CLAEX CH 16 NEURO

The nurse determines that a child is experiencing late signs of increased intracranial pressure based on assessment of which of the following? Select all that apply. Irregular respirations Bradycardia Sunset eyes Fixed dilated pupils Increased blood pressure

Late signs of increased intracranial pressure include bradycardia, fixed and dilated pupils, and irregular respirations. Increased blood pressure and sunset eyes are early signs of increased intracranial pressure.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which of the following interventions would be most appropriate? Have the child sleep without a pillow under his head. Have the parents call the doctor if the child vomits more than twice. Review the signs of increased intracranial pressure with parents. Teach the child and his parents to keep a headache diary.

Teach the child and his parents to keep a headache diary. headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress.

A 6-year-old has had a viral infection for the past 5 days and is now having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which of the following questions? "Did you use any medications like aspirin for the fever?" "Did you give your child any acetaminophen, such as Tylenol?" "How high did his temperature rise when he was ill?" "What type of fluids did your child take when he had a fever?"

"Did you use any medications like aspirin for the fever?"Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection.

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? "Always keep his head raised 30 degrees." "Limit the amount of television he watches." "Watch for changes in his behavior or eating patterns." "Call the doctor if he gets a headache."

"Watch for changes in his behavior or eating patterns."Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure.

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which of the following as a neural tube defect? Spina bifida occulta Encephalocele Anencephaly Arnold-Chiari malformation

Arnold-Chiari malformationArnold-Chiari malformation is a deformity of the cerebellar tonsils being displaced into the upper cervical canal. all others neuro tube defects

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which of the following as a risk factor for hemorrhagic stroke? Congenital heart defect Sickle cell disease Meningitis Arteriovenous malformations (AVMs)

Arteriovenous malformations (AVMs) Meningitis or other infection is a risk factor for ischemic stroke. all others ishmeic stroke

The nurse assesses a child and finds that the child's pupils are pinpoint. The nurse interprets this finding as indicating which of the following? Seizure activity Brain stem dysfunction Intracranial mass Brain stem herniation

Brain stem dysfunction Pinpoint pupils are commonly observed in poisonings, brain stem dysfunction, and opiate use.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for which of the following? Closed head injury Intracranial hemorrhaging Congenital hydrocephalus Positional plagiocephaly

Closed head injury A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for closed head injury.

During the physical assessment of a 2r-month-old infant, the nurse suspects the child may have hydrocephalus. Which of the following signs or symptoms was observed? Dramatic increase in head circumference Pupil of one eye dilated and reactive Posterior fontanel is closed Vertical nystagmus

Dramatic increase in head circumference A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which of the following interventions should the nurse take initially? Palpate the child's fontanels. Educate the family about preventing bacterial meningitis. Encourage the mother to hold and comfort the infant. Institute droplet precautions in addition to standard precautions.

Institute droplet precautions in addition to standard precautions.Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Palpating the fontanels is used to assess for hydrocephalus.Educating the family about preventing bacterial meningitis would be appropriate later on once the initial infection has been controlled.Encouraging the mother to hold and comfort the child is an intervention but not the priority one: the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread.

While observing a child, the nurse notes that the child's arms and legs are extended and pronated. The nurse interprets this as indicating damage to which of the following? Meninges Cerebral cortex Cranial nerves Midbrain

Midbrain The observations indicate decerebrate posturing, which occurs with damage to the midbrain. Meningeal irritation as with bacterial meningitis is manifested by opisthotonus in an infant. With this position, the head and neck are hyperextended to relieve discomfort.Decorticate posturing as evidenced by arm adduction, elbow flexion with arms over the chest, and wrist flexion with fisted hands indicates damage to the cerebral cortex.Damage to the cranial nerves would be manifested by defects in motor and/or sensory function depending on the cranial nerves affected.

When assessing a neonate for seizures, which of the following would the nurse expect to find? Select all that apply. Tachycardia Jitteriness Elevated blood pressure Ocular deviation Tonic-clonic contractions

Tachycardia Jitteriness Elevated blood pressure Ocular deviation Neonatal seizures may be difficult to recognize but may be manifested by tremors, jitteriness, tachycardia and elevated blood pressure, and ocular deviation. Tonic-clonic contractions typically are more common in older children.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. Which of the following would the nurse assess? Select all that apply. Motor response Eye opening Verbal response Posture Fontanels

The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which of the following interventions is most effective for eliminating breakthrough seizures? Treating the child as though she did not have epilepsy Placing the child on her side on the floor Understanding the side effects of medications Instructing her teacher how to respond to a seizure

Understanding the side effects of medications The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them.

