chp 54 exam 3
The nurse is assessing the level of consciousness of a 10-year-old client in the emergency department. What would be important questions for the nurse to ask the child or the parent? (Select all that apply.) a. "Has the child been huffing (ingesting) any household products?" b. "Has the child had recent head trauma?" c. "Has the child ever had a brain tumor or shunt?" d. "Does the child have animals at home?" e. "Has the child been sick?"
Answer: a. "Has the child been huffing (ingesting) any household products?"; b. "Has the child had recent head trauma?"; c. "Has the child ever had a brain tumor or shunt?"; e. "Has the child been sick?" Feedback: A complete history is very important when assessing a child for altered levels of consciousness. Head trauma, illness, drug use, and medical history are a few of the valid points when assessing levels of consciousness. Recent animal exposure usually is not related to altered levels of consciousness.
A nurse is caring for an 18-year-old with a C2 injury to the spine following an MVC. Which intervention by the nurse is the most important? a. Observing for ventilator tube displacement b. Positioning the client upright c. Teaching the client how to self-catheterize d. Ensuring proper placement of gastrostomy tube
Answer: a. Observing for ventilator tube displacement Feedback: Injury above C3 segment causes respiratory arrest and death without ventilator support, so it is important for the nurse to make sure the ventilator tube remains in place. The client should be positioned at 35 degrees or above to prevent aspiration; however, this is not the priority. The client will not be able to self-catheterize with this injury, and proper placement of the gastrostomy would be confirmed with an x-ray.
A nurse is evaluating a 1-year-old for possible cerebral palsy. Which findings could be indicators of cerebral palsy? (Select all that apply.) a. Presence of the rooting reflex b. No demonstration of hand dominance c. Vocabulary limited to three words: "mama," "dada," and "ball" d. Frequent arching of the back e. Crawling with three extremities
Answer: a. Presence of the rooting reflex; d. Frequent arching of the back; e. Crawling with three extremities Feedback: Persistent newborn reflexes, such as the rooting reflex, could be an indication of cerebral palsy. The rooting reflex would usually go away by 4 months old. The crawling child should use all four extremities to crawl, not just two or three. Hand predominance could indicate a weakness on one side if evident before the preschool years. A child arching his back or having an abnormal posture could indicate cerebral palsy. It is normal for a 1-year-old to know 1-4 words.
A nurse is caring for a 15-year-old male who is recovering from a concussion after hitting his head during a fall while playing basketball. Which educational statement would be important for the nurse to present to this family? a. The client can experience personality changes within the next 6 months. b. Concussions usually are associated with skull fractures. c. If the client has another concussion in the near future, recovery time should remain the same. d. The client should not play sports for 1 year after the concussion.
Answer: a. The client can experience personality changes within the next 6 months. Feedback: Young athletes should avoid sports for anywhere from 7 days to the entire season after a concussion to avoid getting a second concussion. Several symptoms can occur as a postconcussive syndrome for up to 6 months after a concussion, such as headache, personality changes, poor memory, and vertigo. Multiple concussions can have a significantly longer recovery time. Concussions happen most of the time without any evidence of a skull fracture.
A nurse is providing discharge teaching to the family of a child that just had a ventriculoperitoneal shunt placed. Which statements would indicate that the parents understand the teaching? a. "There is no chance that my child will have a seizure as long as the shunt is functioning correctly." b. "We should let our doctor know if the child complains of double vision." c. "Our child does not need to be followed by any early-intervention programs unless a problem develops." d. "We will observe for symptoms of shunt malfunction until our child has had the shunt for 6 months."
Answer: b. "We should let our doctor know if the child complains of double vision." Feedback: The parents should be taught that there is a risk of the child developing seizures, even if the shunt is functioning properly. All children with this condition should be referred to early-intervention programs for tracking developmental milestones and appropriate therapy. Diplopia (double vision) should be reported to the physician immediately because this could be a sign of a shunt problem. A shunt malfunction can occur at any time.
