PEDS CHAPTER 22 (PREPU LEVEL 8)
A parent of a 2-year-old toddler is concerned that the toddler has a hearing deficit because the toddler does not interact with others. After further testing, a diagnosis of hearing loss is confirmed. Which nursing instruction will be beneficial? Keep the toddler home with the family as long as possible for protection. Enroll the toddler in early preschool education with others of the same age. Begin with picture cards so identification of needs can be made. Speak loudly and directly into the toddler's ear canal.
Enroll the toddler in early preschool education with others of the same age. Explanation: Toddlers with sensory disorders often play by themselves. These children often benefit from very early preschool education programs, which expose them to interesting and stimulating tasks while their initiative is strongest. This allows them to accomplish learning tasks despite their sensory disorder. The toddler should not be kept home but encouraged to interact with others to promote growth and development. The toddler is encouraged to express needs, not point to pictures. No one should shout down the ear canal.
The nurse is performing a neurologic assessment on a 5-month-old infant. Which task should the nurse perform first? Palpate the cranium. Blow on the face. Run a cotton swab over the extremities. Whisper a word in the ears.
Palpate the cranium. Explanation: Palpating the cranium is the least invasive assessment activity and should be performed first. Blowing on the face, running a cotton swab over the extremities, and whispering a word in the infant's ears are all part of the neurologic assessment, but are more invasive and should be performed later in the assessment.
A parent calls the nurse triage line to say the child accidentally got hit in the eye and the parent believes the child will have a black eye. Which instruction is important for the nurse to provide this parent? Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours. Refer the child to an ophthalmologist for further evaluation. Assure the parent that the scleral hemorrhages will resolve. Administer acetaminophen if needed for pain.
Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours. Explanation: A black eye is caused by a simple contusion to the eye. It affects the surrounding tissue of the eye but does not affect the eye itself. It produces swelling and bruising. It also causes scleral hemorrhage due to rupture of the blood vessels. The best treatment for the contusion is to place ice on for 20 minutes then off for 20 minutes for a 24-hour period. This helps reduce the swelling and pain. The bruising (the "black" eye) occurs from the vessels broken and leaking into the tissue. This may take about 3 weeks to go away. The nurse should assure the parent that scleral hemorrhages are benign but may take several weeks to resolve. The child would not need to be referred to an ophthalmologist unless the vision is impaired. Acetaminophen can be given for pain, but it is not the most important form of treatment for the problem.
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges? Positive Kernig sign Negative Brudzinski sign Positive Chadwick sign Negative Kernig sign
Positive Kernig sign Explanation: A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy.
A nurse is preparing a presentation on neurologic development in children. What information should the nurse include in the presentation? Teratogens have little effect on a child's neurologic development. Poverty and caregiver mental illness are shown to contribute to developmental delays in children. Only a small portion of the body's total blood supply is needed to support cerebral metabolism in children. The ratio of body surface area to body weight is much less in children than in adults.
Poverty and caregiver mental illness are shown to contribute to developmental delays in children. Explanation: Poverty, child abuse, and caregiver mental illness have been shown to contribute to development delays in a child's development. An embryo's nervous system develops early in pregnancy, so it is highly susceptible to genetic alterations, maternal exposure to environmental insults, and teratogens such as infections and certain medications. Cerebral metabolism in infants and young children requires a larger, not smaller, portion of the body's blood to maintain its rapid growth and development. The ratio of body surface area to body weight in infants and very young children is much greater than, not less than, that of adults.
The nurse is caring for a 10-year-old child with bacterial conjunctivitis of the right eye. The eye is inflamed and drains a thick, yellow discharge. What should the nurse teach the parents about the care of the eye? Keep the child out of school for at least 2 weeks. Use liquid tear ophthalmic drops for 3 days. Ensure that the child keeps the eye patch on to cover the eye all at all times. Wipe the drainage away from the inner to the outer canthus of the eye.
Wipe the drainage away from the inner to the outer canthus of the eye. Explanation: Conjunctivitis is inflammation of the conjunctiva that causes pustular drainage. The eye should be cleansed from the inner to the outer canthus to prevent the spread of infection to the other eye. The child does not need to miss school for 2 weeks with this eye infection. Ophthalmic medication should be used as prescribed, which might be longer than 3 days. The eye does not need to be covered.
The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction? "I will watch my baby for irritability and difficulty feeding." "My baby's cerebrospinal fluid is increasing intracranial pressure." "The VP shunt will help drain fluid from my baby's brain." "This shunt is the only surgery my baby will need."
