Peds Chapter 38

The nurse is collecting data on an 18-month-old child admitted with a diagnosis of possible seizures. When interviewing the caregivers, which questions would be most important for the nurse to ask?

"Have you checked your child's temperature?"

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 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."

A nurse in the emergency department (ED) is assessing a 2-year-old male child. The parents state the child "has been very feverish the past few days, and today the child developed a purple rash on the chest. The child is now very sleepy."

- lethargic -Unable to lie with hips flexed and straighten the leg out -102.4 degrees -92% on room air

The nurse is caring for a 16-year-old female client who was brought to the emergency room after having several seizures at home.

- vital signs - lab values -medications -neurological status

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply.

-The nurse pads the crib or side rails before a seizure. -The nurse positions the child on the side during a seizure. -The nurse stays with the child and calls for help when a seizure begins. -The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions.

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply.

-complaints of a stiff neck -photophobia -Vomiting

The nurse cares for an infant with myelomeningocele before surgical intervention. What action will the nurse take?

Cover the sac with a saline-moistened dressing.

The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate?

I will help you become comfortable in caring for your daughter.

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding?

Indications of increased intracranial pressure

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element?

Latex

What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?

Projectile vomiting

A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which positions postoperatively? Select all that apply.

Prone Right side lying left side lying

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele?

Risk for infection

A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis?

Sunlight is "too bright"

The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition?

Support for maintaining self-esteem because of his altered lifestyle

A nurse on the neurology unit is monitoring an 8-year-old child admitted with seizures. The child experiences a prolonged tonic-clonic seizure.

THe nurse dhould first enusre proper oxygenation followed by administer IV or IM Benzo's

During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents?

The child shouldn't participate in activities that could be hazardous if a seizure occurs

The nurse is assessing a toddler for motor function. Which activity will be the most valuable?

Watch the child reach for a toy.

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.

eye opening, verbal response, motor response,

The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which problem

head trauma

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

moving the infant's head every 2 hours

The nurse is providing preoperative care for a newborn with myelomeningocele. Which action is the central nursing priority?

prevent rupture or leaking of cerebrospinal fluid

A child was just brought into the emergency department after falling off a skateboard. The parents report that their child lost consciousness briefly and they noticed watery drainage coming from the nose. What action should the nurse take first?

Notify the emergency department health care provider of the information the parents reported.