Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - ML4
Correct response: serum glucose level Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.2 Common Types of Seizures, p. 1345.
A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority? white blood cell count hemoglobin level serum glucose level urinalysis
Correct response: Loss of motor activity accompanied by a blank stare Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.2 Common Types of Seizures, p. 1344.
Absence seizures are marked by what clinical manifestation? Brief, sudden onset of increased tone of the extensor muscle Loss of motor activity accompanied by a blank stare Loss of muscle tone and loss of consciousness Sudden, brief jerks of a muscle group
Correct response: hydrocephalus Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1350.
After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect? anencephaly encephalocele spina bifida occulta hydrocephalus
Correct response: steroid. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, DRUG GUIDE 38.1, p. 1342. Rationale: Increased intracranial pressure (ICP) may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. The diuretic mannitol may be used to decrease edema. An anticonvulsant is used with increased ICP to prevent seizures. An antihistamine would not be warranted for the treatment of a head injury.
Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): diuretic. anticonvulsant. antihistamine. steroid.
Correct response: Report the findings to the pediatric health care provider. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Craniosynostosis, p. 1356.
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? Document that the infant has microcephaly. Report the findings to the pediatric health care provider. Reassess the head circumference in 24 hours. Tell the parent the infant's brain is underdeveloped.
Correct response: Risk for injury related to seizure activity Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1361. The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and the history of seizures does not impact the airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.
In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care?
Correct response: "Take your time feeding your baby." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1352.
The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate? "Take your time feeding your baby." "You won't need to change diapers often." "Lay him down after feeding." "You'll see a big difference after the surgery."
Correct response: Tell me your concerns about your child's shunt. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1355.
The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session? Tell me your concerns about your child's shunt. Call the doctor if she gets a persistent headache. Always keep her head raised 30º. Her autoregulation mechanism to absorb spinal fluid has failed.
Correct response: eye opening verbal response motor response Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Nursing Process Overview for the Child with a Neurologic Disorder, p. 1330.
The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. fontanels (fontanelles) eye opening motor response posture verbal response
Correct response: Signs of increased intracranial pressure (ICP) Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Nursing Process Overview for the Child with a Neurologic Disorder, p. 1333.
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Onset and character of fever Degree and extent of nuchal rigidity Occurrence of urine and fecal contamination Signs of increased intracranial pressure (ICP)
Correct response: toddlers Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TRAUMA, p. 1368. Rationale: Toddlers and older adolescents have the highest actual rate of death from drowning.
Which of these age groups has the highest actual rate of death from drowning? school-aged children toddlers preschool children infants
Correct response: intracranial hemorrhaging Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Intracranial Arteriovenous Malformation, p. 1355.
Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? intracranial hemorrhaging congenital hydrocephalus early closure of the fontanels (fontanelles) moderate closed-head injury
Correct response: "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1361.
The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine."
Correct response: Cerebral edema Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Nursing Process Overview for the Child with a Neurologic Disorder, p. 1337. The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload
To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority? Renal failure Left-sided heart failure Cardiogenic shock Cerebral edema
Correct response: oxygen gauge and tubing suction at bedside padding for side rails Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, BOX 38.1 Seizure Precautions, p. 1338.
A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply. suction at bedside tongue blade oxygen gauge and tubing smelling salts padding for side rails
Correct response: moving the infant's head every 2 hours Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1356.
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? massaging the scalp gently every 4 hours moving the infant's head every 2 hours measuring the intake and output every shift giving the infant small feedings whenever he is fussy
Correct response: "I hate to think that I will need to be worried about my child having seizures for the rest of his life." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, SEIZURE DISORDERS, p. 1349.
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully."
Correct response: drinking three cans of diet cola Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, CHRONIC DISORDERS, p. 1370.
The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger? use of nonaccented soap 11 p.m. bedtime; 6:30 a.m. wake-up drinking three cans of diet cola swimming twice a week
Correct response: Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.2 Common Types of Seizures, p. 1344.