"This shunt is the only surgery my baby will need." Explanation: Hydrocephalus results from an imbalance in the production and absorption of CSF. In hydrocephalus, CSF accumulates within the ventricular system and causes the ventricles to enlarge, and increases in ICP subsequently occur. A VP shunt can be used to drain excess CSF, but it will need to be replaced as the child grows, requiring shunt revision surgery at various times during the client's life. The parent should be taught to monitor for signs and symptoms of increased ICP, which include irritability and vomiting. Increased ICP indicates the shunt is not functioning properly.
The nurse is performing discharge teaching with the parents of a 3-month-old infant with deformational plagiocephaly (DP). Which statement by the parents requires further follow-up by the nurse? "We do not have a bassinet, so we will use a car seat." "We will limit tummy time to about 30 to 60 minutes." "We will switch our infant's position frequently." "We will play on the floor with toys during tummy time."
"We do not have a bassinet, so we will use a car seat." Explanation: "We do not have a bassinet, so will we use a car seat," requires further follow-up by the nurse, because it is recommended to only use car seats while traveling in a car. Car seats can inhibit mobility and contribute to DP. Thirty to 60 minutes of tummy time per day, switching the client's position frequently, and playing on the floor with toys during tummy time are all recommended. Therefore, the statements, "We will limit tummy time to about 30 to 60 minutes," "We will switch our infant's position frequently," and "We will play on the floor with toys during tummy time" are all appropriate and require no further follow-up by the nurse.
A nurse is providing discharge teaching to the parents of a child hospitalized with hydrocephalus, who had a ventriculoperitoneal (VP) shunt placed. The nurse should intervene if the parents make which statement? "We will report any changes in behavior or signs of infection immediately." "We expect our child to continue engaging in normal activities, including sports." "The shunt will need to stay in place for the rest of our child's life." "The shunt may need to be repositioned as our child grows."
"We expect our child to continue engaging in normal activities, including sports." Explanation: The nurse should intervene if the parents expect the child to engage in sports. The nurse will need to determine which type of sports the child will engage in. A child with a VP shunt should avoid contact sports such as football because of the risk of shunt damage. The parents should report any changes in behavior or signs of infection immediately so that treatment can begin promptly. VP shunts are typically needed for life and have the potential to become displaced as the child grows.
An infant is diagnosed with nasolacrimal duct obstruction. The nurse is instructing the parents on how to perform lacrimal massage. The nurse determines the need for additional teaching based on which statement by the parents? "We should do the massage along with warm compresses." "We will press on the outer corner of the eye for several seconds." "We should do the massage every morning and every evening." "We should stroke the area about 10 times with each session."
"We will press on the outer corner of the eye for several seconds." Explanation: Caregivers can perform lacrimal massage at home in conjunction with applying warm compresses to open the membrane. Caregivers should place the index finger between the inner corner of the child's eye and the side of the nose and press in and down over the lacrimal sac for a few seconds. The recommended frequency of the massage technique is 10 strokes to each eye once in the morning and once in the evening.
The nurse receives a call from the parent of a 4-month-old infant who underwent endoscopic surgery for craniosynostosis 2 months earlier. The parent reports that the infant's skin appears red on the both temples. How should the nurse respond? "Your infant should be evaluated in person, because a new helmet may be needed." "It is time for your infant to stop wearing the helmet." "This is a sign of infection." "This is a normal finding after surgery; it will resolve on its own."
"Your infant should be evaluated in person, because a new helmet may be needed." Explanation: Erythema may indicate the development of pressure points as the infant's head begins to grow, in which case the infant would need a new helmet. Therefore, "Your infant should be evaluated in person, because a new helmet may be needed," is the correct response. "It is time for your child to stop wearing the helmet," is an incorrect response, because a molding helmet should be worn for 3 to 4 months after endoscopic surgery. "This is a sign of infection," is an incorrect response, because further evaluation is needed to determine the presence of an infection. "This is a normal finding after surgery; it will resolve on its own," is an incorrect response, because erythema on the temples bilaterally is a sign that pressure points are developing.
The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? Administer lorazepam IV as prescribed. Perform a glucose finger stick to determine the child's blood sugar level. Administer carbamazepine as prescribed. Observe and document the length of time of the seizure and type of movement observed.
