PEDS EXAM 2

CH16: The nurse is caring for a 3-year-old child who experienced a febrile seizure for the first time. What statements by the parents of the child should the nurse address further? Select all that apply.

"I am afraid that our 10-year-old will start having febrile seizures." "It is so scary to think that our child will likely develop epilepsy now." Rationale: It is very unlikely that the 10-year-old child will develop febrile seizures. Febrile seizures usually affect children who are younger than 5 years of age, with the peak incidence occurring in children between 12 and 18 months old; it is rare to see febrile seizures in children younger than 6 months and older than 5 years of age. Children who experience one or more simple febrile seizures have a slightly greater risk of developing epilepsy than the general population, so it is not "likely" that the child will develop epilepsy.

CH16: 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?

"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Rationale: 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.

The nurse takes an infant's apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant?

100 bpm

CH16: The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III?

A bright-colored toy is moved in the child's visual fields. Rationale: Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement.

CH16: A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room?

A private room near the nurses' station Rationale: A child who has the diagnosis of bacterial meningitis will need to be placed in a private room until he or she has received IV antibiotics for 24 hours because the child is considered contagious. Additionally, bacterial meningitis can be quite serious; therefore, the child should be placed near the nurses' station for close monitoring and easier access in case of a crisis.

The nurse is conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention?

Accentuated third heart sound An accentuated third heart sound is suggestive of sudden ventricular distention. Decreased blood pressure; cool, clammy, and pale extremities; and a heart murmur are all associated with cardiovascular disorders. However, these findings do not specifically indicate sudden ventricular distention.

CH19: When does the fetal heart present?

Around postconceptual day 17.

The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first?

Assess blood pressure in all extremities.

CH16: Meningitis medication

Ceftriaxone, Vancomycin

CH16: 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 Rationale: 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.

CH16: 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 Rationale: A change in the level of consciousness is the initial finding in the client who is experiencing an increase in intracranial pressure.

CH16: Vagal nerve stimulator

Connects to the vagal nerve because sometimes seizures can be stopped with this stimulation

CH16: The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse will be correct in telling the parent which information in regard to seizures?

Convulsive activity often occurs in seizures Rationale: During seizures, convulsive activity is typically noted. Breath-holding spells are typically provoked by pain or the child being upset, have a normal EEG pattern, and are typically outgrown by the time the child reaches preschool age.

Most likely observe when assessing a client with congenital adrenogenital hyperplasia

Enlarged clitoris

CH16: 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:

Enterovirus Rationale: 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.

CH16: 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 Rationale: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

Diuretics for HF

Furosemide

CH16: Expected meningitis in hospital leads to...

ISOLATION

A 12-year-old child is diagnosed with hyperthyroidism. What problem would the nurse anticipate the child may have in school?

Inability to submit neat handwriting assignments

An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply?

Ineffective tissue perfusion related to inefficiency of the heart as a pump

CH19: The primary health care provider has prescribed intravenous furosemide for a child diagnosed with congestive heart failure (CHF). Which action will the nurse take when administering this medication?

Infuse no more than 4 mg per minute. Rationale: Diuretics such as furosemide, along with fluid restriction in the acute stages of CHF, help to eliminate excess fluids in the child with congestive heart failure. The nurse would administer no more than 4 mg of IV furosemide per minute to prevent ototoxicity

CH16: The young child has been diagnosed with bacterial meningitis. Which nursing interventions are appropriate? Select all that apply.

Initiate droplet isolation Identify close contacts of the child who will require post-exposure prophylactic medication Administer antibiotics as ordered Initiate seizure precautions Rationale: The child with bacterial meningitis should be placed in droplet isolation until 24 hours following the administration of antibiotics. Close contacts of the child should receive antibiotics to prevent them from developing the infection. The nurse should administer antibiotics and initiate seizure precautions. Children with bacterial meningitis have an increased risk of developing problems associated with increased intracranial pressure.

CH16: treatment for Reyes syndrome

Mannitol (for cerebral edema), monitor ICP

CH19: Disorders with increased pulmonary blood flow

Patent ductus arteriosus (PDA) Atrial septal defect (ASD) Ventricular septal defect (VSD) L—>R

A nurse is teaching a child with type 1 diabetes mellitus how to self-inject insulin. Which method should she recommend to the child for regular doses?

