Week 4 Child w/ Neurolgical Disorder
An important nursing intervention when caring for a child who is experiencing a seizure is to: a. Describe and record the seizure activity observed. b. Restrain the child when a seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration.
A
Which clinical manifestations would suggest hydrocephalus in a neonate? a.Bulging fontanel and dilated scalp veins b.Closed fontanel and high-pitched cry c.Constant low-pitched cry and restlessness d.Depressed fontanel and decreased blood pressure
A
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? A. "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." B. "She has been irritable for the last hour....seems like she is just upset for some reason." C. "She always cries when the person holding her has on glasses...I guess glasses scare her." D. "She typically breastfeeds, but lately we have had to supplement with some oat cereal."
B
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? A. Encourage the parents to hold the child B. Monitor temperature every 4 hours C. Take vital signs every 4 hours D. Decrease environmental stimulation
D
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? A. measuring the intake and output every shift B. massaging the scalp gently every 4 hours C. giving the infant small feedings whenever he is fussy D. moving the infant's head every 2 hours
D
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. A. oxygen gauge and tubing B. tongue blade C. suction at the bedside D. smelling salts E. padding for side rails
A, C, E
The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply. A. increased head circumference B. parent states, "My infant does not act right." C. vomiting D. blood pressure decreased from baseline E. pulse rate of 60 beats/min and regular
A, B, C, E
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence of seizure? A. Sudden, momentary loss of muscle tone, with a brief loss of consciousness B. Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention M C. Muscle tone maintained and child is frozen in position D. Brief, sudden contracture of a muscle or muscle group
B
The nurse cares for a 7-year-old child with a new-onset seizure disorder. Which prescription will the nurse anticipate for this client? A. ketogenic diet B. vagus nerve stimulation C. use of anticonvulsant medications D. frequent temperature assessment
C
The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? A. intracranial hemorrhaging B. positional plagiocephaly C. head trauma D. congenital hydrocephalus
C
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)? A. While calling the child's name, the child stares straight ahead and does not turn to the sound. B. While stimulating the child's foot, the big toe points upward and other toes fan outward. C. While turning the child's head to the left, the eyes turn to the right. D. While assessing the child's pupils, there is no change in diameter in response to light.
D
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? A. Onset and character of fever B. Degree and extent of nuchal rigidity C. Occurrence of urine and fecal contamination D. Signs of increased intracranial pressure (ICP)
D
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? A. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." B. "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." C. "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." D. "I need to set an alarm to wake up and check his temperature during the night when he is sick."
A 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.