PrepU ch.22
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 incisional sites level of consciousness abdominal circumference bowel sounds abdomen
abdomen bowel sounds abdominal circumference
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." "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." "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."
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? "We will monitor your child closely and keep your child comfortable." "Your child will need high doses of antibiotics to treat the infection." "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."
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 stroke the area about 10 times with each session." "We should do the massage along with warm compresses." "We should do the massage every morning and every evening." "We will press on the outer corner of the eye for several seconds."
"We will press on the outer corner of the eye for several seconds."
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?" "What immunizations has she had?" "Does she vomit frequently?" "Does she have headaches when she gets out of bed?"
"Does she have headaches when she gets out of bed?"
A 1-year-old has just undergone surgery to correct craniosynostosis. When talking with the parents, which of the following would be most appropriate? "I'll be watching his hemoglobin and hematocrit closely." "I told you yesterday there would be facial swelling." "This condition only happens in 1 out of 2,000 births." "Now that the surgery was successful, do you have any questions?"
"Now that the surgery was successful, do you have any questions?"
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? Excess watering of the eyes. Absence of the red reflex. Sclera appears to be blue. Edema of the eyelids.
Absence of the red reflex.
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? Observe and document the length of time of the seizure and type of movement observed. Perform a glucose finger stick to determine the child's blood sugar level. Administer carbamazepine as prescribed. Administer lorazepam IV as prescribed.
Administer lorazepam IV as prescribed.
Antibiotic therapy to treat meningitis should be instituted immediately after which event? Initiation of IV therapy Identification of the causative organism Admission to the nursing unit Collection of cerebrospinal fluid (CSF) and blood for culture
Collection of cerebrospinal fluid (CSF) and blood for culture
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? Monitor temperature every 4 hours Encourage the parents to hold the child Decrease environmental stimulation Take vital signs every 4 hours
Decrease environmental stimulation
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. Administer acetaminophen if needed for pain. Assure the parent that the scleral hemorrhages will resolve.
Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours.
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? myopia nystagmus astigmatism amblyopia
astigmatism
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? central auditory dysfunction conductive sensorineural mixed hearing loss
conductive
Which measures should receive priority when planning care for the child who is having surgery to remove a cataract? evaluation of intraocular pressure (IOP) and adherence to the occlusive patch regimen regular insertion and removal of contact lenses prophylactic antibiotic drops regular evaluation of the intraocular lens implant
evaluation of intraocular pressure (IOP) and adherence to the occlusive patch regimen
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. Moro Babinski swallow cough gag
gag cough swallow
The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? hypertension hyperthermia poor handwriting tachypnea
hypertension
A 9-year-old child with a history of epilepsy is brought to the emergency department. The child has been having a series of tonic-clonic seizures over the past 5 minutes and has not recovered from them between episodes. Which medication would the nurse anticipate being used to control the child's seizures? carbamazepine gabapentin ethosuximide lorazepam
lorazepam
After experiencing a head injury the child keeps falling asleep when no one is rousing him. When documenting this in the medical record which term is most appropriate? stupor lethargic unconscious obtunded
obtunded
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? decreased level of consciousness obtunded stupor fully conscious
obtunded
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. padding for side rails tongue blade oxygen gauge and tubing smelling salts suction at bedside
oxygen gauge and tubing suction at bedside padding for side rails
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 in an infant car seat after feeding the infant placing the infant prone in the crib after feeding the infant placing the infant supine 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
Put the following events of a tonic-clonic eizure in correct order: Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1prodromal period 2tonic stage 3postictal period 4clonic stage
prodromal period tonic stage clonic stage postictal period
After administering eye drops to a child, the nurse applies gentle pressure to the inside corner of the eye at the nose for which reason? to promote dispersion over the cornea to enhance systemic absorption to stabilize the eyelid to ensure the medication stays in the eye
to ensure the medication stays in the eye
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Brief, sudden contracture of a muscle or muscle group Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Muscle tone maintained and child frozen in position Sudden, momentary loss of muscle tone, with a brief loss of consciousness
Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention
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." "I will give the medication to him when I first wake him up in the morning." "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I'm glad to know he will only need this medication for a short time to stop his seizures."
"I need to watch for any new bruises or bleeding and let my health care provider know about it."
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." "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."
"Your infant will need to wear a helmet after the defect is corrected for most hours of the day."
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 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
During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents? The drug must be discontinued immediately if even the slightest problem occurs The child shouldn't participate in activities that could be hazardous if a seizure occurs Drug dosage will be adjusted depending on the frequency of seizure activity Plasma levels of the drug will be monitored on a daily basis
The child shouldn't participate in activities that could be hazardous if a seizure occurs
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. Avoid excessive sunlight. Use a soft toothbrush.
Use a soft toothbrush.
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 white blood cell count urinalysis hemoglobin level
serum glucose level