Subcutaneously in the outer thigh

CH16: febrile seizure

Sudden high fever, short 15 seconds to longer

CH16: 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 Rationale: Until seizure control is certain, clients shouldn't participate in activities (such as riding a bicycle) that could be hazardous if a seizure were to occur.

CH19: The child has returned to the nurse's unit following a cardiac catheterization. The insertion site is located at the right groin. Peripheral pulses were easily palpated in bilateral lower extremities prior to the procedure. Which finding should be reported to the child's physician? Select all that apply.

The child's right foot is cool with a pulse assessed only with the use of a Doppler. The child has a temperature of 102.4° F (39.1° C). The child is reporting nausea.

CH16: Which of these age groups has the highest actual rate of death from drowning?

Toddlers Rationale: Toddlers and older adolescents have the highest actual rate of death from drowning.

CH16: 2 types of meningitis, which is more severe?

Viral and bacterial (most severe, sepsis)

CH16: The nurse is assessing a toddler for motor function. Which activity will be the most valuable?

Watch the child reach for a toy Rationale: Watching the child reach for a toy would be most valuable for assessing motor function because the infant should be able to extend extremities to a normal stretch.

CH19: Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?

altered cardiopulmonary tissue perfusion risk Rationale: Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion.

CH16: A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?

"Did you use any medications, like aspirin, for the fever?" Rationale: 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.

CH16: 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." Rationale: Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery.

CH16: 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." Rationale: 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.

When educating the family of an infant with a small, asymptomatic atrial septal defect (ASD), what information would be included in the education?

"Most infants do not need surgical repair for this."

CH16: 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." Rationale: 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.

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?

"Sometimes it is hard to tell what products may contain aspirin." Rationale: Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. Two common medications containing salicylates are bismuth subsalicylate and effervescent heartburn relief antiacid.

A 10-year-old child has been diagnosed with type 1 diabetes. The child is curious about the cause of the disease and asks the nurse to explain it. Which explanation will the nurse provide?

"Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood."

CH19: A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?

"We can stop the penicillin when her symptoms disappear." Rationale: For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

CH19: The nurse is caring for a 7-year-old who is being discharged following surgery with a Gore® Helex device to repair an atrial septal defect. The parents of the child demonstrate understanding of the procedure with which statements? Select all that apply.

"We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed."

CH16: Define epilepsy

2 recurrent or unprovoked seizures at least 24 hours apart or a single unprovoked seizure during a time period of 10 years following 2 unprovoked seizures

Which nursing diagnosis would best apply to a child with rheumatic fever?

Activity intolerance related to inability of heart to sustain extra workload Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness.

CH19: What is Congenital HD?

Anatomic abnormalities that prevent normal cardiac circulation to the pulmonary system and/or to the systemic system.

The parents of a child who was diagnosed with diabetes insipidus ask the nurse, "How does this disorder occur?" When responding to the parents, the nurse integrates knowledge that a deficiency of which hormone is involved?

Antidiuretic hormone

The primary health care provider has ordered a thyroid scan to confirm the diagnosis of hyperthyroidism. Which would the nurse do before the scan?

Assess the client for allergies.

CH16: 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?

Assess the client's respiratory status. Rationale: 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.

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection?

Avoid drawing a blood specimen from the right femoral vein before the procedure

CH16: Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis?

Avoid making noise when in the child's room. Rationale: Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch.

CH16: Infectious disorders of the neurological system

Bacterial meningitis Aseptic meningitis (viral) Encephalitis Reye's Syndrome (rare)

CH16: 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. Rationale: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear)

CH16: Hydrocephalus

Born with it Congenital disorder: fluid-filled ventricles May see signs of ICP

CH16: Meningitis ICP findings

Bradycardia, HTN, respiratory aspirations

CH16: 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 Rationale: Decerebrate posturing is seen with injuries occurring at the level of the brain stem.

Cushings Syndrome

Caused by overproduction of the adrenal hormone cortisol

CH19: The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?

Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl. Rationale: Total cholesterol levels below 170 mg/dl and LDL levels less than 100 mg/dl are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dl and LDL levels greater than or equal to 130 mg/dl are considered elevated and place this child at greatest risk.

CH19: Obstructive disorders

Coarctation of the aorta Aortis stenosis Pulmonary stenosis

CH16: Which can only have an aura?

Complex partial or generalized tonic clonic (more common)

The nurse is seeing a new client in the clinic who reports polyuria and polydipsia. These conditions are indicative of which endocrine disorder?