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Sudden, momentary loss of muscle tone, with a brief loss of consciousness Muscle tone maintained and child frozen in position Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Brief, sudden contracture of a muscle or muscle group
Correct response: Use a doll with electrodes attached to the head. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, 38.1 Common Laboratory and Diagnostic Tests, p. 1334. Rationale: The best way for the nurse to explain the procedure to the child is via a doll with attached electrodes that the child can play with, feel, and manipulate the electrodes. This helps to reduce the child's anxiety and aids in cooperation.
The nurse is preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child? Tell the child he or she can take a nap during the procedure. Assure the child the procedure will not hurt. Show the child a video of the procedure. Use a doll with electrodes attached to the head.
Correct response: head trauma Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TRAUMA, p. 1363.
The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? positional plagiocephaly head trauma intracranial hemorrhaging congenital hydrocephalus
Correct response: Teach the child and his parents to keep a headache diary. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, CHRONIC DISORDERS, p. 1371.
A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? Have the parents call the doctor if the child vomits more than twice. Review the signs of increased intracranial pressure with parents. Have the child sleep without a pillow under his head. Teach the child and his parents to keep a headache diary.
Correct response: ensuring the parents know how to properly give antibiotics. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1355.
The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is: establishing seizure precautions for the child. ensuring the parents know how to properly give antibiotics. maintaining effective cerebral perfusion. encouraging development of motor skills.
Correct response: "I need to watch for any new bruises or bleeding and let my health care provider know about it." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.3 Common Anticonvulsant Medications, p. 1346.
The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I need to watch for any new bruises or bleeding and let my health care provider know about it." "I'm glad to know he will only need this medication for a short time to stop his seizures." "I will give the medication to him when I first wake him up in the morning."
Correct response: Assess the level of consciousness (LOC). Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Nursing Process Overview for the Child with a Neurologic Disorder, p. 1330.
A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? Place the child on fall precaution. Notify the primary health care provider. Place a patch over the client's affected eye. Assess the level of consciousness (LOC).
Correct response: Dramatic increase in head circumference Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1354.
During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? Dramatic increase in head circumference Vertical nystagmus Posterior fontanel (fontanelle) is closed Pupil of one eye dilated and reactive
Correct response: "Sometimes it is hard to tell what products may contain aspirin." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1363.
The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my children aspirin!" What could the nurse say to begin educating the parent? "Do not worry; you are in good hands. We have it under control now." "Do you think that maybe your child took aspirin on his or her own?" "Sometimes it is hard to tell what products may contain aspirin." "Aspirin in combination with the virus will make the brain swell and the liver fail."
Correct response: Battle sign. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.6 Common Head Injuries Seen in Children, p. 1364. Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area)
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: Battle sign. raccoon eyes. otorrhea. rhinorrhea.
Correct response: Decrease environmental stimulation Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1361.
A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? Decrease environmental stimulation Take vital signs every 4 hours Monitor temperature every 4 hours Encourage the parents to hold the child
Correct response: Risk for injury Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.2 Common Types of Seizures, p. 1344.
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority? Risk for injury Risk for self-care deficit: bathing and dressing Risk for delayed development Risk for ineffective tissue perfusion: cerebral
Correct response: The child will remain free from injury during a seizure. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TEACHING GUIDELINES 38.1, p. 1348.
The nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client? The caregivers will be prepared to care for the child at home. The child will remain free from injury during a seizure. The child will have an understanding of the disorder. The family will understand seizure precautions.
Correct response: Institute droplet precautions in addition to standard precautions. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1361. Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given.
A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? Encourage the mother to hold and comfort the infant. Palpate the child's fontanels (fontanelles). Educate the family about preventing bacterial meningitis. Institute droplet precautions in addition to standard precautions.
Correct response: "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, COMMON LABORATORY AND DIAGNOSTIC TESTS 38.1, p. 1334.
A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose." "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder." "Since the EEG was negative there must be some other cause for the seizures. The lumbar puncture is necessary to determine what the cause is."