Administer lorazepam IV as prescribed. Explanation: A seizure lasting longer than 30 minutes is considered status epilepticus and is an emergency situation. An IV benzodiazepine such as lorazepam is administered to help stop the seizure. Checking blood glucose levels, monitoring length and type of seizure, and administration of anti-seizure medication such as carbamazepine all are correct interventions for clients with seizures, but these are not the priority action.
A nursing instructor is teaching about eye disorders in childhood. Which statement made by a student indicates a need for further instruction? "Glaucoma is caused by increased intraocular pressure." "Cataracts are only present in adults." "Cataracts can be present at birth." "A cataract is a marked opacity of the lens."
"Cataracts are only present in adults." Explanation: A cataract is a marked opacity of the lens and may be present at birth. It can cause blindness if not treated early. The cataract can be removed as early as 2 weeks of age and the best results are achieved if removed by 3 months of age. Glaucoma is increased intraocular pressure causing damage to the optic nerve.
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? "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "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." "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 hate to think that I will need to be worried about my child having seizures for the rest of his life." Explanation: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.
A 1-year-old has just undergone surgery to correct craniosynostosis. When talking with the parents, which of the following would be most appropriate? "Now that the surgery was successful, do you have any questions?" "This condition only happens in 1 out of 2,000 births." "I told you yesterday there would be facial swelling." "I'll be watching his hemoglobin and hematocrit closely."
"Now that the surgery was successful, do you have any questions?" Explanation: Often what parents need most is someone to listen to their concerns. Although this is a good time for education, let the parents adjust to their baby's appearance. The nurse needs to adapt the teaching to the parents' questions, comments, and knowledge level.
The nurse is caring for a child diagnosed with aseptic meningitis. When explaining the treatment plan to the parents, which information would the nurse likely include? "Your child will need high doses of antibiotics to treat the infection." "We will monitor your child closely and keep your child comfortable." "Until your child improves, we cannot give your child anything to eat." "We will need to move your child to the intensive care unit for care."
"We will monitor your child closely and keep your child comfortable." Explanation: Aseptic meningitis is not as severe as bacterial meningitis and is usually self-limiting, requiring only supportive care. It is caused by a virus so antibiotics would not be needed. Antibiotics would be used to bacterial meningitis. Food would be withheld (NPO) if nausea and vomiting were prominent. Intensive care would be likely if the child had bacterial meningitis leading to sepsis.
During physical assessment of a 2-year-old child, the nurse suspects that the child may have a cataract in one eye based on assessment of which of the following? Sclera appears to be blue. Excess watering of the eyes. Absence of the red reflex. Edema of the eyelids.
Absence of the red reflex. Explanation: The absence of the red reflex and a white, opaque appearance of the lens are telltale signs of a cataract. A blue tinge to the sclera and excess watering of the eyes are signs of glaucoma. Edema of the eyelids is a sign of allergic conjunctivitis.
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? Cerebral edema Renal failure Left-sided heart failure Cardiogenic shock
Cerebral edema Explanation: 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. Renal failure and cardiogenic shock aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.
The nurse is preparing hospital discharge instructions for a 7-year-old girl recovering from head trauma and receiving gastrostomy feedings. Which activity is most important before the child is discharged home? Determining the parents' ability to administer the enteral feedings. Assessing the parents' emotional status. Helping the family to access financial resources. Preparing a list of home equipment and supplies needed.
Determining the parents' ability to administer the enteral feedings. Explanation: The parents' ability to maintain their child's nutrition is essential to the child's well-being. The transition can go forward while still resolving financial resource adequacy and the emotional status of the parents. Equipment and supplies will be ordered as part of discharge planning and are not needed until the parents can safely administer feedings.
Which of the following would a nurse assess in a child with pneumococcal meningitis? nuchal rigidity chills otitis media productive cough
nuchal rigidity Explanation: Pneumococcal meningitis is manifested by fever, irritability, and nuchal rigidity. Pneumococcal pneumonia is manifested by a temperature of 102 °F (38.9 °C) to 103 °F (39.4 °C), chills, productive cough, and otitis media.
A 1-year-old comes to the clinic for a routine visit. The eye examination reveals an enlarged, edematous, and hazy cornea. The child appears sensitive to light. What should the nurse suspect? Cataract Infantile glaucoma Stye Conjunctivitis
Infantile glaucoma Explanation: Glaucoma is increased intraocular pressure caused by inadequate or blocked drainage of aqueous humor. The cornea, which appears enlarged, may be edematous and hazy. In addition there may be tearing, pain, and photophobia. Conjunctivitis (pink eye) is a contagious infection of the conjunctiva. A stye (hordeolum) is a localized infection of the sebaceous gland of the eyelid. A cataract is a cloudiness or opacity of the lens of the eye. It can be congenital in children.