Diabetes insipidus (DI)

CH26: Posterior pituitary

Diabetes insipidus (DI) Syndrome of inappropriate anti diuretic hormone (SIADH) secretion

CH16: What can lumbar puncture tell us?

Diagnostic tool for meningitis

CH16: How to stop status epilepticus

Diazepam or Lorazepam Follow with phenobarbital

CH16: Hydrocephalus pharmacological therapy

Diuretics Anticonvulsants Antibiotics

Common cause of hyperthyroidism

Graves disease

A child is diagnosed with hyperthyroidism. What finding would the nurse expect to assess?

Heat intolerance

Christen Sign

Irritability of the facial nerve

CH19: What is perfusion?

It is blood moving through the tissues and how well or or how poor the tissues receive that blood

CH16: Absence seizures are marked by what clinical manifestation?

Loss of motor activity accompanied by a blank stare Rationale: An absence seizure consists of a sudden, brief arrest of the child's motor activity accompanied by a blank stare and loss of awareness. A tonic seizure consists of a brief onset of increased tone or muscle. A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. An atonic seizure involves a sudden loss of muscle tone and loss of consciousness.

Which results would indicate to the nurse the possibility that a neonate has congenital hypothyroidism?

Low T4 level and high TSH level Screening results that show a low T4 level and a high TSH level indicate congenital hypothyroidism and the need for further tests to determine the cause of the disease.

Stenosis means...

Narrowing

CH16: Findings for CSF, in diagnosing viral meningitis

Normal glucose, small increase protein and WBC Clear, negative gram stain

CH19: A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?

Notify the doctor immediately Rationale: The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed.

CH16: 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 Padding for side rails Rationale: 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 assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?

Positive Kernig sign Rationale: 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.

CH19: Where does pressure occur with baby's first breath?

Pressure becomes greater on the LEFT, so the foramen ovals closes due to the pressure in the L atrium increase

CH16: While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority?

Protect the child from hitting the arms against the bed. Rationale: Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may be indicated to stop the seizure.

CH16: Main intervention for meningitis

RESTRICT FLUIDS

CH16: 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?

Remove any blankets or heavy clothing and replace with a thin sheet Rationale: 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.

CH19: A child with a cardiac structural defect is receiving oxygen therapy. In which position should the child be placed to promote optimal benefits?

Semi-Fowler Rationale: Due to the hemodynamic changes accompanying the underlying structural defect, oxygenation is key. Provide frequent ongoing assessment of the child's cardiopulmonary status. Assess airway patency and suction as needed. Position the child in the Fowler or semi-Fowler position to facilitate lung expansion.

CH16: Need to assess during postictal state?

Swallowing

An elementary school child takes metformin three times each day. Which disorder would the school nurse expect the child to have?

T2DM

CH16: A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate?

Teach the child and his parents to keep a headache diary. Rationale: A 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.

CH16: 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. Rationale: Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.

CH19: What to do when patient is having tet spells?

Tell pt knee to chest, calm them, administer oxygen or fluids

CH16: 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 should first ensure proper oxygenation followed by administer intravenous (IV) or intramuscular (IM) benzodiazepine

CH16: Name generalized seizures

Tonic-clonic Absence Myoclonic Atonic/Akinetic

An infant on the pediatric floor has diabetes insipidus. Which assessment data are important for the nurse to monitor while the infant is on strict fluid precautions?

Urine output

CH19: The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?

Wheezing Rationale: The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis. Stomach upset, nausea, and abdominal distress are common with oral antibiotics and do not need to be reported immediately.

CH16: 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 assessing the child's pupils, there is no change in diameter in response to a light. 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.

CH19: The nurse is caring for a 3-month-old infant with history of congenital heart disease. The infant is brought to the emergency department with nausea and vomiting for 3 days. Admission laboratory results confirm dehydration. The nurse realizes that the dehydrated infant is at risk for:

a cerebrovascular accident (stroke). Rationale: Children who have defects that cause decreased pulmonary blood flow have decreased oxygen saturation. To compensate, the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells. The increased red blood cells makes the blood more viscous. If an infant with heart disease becomes dehydrated the infant can develop thrombi from the increased amounts of red blood cells and the viscosity of the blood. This places the infant at risk for a cerebrovascular accident (stroke).

The nurse is caring for a newborn in the hospital. Which assessment finding is most concerning?

a fixed split-S2 heart sound

CH16: 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 as a risk factor for hemorrhagic stroke?

arteriovenous malformations (AVMs) Rationale: Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke.