Correct response: The child is easily distracted and can't concentrate. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.6 Common Head Injuries Seen in Children, p. 1364.
The nurse is caring for an 8-year-old girl who was in a car accident. What would lead the nurse to suspect a concussion? The child is easily distracted and can't concentrate. The child is weak and has blurry vision. The child has vomited and has bruising behind her ear. The child is bleeding from the ear and draining fluid from the nose.
Correct response: "What questions or concerns do you have about this device?" Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, BOX 38.3 Nursing Management of External Ventricular Drainage (EVD) Device, p. 1355.
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session? "Do you understand why you clamp the drain before she sits up?" "What do you know about her autoregulation mechanism failing?" "What questions or concerns do you have about this device?" "Why do you always keep her head raised 30 degrees?"
Correct response: "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1363.
A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus."
Correct response: "He was just staring into space and was totally unaware." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TABLE 38.2 Common Types of Seizures, p. 1344.
The nurse is collecting data from the caregivers of a child admitted with seizures. Which statement indicates the child most likely had an absence seizure? "He kept smacking his lips and rubbing his hands." "He usually is very coordinated, but he couldn't even walk without falling." "His arms had jerking movements in his legs and face." "He was just staring into space and was totally unaware."
Correct response: change in level of consciousness Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, COMPARISON CHART 38.1 Early versus Late Signs of Increased Intracranial Pressure, p. 1333.
A 4-year-old child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child, which will be the first change noted in the presence of increasing intercranial pressure? increase in heart rate reduction in heart rate change in level of consciousness decline in respiratory rate
Correct response: Assess the client's respiratory status. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, STRUCTURAL DEFECTS, p. 1353. The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway.
The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? Measure the client's head circumference. Monitor the client for signs of infection. Assess the client's respiratory status. Educate the family on the shunt.
Correct response: "Use this information to teach family and friends." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, SEIZURE DISORDERS, p. 1347.
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "You'll always need a monitor in his room." "Use this information to teach family and friends." "If he is out of bed, the helmet's on the head." "Bike riding and swimming are just too dangerous."
Correct response: Gather appropriate equipment and signage for respiratory isolation precautions. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, INFECTIOUS DISORDERS, p. 1360.
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized. Place multiple pillows in the room to assist with propping the child's head up. Gather appropriate equipment and signage for respiratory isolation precautions. Provide information regarding policies of the unit's playroom for the parents to review.
Correct response: "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY, p. 1328.
The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse? "You probably don't have anything to worry about. It is common for toddlers to fall." "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." "Most mothers are concerned because their toddlers fall a lot. As long as your child seems to be developmentally normal it shouldn't be a concern." "I understand your concern, but toddlers fall and hit their heads a lot since they are not very coordinated yet."
Correct response: While assessing the child's pupils, there is no change in diameter in response to a light. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, TRAUMA, p. 1365. Rationale: To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination
The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? While stimulating the child's foot, the big toe points upward and other toes fan outward. While assessing the child's pupils, there is no change in diameter in response to a light. While calling the child's name, the child stares straight ahead and does not turn to the sound. While turning the child's head to the left, the eyes turn to the right.
Correct response: Check tubing clamps to ensure they are open. Ensure the tubing is not kinked. Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, BOX 38.3 Nursing Management of External Ventricular Drainage (EVD) Device, p. 1355.
The nurse is caring for a child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What action(s) by the nurse should be performed now? Select all that apply. Ensure the tubing is not kinked. Ensure the drip chamber is below the child's clavicles. Encourage the child to cough and deep breathe to facilitate drainage. Check the child's temperature. Check tubing clamps to ensure they are open.
Correct response: "She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Nursing Process Overview for the Child with a Neurologic Disorder, p. 1333.
The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? "She has been irritable for the last hour....seems like she is just upset for some reason." "She always cries when the person holding her has on glasses...I guess glasses scare her." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." "She typically breastfeeds, but lately we have had to supplement with some rice cereal."