A nurse suspects that a child has developed pneumococcal meningitis based on assessment of which of the following? nuchal rigidity chills otitis media productive cough
nuchal rigidity Explanation: Pneumococcal meningitis is manifested by fever, irritability, and nuchal rigidity. Pneumococcal pneumonia is manifested by a temperature of 102° to 103°F (38.9° to 39.4°C), chills, productive cough, and otitis media.
A nurse has received the above hand-off report for a client hospitalized with blunt head trauma following a motor vehicle accident. What is the nurse's priority in providing care for the client? Maintain hydration. Provide pain relief. Observe for behavioral changes. Ensure adequate rest
Observe for behavioral changes. Explanation: The nurse's priority is to monitor the client for any changes in behavior. Even subtle changes such as sleepiness or lethargy could indicate worsening of the client's condition. Maintaining adequate hydration, rest, and pain relief should all be part of the nurse's plan of care, but they are not the priority.
The nurse is providing care to an infant with hydrocephalus who has had a ventriculoperitoneal shunt inserted. The nurse documents the infant's assessment. Which finding(s) would lead the nurse to notify the health care provider about the possibility that the child has developed a paralytic ileus? Select all that apply. temperature level of consciousness abdomen bowel sounds abdominal circumference incisional sites
abdomen bowel sounds abdominal circumference Explanation: A continued absence of bowel sounds coupled with an increase in abdominal circumference related to distention may indicate paralytic ileus. The other assessment parameters are within acceptable limits and do not suggest a paralytic ileus.
The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the child questions. How should the nurse document the child's level of consciousness? fully conscious stupor obtunded decreased level of consciousness
obtunded Explanation: Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Fully conscious describes a child who has no neurologic changes. Stupor exists when the child only responds to vigorous stimulation. Decreased level of consciousness is a vague term that does not describe the assessment findings.
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. oxygen gauge and tubing suction at bedside tongue blade padding for side rails smelling salts
oxygen gauge and tubing suction at bedside padding for side rails Explanation: When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.
A nurse is administering carbamazepine to a 4-year-old child diagnosed with epilepsy. The health care provider has prescribed 10 mg/kg/day by mouth. The child weighs 32 lb (14.52 kg). How many milligrams should the nurse administer? Record your answer rounded to the whole number.
145 Explanation: Multiple the child's weight in kilograms by the dose prescribed. 14.52 kg × 10 mg/kg/day = 145.2 mg/day Rounded to a whole number, the nurse administers 145 mg/day
A child has been diagnosed with strabismus. After further examination, the client is told that the resting position of the right eye is convergent. The nurse further explains that this means which of the following? The resting position of the eye is turned out. The resting position of the eye is turned in. One pupil is higher than the other. The same eye deviates constantly.
The resting position of the eye is turned in. Explanation: In strabismus, the resting position of one eye may be divergent (turned out) or convergent (turned in). One pupil may be higher than the other (vertical strabismus). Strabismus may be monocular, in which the same eye deviates constantly.
The nurse is assessing the vision of 9-year-old boy. His vision appears normal on a vision screening test, although the nurse notices that he has to tilt his head occasionally as he is reading the chart. His mother tells the nurse that he has trouble reading and reports having a headache after doing his homework. Which condition should the nurse suspect in this boy? astigmatism amblyopia myopia nystagmus
astigmatism Explanation: Astigmatism is an irregular curvature of the cornea, causing light to focus incorrectly on the retina resulting in an uneven quality of vision. On any given page of print, therefore, the child may see only half the letters or can have great difficulty reading or following written instructions. The child may report headache and vertigo after doing close work. Even though their vision appears deceptively normal on vision screening tests (they are able to see all of the numbers on a chart by tilting their head), these children need to be referred to an ophthalmologist on the basis of other problems such as vertigo, headaches, and difficulty with reading.
The nurse will help parents of a child with amblyopia understand that occluding vision in the unaffected eye is therapeutic because: occlusion relieves eye strain in the affected eye. use of the affected eye promotes vision development. the pain of amblyopia is relieved in both eyes. pupil size in the affected eye will increase.
use of the affected eye promotes vision development. Explanation: When lack of convergence of an image creates unclear vision in a child, vision is suppressed in one eye, resulting in disuse and lack of visual development. Occluding the unaffected eye forces use of the affected eye and development of vision. Occlusion does not impact eye strain, pain, or pupil size.