A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note?

bounding pulse A bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. Narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. A normal pulse would not be expected with aortic regurgitation.

Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism?

early identification

CH16: 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:

ensuring the parents know how to properly give antibiotics. Rationale: Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected.

CH16: Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?

intracranial hemorrhaging Rationale: Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage.

The health care provider suspects an infant may have a ventricular septal defect. The parents ask the nurse what diagnostic tests the infant will need to have to determine this diagnosis. For what test(s) should the nurse provide education to the family? Select all that apply.

magnetic resonance imaging (MRI) echocardiogram Cardiac catheterization

CH19: The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding?

softening of the nail beds Rationale: Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends.

The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which response by the mother would lead the nurse to suspect that the child is experiencing heart failure?

"He gets sweaty when he eats."

CH16: 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 was just staring into space and was totally unaware." Rationale: Absence seizures rarely last longer than 20 seconds. The child loses awareness and stares straight ahead but does not fall

A child will be undergoing a Holter monitor test. Which statement by the parent indicates the need for further instruction?

"My child cannot have any thing to eat or drink after midnight the day of the test."

CH16: What is status epilepticus?

Longer than 30 min (Medical emergency)

The nurse is caring for a child who has been experiencing hypercyanotic episodes. Which treatments will be effective in managing them? Select all that apply.

Provide supplemental oxygen. Assist the child to a knee-chest position.

A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse?

These wires are connected to the heart and will detect if your infant's heart gets out of rhythm.

CH16: Hydrocephalus treatment

VP shunt (ventriculoperitoneal shunt) EVD (external ventricular drain)

CH19: A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers?

nonsterioidal anti-inflammatory drugs (NSAIDs) Rationale: Medications used in the treatment of rheumatic fever include penicillin, NSAIDs, and corticosteroids. Insulin would be given for diabetes and phenytoin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.

CH16: The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain?

video electroencephalogram Rationale: A video electroencephalogram can determine the precise localization of the seizure area in the brain.

CH19: The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?

"It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain." Rationale: Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child.

The nurse is educating the parents of a client newly diagnosed with type 1 diabetes. Which statement by the parents indicates additional teaching is needed?

"Our child should not participate in sports or physical activity."

CH16: 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?

"Use this information to teach family and friends." Rationale: Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions.

CH19: The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse?

"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." Rationale: For children with congenital defects with increased pulmonary blood flow, oxygen supplementation is not helpful. Oxygen acts as a pulmonary vasodilator. If pulmonary dilation occurs, pulmonary blood flow is even greater, causing tachypnea, increasing lung fluid retention, and eventually causing a much greater problem with oxygenation; therefore, preventing the development of pulmonary disease via early surgical correction is essential.

CH16: 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 Rationale: 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.

A woman in her first trimester of pregnancy has just been diagnosed with acquired hypothyroidism. The nurse is alarmed because this condition can lead to which pregnancy complication?

Decreased cognitive development of the fetus If acquired hypothyroidism exists in a woman during pregnancy, her infant can be born intellectually disabled, because there was not enough iodine present for fetal growth. It is important, therefore, that girls with this syndrome be identified before they reach childbearing age.

Purpose of BUN and Creatinine testing

Evaluate renal function

When discussing congenital adrenal hyperplasia with a child's parents, the nurse would advise them that administration of which drug is anticipated?

Hydrocortisone Congenital adrenal hyperplasia is an autosomal inherited disease. The adrenal glands produce an insufficient supply of the enzymes required for the synthesis of cortisol and aldosterone. Hydrocortisone is a corticosteroid that is used to replace the supply of cortisol. It would be administered throughout the life of the child. The other drugs are not necessary to treat this disorder.

Aortic regurgitation?

Inadequate CLOSURE of aortic valve during diastole that results in reverse blood flow through aortic valve.

Lab results for congenital hypothyroidism

Low T4 and high TSH levels

CH16: The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position?

Lying on one side, with the back curved Rationale: Lumbar puncture involves placing a needle between the lumbar vertebrae into the subarachnoid space. For this procedure, the nurse should position the client on one side with the back curved because curving the back maximizes the space between the lumbar vertebrae, facilitating needle insertion. Prone and seated positions don't achieve maximum separation of the vertebrae.

CH16: The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Rationale: 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.

Coarctation of the aorta means...