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the following in the order that reflects this progression. oriented to person place time disoriented stupor coma obtundation

oriented to person place time Disoriented obtundation Stupor Coma Levels of consciousness in order from most alert to least alert are orientated to person, place, and time (full consciousness); confusion (disorientation); obtundation; stupor; and finally coma.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate? "During delivery, your vaginal wall put pressure on the baby's head." "It's normal for this to happen, but they don't really know why." "Your baby's head became blocked inside your vagina while you were pushing." "The forceps used during delivery caused this to happen."

"During delivery, your vaginal wall put pressure on the baby's head." Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery

A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate to give in this situation? Select all that apply. Lorazepam Carbamazepine Diazepam Fosphenytoin Gabapentin

Commonly used medications for treating status epilepticus include lorazepam, diazepam, and fosphenytoin. Gabapentin and carbamazepine are anticonvulsants used to treat and prevent seizures in general.

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. Which of the following would the nurse identify as a possible trigger? Swimming twice a week Use of nonscented soap Drinking three cans of diet cola 11 p.m. bedtime; 6:30 a.m. wake-up

Drinking three cans of diet cola Cola contains caffeine, which is an associated trigger.

A child is diagnosed with aseptic meningitis. The child's mother states, "I don't know where she would have picked this up." The nurse prepares to respond to the mother, based on the understanding that this disorder is most likely caused by which of the following? Haemophilus influenza type B Enterovirus Escherichia coli Streptococcus group B

Enterovirus Aseptic meningitis is the most common type of meningitis, and if a causative organism can be identified, it is usually a virus such as enterovirus. H. influenza type B is a cause of bacterial meningitis. E. coli is a cause of bacterial meningitis. Streptococcus group B is a cause of bacterial meningitis.

The nurse is caring for an 8-year-old girl who was in a car accident. Which of the following would lead the nurse to suspect a concussion? The child is bleeding from the ear and draining fluid from the nose. 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 easily distracted and can't concentrate. A child with a concussion will be distracted and unable to concentrate.

A mother has brought her 5-month-old son to the clinic because he has been drowsy and unresponsive. The child has hydrocephalus and had a shunt placed about a month previously. Which of the following symptoms indicate that the shunt is infected? The child has a high-pitched cry. The fontanels are bulging or tense. The child is not responding or eating well. The child's pupil reaction time is rapid and uneven.

The child is not responding or eating well. Poor feeding and decreased responsiveness are signs of an infection. The nurse might also observe localized inflammation along the shunt tract.

After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on which of the following? The swelling is limited to one small area without crossing the sagittal suture. The infant had a low birthweight when born at term. The swelling crosses the midline of the infant's scalp. The infant had low-set ears and facial abnormalities.

The swelling crosses the midline of the infant's scalp.The fact that the swelling crosses the midline of the infant's scalp indicates caput succedaneum. If the swelling is limited and does not cross the midline or suture lines, it would suggest cephalohematoma.Low birthweight does not suggest caput succedaneum.Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele.

A nurse is providing information to the parents of a child diagnosed with absence seizures. Which of the following would the nurse expect to include when describing this type of seizure? Select all that apply. The child will commonly report a strange odor or sensation before the seizure. You might have mistaken this type of seizure for lack of attention. Your child will probably sleep deeply for r to 2 hours after the seizure. This type of seizure is usually short, lasting usually for no more than 30 seconds. You might see a blank facial expression after a sudden stoppage of speech. This type of seizure is more common in girls than it is in boys.

You might have mistaken this type of seizure for lack of attention. This type of seizure is usually short, lasting usually for no more than 30 seconds. You might see a blank facial expression after a sudden stoppage of speech. This type of seizure is more common in girls than it is in boys. Absence seizures are more common in girls than boys and are characterized by a sudden cessation of motor activity or speech with a blank facial expression or rhythmic twitching of the mouth or blinking of the eyelids. This type of seizure lasts less than 30 seconds and may have been mistaken for inattentiveness because of the subtle changes. Absence seizures are not associated with a postictal state.