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? serum glucose level hemoglobin level white blood cell count urinalysis
serum glucose level Explanation: Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expend energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review.
The nurse has finished teaching the mother of a 5-year-old male diagnosed with bacterial conjunctivitis how to manage her son's infection at home. Which statement by the mother would indicate a need for further education? "I will use a warm compress to help loosen crust that accumulated on his eyelid overnight." "I will wash my hands immediately after caring for him." "I will use Visine drops in his infected eye to help reduce redness." "I will encourage my son to not touch his eyes."
"I will use Visine drops in his infected eye to help reduce redness." Explanation: Using a warm compress to remove crust from eyelids, washing hands frequently, and refraining from touching infected eyes are all ways to help manage bacterial conjunctivitis and prevent spreading the infection. Visine should not be used as it does not treat the cause of the infection and can cause rebound redness.
The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child? Inability to articulate the sounds of the letter 'R' and "S" when vocalizing A delay or lack of clear, understandable speech pattern Purulent draining from one or both ears associated with pain behaviors A history of supplemental oxygen use at birth or shortly after birth
A delay or lack of clear, understandable speech pattern Explanation: A hearing impairment will often cause a delay or absence of normal speech and language development in a child. Toddlers typically do not vocalize the sounds of the letter 'R" and "S" until older. Purulent drainage may represent an ear infection. Oxygen at birth may be problematic for vision, but not hearing.
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. Which of the following would the nurse include as characteristic of a seizure? Select all that apply. Cyanosis occurs at the onset of the seizure. Convulsive activity occurs. The client is bradycardic. The EEG is normal. Crying is not typically noted.
Convulsive activity occurs. Crying is not typically noted. Explanation: During seizures, crying is not typically noted while convulsive activity typically occurs. During a breath-holding spell, the child is bradycardic, cyanosis occurs at the onset, and the EEG is normal.
The nurse is providing care to an infant with microcephaly. When reviewing the prenatal and birth history, the nurse would identify the mother's exposure to which infection as a potential contributing factor? Candida cytomegalovirus gonorrhea chlamydia
cytomegalovirus Explanation: Microcephaly is diagnosed as either primary, in which a genetic, chromosomal, or hereditary cause is implicated, or secondary, in which the defect occurs as a result of exposure to irradiation, maternal infection with toxoplasmosis, rubella, or cytomegalovirus, or maternal use of alcohol or tobacco. Candida, gonorrhea, or chlamydia are not associated with microcephaly.
The nurse is assessing a child with a suspected traumatic brain injury. The child is disoriented to place and time, but not person, and is having difficulty following commands. The nurse would use which terminology to document the child's level of consciousness? clouding of consciousness confusion obtundation stupor
confusion Explanation: Based on the assessment, the child is exhibiting confusion. A clouding of consciousness is reflected by the child being inattentive and sleepy. Obtundation is demonstrated by blunted senses, where the child requires mild-to-moderate stimulation to be aroused and is more sleepy than usual. A child who is stuporous responds to vigorous stimulation only.
Antibiotic therapy to treat meningitis should be instituted immediately after which event? Admission to the nursing unit Initiation of IV therapy Identification of the causative organism Collection of cerebrospinal fluid (CSF) and blood for culture
Collection of cerebrospinal fluid (CSF) and blood for culture Explanation: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of IV therapy aren't, by themselves, appropriate times to begin antibiotic therapy.
A young child in the clinic has watery eyes and reddened conjunctiva. The child keeps the eyes closed a lot, because it hurts to have them open. Which problem does the nurse suspect for this client? Chalazion Stye Conjunctivitis Blepharitis marginalis
Conjunctivitis Explanation: Conjunctivitis is inflammation of the conjunctiva and is demonstrated by watery eyes with reddened conjunctiva and sensitivity to light. Sticking of eyelids with pustular drainage is also a sign. It is very contagious and requires antibiotics for treatment. Blepharitis is a chronic scaling with discharge along the eyelid margin. A stye is a localized infection of the sebaceous gland of the eyelid. A chalazion is a chronic painless infection of the meibomian gland. The stye and blepharitis will require antibiotic treatment. A chalazion will clear on its own.
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? Take vital signs every 4 hours Monitor temperature every 4 hours Decrease environmental stimulation Encourage the parents to hold the child
Decrease environmental stimulation Explanation: A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.
