Pressure on the hypothalamus, the temperature-regulating center of the brain, causes temperature imbalances. Infection after surgery is not expected, even if the child has diabetes. Infection occurs when proper procedures are not followed. After an operation, a temperature increase caused by an inflammatory response rarely exceeds 101° F. A high fever is not expected after surgical procedures. Viscid secretions do not cause an elevated temperature unless an infection is present. pg 1369

Which is a priority nursing intervention for a child who is asking to discontinue the anticonvulsant drugs? A. Evaluate the urine reports frequently B. Ensure that the child is taking adequate fluids C. Ensure that the dose is decreased gradually D. Evaluate liver function tests frequently

C. Ensure that the dose is decreased gradually The nurse ensures that the dose is decreased gradually, because a sudden withdrawal can cause an increase in the number and severity of seizures. The urine reports are evaluated frequently when the drug dose is increased or changed to detect serum levels. taking adequate fluids will not help counter the withdrawal symptoms of a drug. Liver function tests are necessary when a dose is increased or changed to assess organ function. pg 1381

The parents express concern to the nurse that they are not using the proper feeding techniques for their child with cerebral palsy (CP). After further discussion the nurse notes that the parents are using the appropriate diet and positioning during and after feedings and are performing suitable jaw control techniques. Which outcome confirms the parents are using adequate oral feeding efficiency for their child? A. Improvement of mobility B. Development of maturity C. Gain of child's overall weight D. Development of temperament

C. Gain of child's overall weight. The child's weight gain is a measure of adequate oral feeding efficiency. Once the child has an appropriate diet tailored to suit activity and metabolic needs, the child will gain adequate weight. Otherwise, a child with CP is at risk for growth failure and chronic malnutrition. Improvement of mobility and development of maturity and temperament are not considered outcomes of adequate oral feeding efficiency. They are part of general development and naturalization that the parents need to focus on developing in the child. pg 1460

Which medication helps reduce intracranial pressure (ICP) elevations greater than 20 to 25 mm Hg in a child? A. Phenytoin (Dilantin) B. Rectal diazepam (Valium) C. Mannitol (Osmitrol) D. Ibuprofen (Motrin)

C. Mannitol (Osmitrol) Mannitol (Osmitrol) is an osmotic diuretic that is administered intravenously to lower the ICP in 1 to 5 minutes. Phenytoin (Dilantin) is prescribed for the management of status epilepticus. Rectal diazepam (Valium) is used for safe, quick, and effective treatment of status epilepticus. Ibuprofen (Motrin) is used to reduce the temperature during a febrile seizure. pg 1363

What does the nurse assess in a child who shows other symptoms of hydrocephalus such as sluggish pupils and dilation of scalp veins during crying? A. Evaluates the electroencephalogram (ECG) reports B. Assesses for signs of bacterial meningitis C. Measures the child's head circumference D. Assesses the child's motor functions

C. Measures the child's head circumference in hydrocephalus , the child's head circumference grows at an abnormal rate. The nurse measures the head circumference over 4 weeks and evaluates the measurements. Hydrocephalus is confirmed if the head circumference crosses at least one percentile line on the head measurement chart within 2 to 4 weeks. The nurse evaluates the child's EEG reports to assess seizure disorders. Bacterial meningitis is indicated if the child has fever and signs of meningeal irritation, including nausea, vomiting, irritability, back pain, and nuchal rigidity. The nurse evaluates motor functions in a child to assess the child's level of consciousness and not hydrocephalus. pg 1388

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is what? A. an absence seizure B. a generalized seizure C. status epilepticus D. A simple partial seizure

C. status epilepticus Status epilepticus is a generalized seizure that lasts more than 30 minutes. Absence seizures are brief losses of consciousness. Generalized seizures are the most common of seizures. They have a tonic phase of approximately 10 to 20 seconds. They involve both hemispheres of the brain. Simple partial seizures are characterized by varying sensations. pg 1382

The nurse is assessing a 9-year-old child for the presence of Reye's syndrome (RS). What information about the child is most useful for the nurse during assessment? A. the child reports having a rash recently B. the child had an episode of acute tonsillitis C. the child reports having a recent viral infection d. the child has had a fractured radius and ulna

C. the child reports having a recent viral infection The etiology of RS is not well understood, but most cases follow a common viral illness, typically influenza or varicella. A rash is not a symptom of Reye's syndrome. Tonsillitis is not specifically related to Reye's syndrome. It is an inflammation of the tonsils most commonly caused by a viral or bacterial infection. Fractured bones are not specifically related to Reye's syndrome. They indicate physical trauma. pg 1377

What is a neural tube defect that is not visible externally in the lumbosacral area? A. Meningocele B. Myelomeningocele C. Spina bifida cystica D. Spina bifida occulta

D. Spina bifida occulta Spina bifida occulta is completely enclosed. Often this defect will not be noticed. Meningocele contains meninges and spinal fluid but no neural tissue. Unless there are associated cutaneous findings, it is often not identified until later. Myelomeningocele is a neural tube defect that contains meninges, spinal fluid, and nerves. Spina bifida cystica is a cystic formation with an external saclike protrusion. pg 1462

What do the major goals of therapy for children with cerebral palsy include? a. Reversing degenerative processes that have occurred B. curing the underlying defect causing the disorder. C. preventing spread to individuals in close contact with the children. D. recognizing the disorder early and promoting optimal development.

D. recognizing the disorder early and promoting optimal development. Because cerebral palsy is currently a permanent disorder, the goal of therapy is to promote optimal development. This is done through early recognition and beginning of therapy. It is very difficult to reverse degenerative processes. The underlying defect cannot be cured. Cerebral palsy is not contagious.

A 5-month-old infant is receiving treatment for hydrocephalus. A ventriculoperitoneal (VP) shunt has been inserted into the baby. What is an appropriate intervention by the nurse to ensure the patient's safety? A. Keep the infant in a prone position for a minimum of 12 hours B. Apply sterile, saline-moistened dressings to the incision daily. C. Observe for signs and symptoms of cerebrospinal fluid leakage D. teach parents the signs of an increase in intracranial pressure

D. teach parents the signs of an increase in intracranial pressure Parents must be taught how to identify signs of increased intracranial pressure because this would indicate that the shunt has malfunctioned, which is an urgent situation. The prone position places too much pressure on the shunt; the infant should be flat and turned onto the unaffected side. Dry, sterile dressings are applied postoperatively to prevent infection. Cerebrospinal fluid is not expected to drain from the incision. pg 1388