Narrowing of the aorta

CH19: An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the firstpriority?

Place the infant in the knee-chest position. Rationale: Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot.

CH19: What are the main structures of the fetal circulations?

Placenta, umbilical vein, ductus venous, foremen ovals, ductus arteriosus and umbilical arteries

CH16: Hydrocephalus clinical manifestations

Poor feeding Large head Bulging of anterior fontanelles Setting sun sign High-pitched cry Irritability Projectile vomiting

CH19: A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta?

Pulses weaker in lower extremities compared to upper extremities Rationale: With coarctation of the aorta there is a narrowing causing the blood flow to be impeded. This produces increased pressure in the areas proximal to the narrowing and a decrease in pressures distal to the narrowing. Thus, the infant would have decreased systemic circulation. The upper half of the body would have an increased B/P and be well perfused with strong pulses. The lower half of the body would have decreased B/P with poorer perfusion and weaker pulses.

The nurse is assessing a 5-year-old child whose parent reports the child has been vomiting lately, has no appetite, and has had an extreme thirst. Laboratory work for diabetes is being completed. Which symptom would differentiate between type 1 diabetes from type 2 diabetes?

Recent weight loss

CH16: Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis.

Signs and increased intracranial pressure (ICP) Rationale: Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding?

The liver size increases in right-sided heart failure.

A school-age child is diagnosed as having Cushing syndrome from long-term therapy with oral prednisone. What assessment finding is consistent with this child's diagnosis and treatment?

There are purple striae on the abdomen.

A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age. A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.

The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason?

To build the blood levels to a therapeutic level The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

CH19: Mixed disorders

Transposition of the great vessels (arteries) (TGV) Truncus arteriosus Hypoplastic left heart syndrome

CH19: Where does oxygenation of the fetus occur?

Via the placenta

Hypoparathyroidism:

deficient production of parathyroid hormone

The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?

heart failure

CH19: The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?

heart failure Rationale: Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms.

The nurse caring for a female adolescent with polycystic ovary syndrome (PCOS) identifies "Disturbed body image related to signs and symptoms of the disease" as a nursing diagnosis that applies to this client. What signs and symptoms would support this nursing diagnosis?

hirsutism balding of hair on head increased muscle mass acne

CH16: The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

moving the infant's head every 2 hours Rationale: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time.

CH16: 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?

"Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Rationale: The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.

CH16: A pregnant client asks if there is any danger to the development of her fetus in the first few weeks of her pregnancy. How should the nurse respond?

"During the first 3 to 4 weeks of pregnancy, brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma." Rationale: Brain and spinal cord development occur during the first 3 to 4 weeks of gestation. Infection, trauma, teratogens (any environmental substance that can cause physical defects in the developing embryo and fetus), and malnutrition during this period can result in malformations in brain and spinal cord development and may affect normal central nervous system (CNS) development. Good health before becoming pregnant is important but must continue into the pregnancy. Hardening of bones occurs during 13 to 16 weeks' gestation, and the respiratory system begins maturing around 23 weeks' gestation.

CH16: The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure?

"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." Rationale: Correct positioning for a lumbar puncture is to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.

CH16: An infant with a ventriculoperitoneal (VP) shunt in place is brought to the clinic because of being drowsy and less responsive. Which question in the health history would provide information to the nurse indicating that the VP shunt is perhaps infected?

"Has your child been eating well the last few days?" Rationale: The major complications for children who have shunts are infection and shunt malfunction. The symptoms a child would exhibit with an infection are poor feeding; increased temperature and heart rate; decreased responsiveness; and localized inflammation along the shunt tract.

CH16: 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?

"I need to watch for any new bruises or bleeding and let my health care provider know about it." Rationale: Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to watch for any signs of bruising, bleed, or infection and notify their health care provider if this happens. Administer this medication with food to minimize GI upset. This medication can cause drowsiness, so do not give any sleep-inducing or other sedative type medications. Antiseizure medication does not cure seizures; it only controls the seizures. Lifelong antiseizure medication may be needed.

The nurse is reviewing nutritional recommendations with the parents of a teen diagnosed with hyperlipidemia. Which statements indicate an understanding of the recommended diet for this condition? Select all that apply.

"I should plan to have vegetables with each evening meal served." "Adding fresh fruits to my child's lunch is a good idea." "My child loves chicken and I can still serve it but I need to remove the skin."

CH16: While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education?