The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing in the figure. The nurse is aware that this type of posturing is the result of injury to what area? brain stem cerebral cortex frontal lobe mid-cervical
brain stem Explanation: Decerebrate posturing is seen with injuries occurring at the level of the brain stem. Decorticate posturing occurs with damage of the cerebral cortex. Both types of posturing are characterized by extremely rigid muscle tone. Injuries to the frontal lobe of the brain and the mid-cervical spine would not cause these types of posturing.
A toddler is prescribed amoxicillin for bilateral otitis media. The parent reports that the toddler refuses to take the oral medication. The nurse knows that more education is needed when the parent makes which statement? "I will shake the medication well, and draw up the amount prescribed in the medicine spoon you gave me. I will hold my toddler upright so he does not choke, and I will let him drink the medicine off the spoon." "I will shake the medication well, and draw up the amount prescribed in the syringe you gave me. I will hold my toddler upright so he does not choke, and I will squirt the medication along the gum line." "I will shake the medication well, and draw up the amount prescribed. I will allow my toddler to suck in the medication while I hold him." "I will shake the medication well, and draw up the medication to the top of the syringe. My spouse and I will hold our toddler down and force the medication down his throat."
"I will shake the medication well, and draw up the medication to the top of the syringe. My spouse and I will hold our toddler down and force the medication down his throat." Explanation: The objective of administering oral medications is to administer the entire dose to the toddler while creating the least aversion to the medication as possible. No force should be used. Allowing the toddler to take the medication slowly from a medicine spoon or syringe is one way to reduce aversion.
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 always cries when the person holding her has on glasses...I guess glasses scare her." "She typically breastfeeds, but lately we have had to supplement with some rice cereal." "She has been irritable for the last hour....seems like she is just upset for some reason." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper."
"She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.
A 3-month-old infant is diagnosed with mild craniosynostosis. When teaching the parents about treatment, which information would the nurse likely include? "Your infant will need to be hospitalized to have open surgery to completely correct this problem." "It is likely your infant will need minimally invasive surgery once the infant reaches 6 months of age." "Your infant will need to wear a helmet after the defect is corrected for most hours of the day." "Treatment focuses on making sure to reposition your infant frequently when lying down."
"Your infant will need to wear a helmet after the defect is corrected for most hours of the day." Explanation: Craniosynostosis is treated by surgery to release the fused suture(s) and to achieve cosmetic improvements for facial and head deformities. Surgery is done before the infant is 6 months of age to achieve the best outcome. Endoscopic surgery is done on infants up to 6 months old and is minimally invasive, but it still requires that the infant wear a helmet afterward. Open surgery is reserved for infants older than 6 months and is done to reshape moderate to severe malformations. Infants receiving open surgery are typically hospitalized for 3 or 4 days because absorbable plates and screws are used to hold the repaired cranial sections in place. A molding helmet is indicated postoperatively for an infant who has a mild deformation or has had endoscopic surgery and should be worn for 23 hours per day for 3 to 4 months. An infant who has had open surgery does not need a helmet to form the cranium postoperatively. Repositioning the infant frequently is a conservative treatment used for infants with deformational plagiocephaly.
The nurse is assessing a 9-year-old child who is suspected of having meningitis. The nurse assesses the child for meningeal irritation using the Kernig sign. Which result would the nurse interpret as positive? Child reports pain behind the knee when leg is extended. Child reports pain when head is raised toward the chest. Child immediately flexes the knees when chin touches chest. Child flexes hips when placed in the supine position.
Child reports pain behind the knee when leg is extended. Explanation: When testing for the Kernig sign, the nurse would lay the child supine with the hips flexed and then try to straighten a leg out. The test is positive if pain behind the knee is experienced when the leg is extended. Younger children may cry out or resist leg extension. Another test for meningeal irritation is the Brudzinski sign. With this test, the nurse lays the child flat and then attempts to raise the child's head toward the chest and place the chin on the chest. Meningeal irritation is present if the child indicates pain or resistance or the child immediately flexes the hips and knees.
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 delayed development Risk for injury Risk for ineffective tissue perfusion: cerebral Risk for self-care deficit: bathing and dressing
Risk for injury Explanation: A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures are the most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to an inability to swallow. All of these symptoms would make Risk for injury the highest priority.
A 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication? Take medication on an empty stomach. Increase intake of citrus foods to promote absorption. Use a soft toothbrush. Avoid excessive sunlight.
