week 7 prepU chapter 22

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.

The nurse is performing a neurological assessment on a child. The previous examination noted the child to be alert but answering questions inappropriately. In this exam, the child only responds to vigorous stimuli. Which action should the nurse take first?

Notify the health care provider.

A nurse has received the above hand-off report for a client hospitalized with blunt head trauma following a motor vehicle accident. What is the nurse's priority in providing care for the client?

Observe for behavioral changes.

A child with poor eye alignment cannot establish single binocular vision but has double vision. Which nursing action is most appropriate for this client?

Refer the child to a pediatric ophthalmologist

The nurse is caring for a 10-year-old child with bacterial conjunctivitis of the right eye. The eye is inflamed and drains a thick, yellow discharge. What should the nurse teach the parents about the care of the eye?

Wipe the drainage away from the inner to the outer canthus of the eye.

The nurse is assessing a 2-year-old for signs and symptoms of increased intracranial pressure. Which of the following would the nurse expect to assess? Select all that apply.

4,5

The parents of a toddler have just learned that their child has profound hearing loss. The parents are very upset and state to the nurse, "It just isn't fair. We did everything right during our pregnancy all the way to this point." How should the nurse respond?

"I can't imagine how difficult this must be. When you're ready I would be happy to arrange a meeting with a support group of other parents with children who have hearing loss."

The nurse has finished teaching the mother of a 5-year-old male diagnosed with bacterial conjunctivitis how to manage her son's infection at home. Which statement by the mother would indicate a need for further education?

"I will use Visine drops in his infected eye to help reduce redness."

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 wear a helmet after the defect is corrected for most hours of the day."

A nurse is providing preoperative care for a newborn with hydrocephalus. What intervention(s) will the nurse include in the newborn's plan of care? Select all that apply.

2,3,4

The nurse is performing a neurologic assessment on a 7-month-old infant. Which task should the nurse perform last?

Elicit the gag reflex.

A nurse is administering ear drops to a 7-year-old girl. What should the nurse do?

Pull the pinna of the ear up and back to straighten the external ear canal.

To give eardrops to a 4-year-old child, what would be the best technique to use?

Pull the pinna of the ear up and back.

A nurse is providing discharge teaching to the parents of a child hospitalized with hydrocephalus, who had a ventriculoperitoneal (VP) shunt placed. The nurse should intervene if the parents make which statement?

"We expect our child to continue engaging in normal activities, including sports."

The mother of a 10-day-old infant reports her baby has been having "lots of eye discharge." What is the best initial response by the nurse?

"Tell me more about this drainage."

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

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

ensure proper oxygenation; administer intravenous (IV) or intramuscular (IM) benzodiazepine

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."

Which of the following would a nurse assess in a child with pneumococcal meningitis?

nuchal rigidity

A nursing instructor is teaching about eye disorders in childhood. Which statement made by a student indicates a need for further instruction?

"Cataracts are only present in adults."

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."

The nurse receives a call from the parent of a 4-month-old infant who underwent endoscopic surgery for craniosynostosis 2 months earlier. The parent reports that the infant's skin appears red on the both temples. How should the nurse respond?

"Your infant should be evaluated in person, because a new helmet may be needed."

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

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.

The nurse is planning care for a preschool-age child diagnosed with bacterial meningitis. What should the nurse identify as a priority goal for this client's care?

Reduce the pain related to nuchal rigidity.

The nurse is assessing a child with a suspected traumatic brain injury. The child is disoriented to place and time, but not person, and is having difficulty following commands. The nurse would use which terminology to document the child's level of consciousness?

confusion

The nurse is teaching a group of parents in the community about accident prevention. When describing accidental head trauma resulting in traumatic brain injury (TBI), the nurse would focus safety education on which age group(s)? Select all that apply.

toddlers, adolescents

The nurse is caring for a 4-year-old client presenting to the emergency department with suspected meningitis. What will the nurse include in the plan of care? Select all that apply.

2,3,4,5

A nurse is providing care for a 2-year-old child hospitalized with a diagnosis of increased intracranial pressure (ICP) secondary to hydrocephalus. Which nursing action(s) will promote comfort and rest for the child? Select all that apply.

3,4,5

The nurse is performing the intake assessment of a 6-month-old in the pediatrician's office. The nurse alerts the physician that the child is showing signs of hearing loss based on what assessment findings? Select all that apply.

1,2,4,5

The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?

A delay or lack of clear, understandable speech pattern

A child is brought to the emergency department and is experiencing status epilepticus. The nurse would expect to administer which treatment as first-line therapy?

lorazepam

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.

gag, cough, swallow

A 17-year-old is brought to the emergency department with a fever, headache, and stiff neck. Bacterial meningitis is suspected. The nurse would anticipate preparing the adolescent for which test to confirm the diagnosis?

lumbar puncture

A nurse is administering carbamazepine to a 4-year-old child diagnosed with epilepsy. The health care provider has prescribed 10 mg/kg/day by mouth. The child weighs 32 lb (14.52 kg). How many milligrams should the nurse administer? Record your answer rounded to the whole number.

145

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."

A toddler is prescribed amoxicillin for bilateral otitis media. The parent reports that the toddler refuses to take the oral medication. The nurse knows that more education is needed when the parent makes which statement?

"I will shake the medication well, and draw up the medication to the top of the syringe. My spouse and I will hold our toddler down and force the medication down his throat."

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.

1,2,4

The nurse is caring for a child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What action(s) by the nurse should be performed now? Select all that apply.

2,3

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

A child has been diagnosed with strabismus. After further examination, the client is told that the resting position of the right eye is convergent. The nurse further explains that this means which of the following?

The resting position of the eye is turned in.