A 5-year-old is admitted to the hospital with suspected meningitis. Which nursing intervention would be included in the child's plan of care? a. Measure the head circumference. b. Dim the lights and quiet room as needed. c. Play music that the child enjoys. d. Provide a high-calorie diet.
Answer: b. Dim the lights and quiet room as needed. Feedback: Due to the neurologic sequela of this disease, reducing external stimuli is extremely important. Lights should be dim and the room quiet. Food usually is held initially and IV fluids initiated. Head circumference usually is only performed for children under 2 years old.
A nurse is assessing the wound of an 8-year-old female who suffered a scalp laceration while playing Frisbee. Which observation by the nurse is the most concerning? a. The extensive bleeding b. The indentation from the Frisbee c. The length of the laceration d. The hypovolemia from the bleeding
Answer: b. The indentation from the Frisbee Feedback: Injuries to the scalp, which can be caused by falls, blunt trauma, or penetration of a foreign body, are usually benign. Bleeding may be extensive, but hypovolemia or shock is uncommon unless the client is an infant. Bony fragments, depressions, CSF leakage, or debris is a cause for concern.
Parents bring a 3-year-old to the emergency department stating that the child has just had her first seizure. The seizure lasted less than 5 minutes and involved jerking movements over the entire body. Prior to the seizure, the child had been sick and started running a fever. Based on the description, the nurse suspects that the child experienced which type of seizure? a. Partial b. Status epilepticus c. Febrile d. Generalized
Answer: c. Febrile Feedback: Febrile seizures usually are associated with fevers. A generalized or partial seizure also has the jerking movements but is not necessarily associated with a fever. Status epilepticus is when the seizure lasts longer than 30 minutes.
Which assessment finding would the nurse not find in a 4-year-old child with neurofibromatosis? a. Walking with a limp b. Seizure activity c. Increased head circumference d. Café au lait spots
Answer: c. Increased head circumference Feedback: Neurofibromatosis is characterized by six or more café au lait spots, axillary and inguinal freckling, and small tumors on the body. Seizures, limping, and an increasing head circumference are not necessarily signs of neurofibromatosis.
Which consideration would be important in planning nursing care for an infant following surgical insertion of a ventriculoperitoneal shunt? a. Pain relief interventions are not utilized routinely for infants. b. Some nuchal rigidity is expected after this procedure. c. The infant is placed in a flat supine position immediately after surgery. d. Administration of intravascular volume expanders is necessary to maintain shunt function.
Answer: c. The infant is placed in a flat supine position immediately after surgery. Feedback: There are no surgical sites in the foot for ventriculoatrial shunt surgery. Volume expanders are not indicated and can increase risk of increased intracranial pressure (ICP). The child's pain always should be managed regardless of age. The infant never should have nuchal rigidity; it indicates meningeal irritation due to infection or increased ICP. The infant is placed in a flat position and the head of the bed is elevated gradually to prevent rapid cerebrospinal fluid drainage.
A nurse is caring for an infant with myelomeningocele following surgical postoperative repair. What would be an important nursing intervention for this client? a. Place the infant in a supine position with the head elevated. b. Cover the surgical site with sterile, saline-soaked gauze. c. Measure the head circumference every other day. d. Assess the surgical site for cerebrospinal fluid leakage and symptoms of infection.
Answer: d. Assess the surgical site for cerebrospinal fluid leakage and symptoms of infection. Feedback: Covering the defect with sterile, saline-soaked gauze is a preoperative intervention. After surgery, the site should be checked for cerebrospinal fluid leakage and infection. Head circumference should be measured daily for signs of increased developing hydrocephalus. The child should never be placed supine, due to the location of the lesion.
When evaluating a child who complains of headaches, which description would lead the nurse to suspect migraine headaches? a. Headaches associated with stress only b. Headaches associated with frequent use of acetaminophen c. Headaches associated with sinus pressure and upper-respiratory symptoms d. Headaches associated with an aura prior to onset
Answer: d. Headaches associated with an aura prior to onset Feedback: Stress-related headaches are tension headaches. Using certain medications more than three times per week can trigger headaches. Sinus headaches do not have an aura, whereas migraine headaches often do.
