Unit 8: Nursing Care: Neurological Alterations
The pediatrician's office nurse is caring for a toddler who recently had a viral illness and experienced a febrile seizure at home. The nurse is providing follow-up teaching. Which statement by the parent indicates that additional teaching is needed?
"Administering acetaminophen to lower a fever will prevent a febrile seizure."
The nurse is providing discharge teaching for the parent of a pediatric client who suffered a head injury after falling off a moving golf cart. Which statement by the parent indicates that additional teaching is needed?
"My child will likely have headaches for several weeks."
Which client does the nurse recognize as the most at risk for experiencing a febrile seizure?
1-year-old with viral bronchiolitis
Which client with a head injury is at the most risk for having poor outcomes?
A client who presents with bradycardia, is unresponsive, and has retinal hemorrhages
The nurse is caring for a pediatric client who suffered a head injury after falling off a bike. Which neurological assessments should the nurse perform? Select all that apply.
Motor function Reflexes Pupil reactivity to light Level of consciousness Vital signs
For each potential health care provider order in the left column, indicate whether the potential order is anticipated or contraindicated.
Anticipated - All except lumbar puncture Contraindicated - lumbar puncture
The nurse has been asked to prepare the client for insertion of an intracranial pressure monitoring device and external ventricular drainage system. Which of the following actions should the nurse take? Select all that apply.
Ensure emergency equipment is transported with the client Call report to the preoperative nurse Administer preoperative medications Prepare surgical consent and witness informed consent
Match the diagnostic test with the description of how the findings are used in diagnosing neurological dysfunction.
Findings can identify infection in the cerebral spinal fluid - lumbar puncture Findings may suggest a lesion is present or provide evidence of brain death - EEG Provides visualization of structures to detect structural abnormalities, hemorrhages, tumors, or inflammation - computerized tomography (CT) Provides visualization of structures with the ability to discriminate between tissue types - MRI
The nurse is completing an assessment on a newly admitted infant who is suspected to have shaken baby syndrome. Which assessment finding is the most important to report immediately to the health care provider?
Fixed and dilated pupils
The nurse is caring for a pediatric client who was diagnosed with Reye's syndrome. Which assessment findings are related to Reye's syndrome? Select all that apply.
History of taking bismuth subsalicylate (Pepto-Bismol) during illness Lethargy History of recent influenza illness Profuse vomiting
Indicate whether each finding is improved, unchanged, or declined from prior to the procedure.
Improved - blood pressure, pain unchanged - temperature declined - loc, respiratory status
The client is at risk for which potential complications? Select all that apply.
Increased intracranial pressure Seizures Skull fracture Brain hemorrhage
The nurse is admitting a school-age child to the pediatric acute care unit for suspected Reye's syndrome. Which is the most important order the nurse should request from the health care provider right away?
Liver function panel
Which are the top 4 assessment findings that should be of concern to the nurse?
Loss of consciousness at scene Confusion Vomiting Head pain
The nurse is caring for a 4-year-old client on a pediatric unit. Indicate whether each assessment finding is consistent with Reye's syndrome, a head injury, or febrile seizures. Each finding may be associated with more than one disease process.
Reye's - ALL Head injury - ALL except fever Febrile seizure - Decreased level of consciousness Fever Seizures
The highest priority is to monitor for signs of --- to prevent potential --
increased intracranial, brain damage