Use a soft toothbrush. Explanation: Phenytoin is an anticonvulsant medication. It can be used in the management of seizure disorders. This medication is associated with gingival hyperplasia. This may result in tender and bleeding gums. The use of a soft toothbrush will reduce pain, bleeding and discomfort. There is no need to take this medication on an empty stomach or with citrus foods and beverages. The medication does not make an individual photosensitive.
A group of nursing students are reviewing information about the different types of hearing impairment. The students demonstrate understanding of the information when they identify which of the following as a possible cause of a conductive hearing impairment? Select all that apply. injury to the inner ear brain injury cerumen blockage fluid in the middle ear tympanic membrane scarring
cerumen blockage fluid in the middle ear tympanic membrane scarring Explanation: Possible causes of conductive hearing impairment include blockage by cerumen or a foreign object, fluid in the middle ear, and tympanic membrane scarring. Damage to the inner ear by disease or injury is a possible cause of sensorineural hearing impairment. Brain injury is a cause of central hearing impairment.
The nurse is caring for a child with hearing loss due to damage from chronic inner ear infections. The nurse knows that the child most likely has which type of hearing loss? conductive sensorineural mixed hearing loss central auditory dysfunction
conductive Explanation: Otitis media, middle ear infection, can cause damage to the structures of the middle ear, which can result in conductive hearing loss. Sensorineural hearing loss involves the dysfunction of the nerves and central auditory dysfunction involves dysfunction within the central nervous system.
A nurse is caring for a 1-year-old child with a head injury. The child was previously unconscious but is now alert and oriented. Oral feedings are prescribed. The nurse determines that the child's risk for aspiration is low based on the presence of which reflex(es)? Select all that apply. Babinski Moro gag cough swallow
gag cough swallow Explanation: If the child is conscious and able to take nutrition by mouth, the nurse would elicit the gag, cough, and swallow reflexes to confirm that the child can swallow and thus be a low risk for aspiration. The Moro reflex (startle reflex) typically disappears by 5 to 6 months of age and should not be present. The Babinski reflex is typically present up to 1 year of age and should be negative thereafter. Neither the Moro or Babinski reflex are associated with swallowing.
The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? tachypnea hyperthermia poor handwriting hypertension
hypertension Explanation: Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP.
A child is brought to the emergency department and is experiencing status epilepticus. The nurse would expect to administer which treatment as first-line therapy? phenytoin lorazepam fosphenytoin midazolam
lorazepam Explanation: In the acute care setting, first-line therapy is a benzodiazepine (lorazepam as first choice) given intravenously, followed by phenytoin or fosphenytoin, then phenobarbital, valproate, or levetiracetam. If the seizures persist, an infusion of midazolam, pentobarbital, or propofol may be started.
The nurse is assessing a 4-year-old child whose mother reports that the child is more irritable lately. Which of the following questions would the nurse ask to elicit information suggesting possible increased intracranial pressure (ICP)? "Has there been a change in your child's hearing?" "Does she vomit frequently?" "What immunizations has she had?" "Does she have headaches when she gets out of bed?"
"Does she have headaches when she gets out of bed?" Explanation: Headache is a common symptom of increased intracranial pressure at all ages. Increased intracranial pressure is frequently accompanied by morning headaches caused by the child moving from the bed to a standing position. Although increased ICP can cause vomiting, frequent vomiting might indicate Chiari malformation. Immunization status provides information about infection and meningitis. A change in the level of hearing is not associated with most conditions that cause increased ICP.
The nurse is reviewing discharge planning instructions with the parents of a child who had a ventriculoperitoneal (VP) shunt placed. Which statement by the parents requires further follow-up by the nurse? "Our child may have occasional lethargy." "We will watch for changes in behavior at home." "Our child should be monitored for poor feeding." "If our child has vomiting, something may be wrong with the shunt."
"Our child may have occasional lethargy." Explanation: Lethargy, changes in behavior, poor feeding, and nausea and vomiting may indicate that the shunt has become infected, clogged, or kinked or has developed a blood clot. The statement "Our child may have occasional lethargy," requires further follow-up by the nurse, because this is not an expected symptom during recovery from VP shunt placement. The statement by the parents may indicate that they will not take action if the child becomes lethargic, and the nurse should clarify that lethargy may indicate that a complication with the shunt has occurred.
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 Brief, sudden contracture of a muscle or muscle group Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention
Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Explanation: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.