"I will cradle her in my arms after the procedure for at least 30 minutes." Rationale: During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.

CH19: The parents of a 2-year-old toddler newly diagnosed with tricuspid atresia ask the nurse, "I do not understand why our toddler's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is best?

"The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." Rationale: Clubbing (which is what the parents are describing) of fingertips or toes can occur from the chronic hypoxia that occurs with disorders with decreased pulmonary blood flow, such as tricuspid atresia.

CH16: 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?

"The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Rationale: Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures.

CH16: A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents?

"The surgery was successful. Do you have any questions?" Rationale: Often what parents need most is someone to listen to their concerns. Although this is a good time for education, the parents are more concerned about the success of the surgery than their infant's appearance.

CH16: 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." Rationale: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.

CH16: The nurse is teaching new parents about cephalohematoma. Which statement by the parents suggests the need for further teaching?

"We should expect to see some discoloration on our child's scalp." Rationale: Characteristics of cephalohematoma include swelling that does not cross the midline and typically no discoloration. Causes of cephalohematoma include pressure against the mother's pelvis and commonly a forceps-assisted delivery. In most cases of cephalohematoma, only observation is necessary and resolution occurs within 2 to 9 weeks.

CH16: A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement?

"You look funny. Well, both of you do. I see two of you." Rationale: The caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider.

CH19: The nurse is caring for a pediatric client diagnosed with tetralogy of Fallot. After speaking with the physician, the parents state to the nurse, "The doctor said something about our child having too many red blood cells. We don't understand how that could happen?" What is the best response by the nurse?

"Your child's body is trying to compensate for the low blood oxygen levels from the heart defect by making more red blood cells, but this makes the heart actually work harder." Rationale: To compensate for low blood oxygen levels, the kidneys produce the hormone erythropoietin to stimulate the bone marrow to produce more red blood cells (RBCs). This increase in RBCs is called polycythemia

CH19: The nurse takes an infant's apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant?

100 beats per minute Rationale: Digoxin is a cardiac glycoside that works by increasing the contractility of the heart muscle. It decreases conduction and increases the force of the heart beat. The result is a slowing of the heart rate. An 8-month-old infant has a normal range of heart rate of 80 to 150 beats per minute while awake and resting, and 80 to 130 beats per minute while sleeping. The accepted practice for this age child is to withhold the digoxin if the heart rate is 90 beats per minute or less. It would be safe to administer the drug if the heart rate is 100 beats per minute. If the child has a heart rate of 150 beats per minute, further assessment should be made prior to administering the drug.

CH16: Findings for CSF, in diagnosing bacterial meningitis

Decreased glucose, elevated protein levels, increased WBC

A newborn is diagnosed with the salt-losing form of congenital adrenogenital hyperplasia. On what should the nurse focus when assessing this client?

Dehydration

The nurse is caring for a newborn with 21-OH enzyme deficiency congenital adrenal hyperplasia (CAH). The nurse identifies one goal of the plan of care as being the understanding of the importance of maintaining hormone supplementation. Which outcome criteron demonstrates this goal has been met?

During follow-up visits the child demonstrates normal growth and development.

CH19: When do heart chambers and arteries form?

During gestational weeks 2 through 8

CH16: Reyes Syndrome diagnosis

Elevated ALT, elevated AST, elevated ammonia, cerebral edema, prolonged coats, liver by bx, CT, MRI LP

A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting?

Feeding problems

CH19: After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:

Femoral pulse weaker than brachial pulse Rationale: A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta.

While assessing a neonate with a ventricular septal defect (VSD), the nurse notes crackles and retractions. The nurse obtains the following vital signs: temp 100.2°F (38°C), pulse 134 bpm, respirations 64 breaths/minute, oxygen saturation 97% on room air. What will the nurse do first?

Give furosemide intravenously. A diuretic

CH26: Anterior pituitary

Growth hormone (GH) deficiency (hypopituitarism) Hyperpituitarism-gigantism (rare) Precocious puberty Delayed puberty

CH16: The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem?

Head trauma Rationale: 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 head trauma.

CH19: The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works?

High-frequency sound waves are directed toward the heart Rationale: Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. An echocardiogram involves high-frequency sound waves, directed toward the heart, being used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers; thickness of walls; relationship of major vessels to chambers; and the thickness, motion, and pressure gradients of valves. You can remind parents that echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation.