To give eardrops to a 4-year-old child, what would be the best technique to use? Pull the pinna of the ear downward. Lift the pinna of the ear down and back. Press the pinna of the ear forward. Pull the pinna of the ear up and back.
Pull the pinna of the ear up and back. Explanation: Pulling the pinna upward and back straightens the ear canal in the child older than 3 years of age. To administer otic drops to a child younger than 3 years, the pinna would be pulled downward and back. Pressing the pinna of the ear forward or downward would occlude the ear canal.
The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse? Place the child in a bathtub filled with cool water. Apply ice packs to the child's axillary and groin area. Administer acetaminophen by mouth as prescribed. Remove any blankets or heavy clothing and replace with a thin sheet
Remove any blankets or heavy clothing and replace with a thin sheet Explanation: The child should not have any blankets or clothing that would elevate the temperature further. Removing them is helpful in allowing the heat to dissipate. The child should not be placed in a bathtub because he or she may suffer another seizure and slip underwater. Using ice packs or alcohol can be a shock to an immature nervous system. Antipyretics should be administered as a suppository rather than PO to reduce the risk of aspiration while the child is in the postictal or drowsy state following the seizure.
The nurse is preparing the plan of care for an infant with hydrocephalus who is scheduled for insertion of a ventriculoperitoneal shunt. Which intervention(s) would the nurse likely include for this child preoperatively? Select all that apply. daily chest circumference measurements administration of intravenous antibiotics baseline abdominal circumference measurement frequent head position changes elevation of the head of the bed to 45 degrees
administration of intravenous antibiotics baseline abdominal circumference measurement frequent head position changes Explanation: Preoperatively, nursing care focuses on frequently changing the position of the child's head to prevent impaired skin integrity due to thinning of the skin of the scalp and prolonged pressure on any one area. The child also receives IV antibiotics preoperatively to prevent an infection, and acetazolamide or furosemide to decrease cerebrospinal fluid production or help remove excess fluid. In addition, it is important to obtain head circumference and baseline abdominal circumference before surgery, because paralytic ileus may be a complication after surgery. Measuring chest circumference is inappropriate. Postoperatively, the head of the bed should be no higher than 30 degrees.
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? change in level of consciousness reduction in heart rate increase in heart rate decline in respiratory rate
change in level of consciousness Explanation: A change in the level of consciousness is the initial finding in the client who is experiencing an increase in intracranial pressure.
The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant? placing the infant supine in the crib after feeding the infant placing the infant in an infant car seat after feeding the infant placing the infant prone in the crib after feeding the infant placing the infant in a Sims position in the crib after feeding the infant
placing the infant in an infant car seat after feeding the infant Explanation: Placing a child or infant in the semi-Fowler position can help reduce cerebral edema and pressure. Using an infant child seat helps to simulate the raised head of the bed. In the supine position, the client is completely flat on his or her spine. Prone is face down and flat. Sims is a side-lying position with one leg flexed. All of the described positions place the client flat, not with the head raised; that would be in the semi-Fowler position.
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."
"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." Explanation: Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Meningococcal conjugate vaccine protects against four types of meningitis. There is nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the infection, or that the adolescent's immune system is compromised.
The mother of a 10-day-old infant reports her baby has been having "lots of eye discharge." What is the best initial response by the nurse? "This is normal in infants of this age." "Tell me more about this drainage." "Do you think this looks like an infection?" "Your baby will need to be seen by a neonatal ophthalmologist."
"Tell me more about this drainage." Explanation: Tearing or discharge from one or both eyes is often first noted at the 2-week checkup. Obtain a thorough history about the eye drainage to distinguish it from neonatal conjunctivitis. Determine the onset and progression of symptoms, as well as the newborn's response to any interventions attempted so far. The best response by the nurse is an attempt to obtain additional information. Telling the child's mother this is normal in the absence of additional information is inappropriate. Asking if this looks like an infection is asking the child's mother to make a diagnosis. There is no need at this time to consult an eye specialist.
A 1-month-old infant is brought to the clinic for a checkup. The nurse documents the assessment. The nurse would anticipate preparing the infant and parents for which test to confirm the diagnosis? skull x-ray head computed tomography lumbar puncture electroencephalogram
head computed tomography Explanation: The nurse would suspect craniosynostosis. Diagnosis of craniosynostosis is based on computed tomography (CT) scans and magnetic resonance imaging (MRI), which also help determine which sutures are fused. A skull x-ray, lumbar puncture, or electroencephalogram are not used to confirm the diagnosis of craniosynostosis.