CH19: A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would mostlikely be seen in a client experiencing polycythemia?

Increased RBC Rationale: Polycythemia can occur in clients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs). This would cause an increased result on the lab tests. This problem does not affect the white blood cells (WBCs).

CH19: A 6-year-old girl is diagnosed with aortic stenosis. The mother asks the nurse what the likely treatment for this condition will involve. What should the nurse tell the mother?

Insertion of a catheter with an uninflated balloon tip into the affected area followed by inflation of the balloon to open the narrowing Rationale: Balloon angioplasty by way of cardiac catheterization is the initial procedure for aortic stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed area. As the balloon is inflated, it breaks any adhesions and opens the area.

CH16: 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. Rationale: The health care provider should be notified immediately if clear liquid fluid is noted draining from the ears or nose following a traumatic accident. Nasal drainage can be tested for glucose at the bedside. If the fluid tests positive for glucose, this is indicative of leakage of cerebrospinal fluid. The other assessments can continue after notifying the health care provider of these findings.

CH16: Main cause of hydrocephalus

Obstruction: a partial obstruction of the normal flow of CSF, either form from one ventricle to another or from the ventricles to other spaces around the brain

CH19: A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

Peeling hands and feet; fever Rationale: Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region.

CH19: The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position. Rationale: The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed. A calm, comforting approach should be used but is not the priority action.

CH19: When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover?

Polycythemia Rationale: Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated.

CH16: 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?

Report the findings to the pediatric health care provider. Rationale: These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain.

CH16: 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 Rationale: 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.

CH16: 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?

Risk for injury related to seizure activity Rationale: The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

CH16: Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):

Steroid 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.

CH19: At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?

Taking pedal pulses for the first 4 hours Rationale: Insertion of a catheter into the femoral vein can cause vessel spasm, interfering with blood circulation in the leg. Assessing pedal pulses ensures circulation is adequate.

CH19: A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?

Tetralogy of Fallot Rationale: Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

CH19: Name disorders with decreased pulmonary blood flow

Tetralogy of Fallot Tricuspic atresia R—>L

CH19: A nurse is providing education to a family about cardiac catheterization. What information would be included in the education?

The catheter will be placed in the femoral artery. Rationale: A cardiac catheterization can be performed via the right side of the heart or the left side. If the catheter is going through the right side it would be inserted into the femoral vein and threaded to the right atrium

CH16: 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. Rationale: A child with a concussion will be distracted and unable to concentrate. Signs and symptoms of contusions include disturbances to vision, strength, and sensation.

CH16: The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be:

The child is in status epilepticus. Rationale: Status epilepticus is the term used to describe a seizure that lasts longer than 30 minutes, or a series of seizures in which the child does not return to his or her previous normal level of consciousness. The child likely is having generalized seizures, but the most accurate description of what is happening is status epilepticus. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes. With absence seizures the child loses awareness and stares straight ahead but does not fall.

CH19: When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding?

The liver size increases in right-sided heart failure. Rationale: The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure.

A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?

This test will check how blood is flowing through the heart.

The nurse is assessing a 16-year-old boy who has had long-term corticosteroid therapy. Which finding, along with the use of the corticosteroids, indicates Cushing disease?

history of rapid weight gain A history of rapid weight gain and long-term corticosteroid therapy suggests this child may have Cushing disease, which could be confirmed using an adrenal suppression test. A round, moon-shaped face is common to both Cushing disease and growth hormone deficiency. A high weight-to-height ratio and delayed dentition are findings with growth hormone deficiency.

A child is diagnosed with hypoparathyroidism. Which electrolyte imbalance would the nurse mostlikely expect to address?

hypocalcemia Hypoparathyroidism results in low production of PTH, which in turn leads to hypocalcemia and hyperphosphatemia.

CH19: A newborn is diagnosed with tetralogy of Fallot. When explaining this condition to the mother, which defect would the nurse's description include?

overriding of the aorta Rationale: One of the components in the tetralogy of Fallot is the overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with four components. The defects in the tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy.

What would be the most important measure to implement for an infant who develops heart failure?

placing the infant in a semi-Fowler position

CH16: While observing a child, the nurse notes that the child's arms and legs are extended and pronated. During shift hand-off, the nurse reports potential damage to:

the midbrain Rationale: The observations indicate decerebrate posturing, which occurs with damage to the midbrain.

CH16: The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client?

use of anticonvulsant medications Rationale: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders.