NCLEX Child Health - Neuro
The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs/symptoms should the nurse expect to find during the initial assessment? Select all that apply.
1. Fever 2. Irritability 3. Nuchal ridigidty
The nurse is performing an admission assessment of a 6-month-old infant suspected of having hydrocephalus. Which finding should the nurse expect to note that is associated with this diagnosis?
A bulging anterior fontanel
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
A bulging anterior fontanel
The nurse is developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure (ICP). Which assessment technique should be performed to detect the presence of an increase in ICP?
Assessing the anterior fontanel for bulging
The nurse is closely monitoring a child with increased intracranial pressure who has been exhibiting decorticate (flexor) posturing. The nurse notes that the child suddenly exhibits decerebrate (extensor) posturing and interprets that this change in the child's condition indicates which finding?
Deteriorating neurological function
The nurse is caring for a child with Reye's syndrome. The nurse monitors for manifestations of which primary problem associated with this syndrome?
Increased intracranial pressure
The mother tells the nurse that the teacher has reported that the child appears to be daydreaming and staring off into space numerous times throughout the day, yet during the remainder of the day, the child is alert and participates in classroom activities. The nurse should suspect that the child has which problem?
Absence seizures
The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. Which instruction should the nurse include in the plan of care?
Call the health care provider if the infant has a high pitched cry
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action should the nurse take?
Document the finding
The nurse is caring for an infant diagnosed with hydrocephalus. Which manifestation should the nurse interpret as the earliest finding of increased intracranial pressure (ICP)?
Irritability
The nurse is monitoring a 7-year-old child who sustained a head injury in a motor-vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?
Nausea
The nurse is caring for a child with increased intracranial pressure after head trauma resulting from a motor vehicle crash. The child is scheduled for a craniotomy due to a depressed skull fracture. In the preoperative period, the primary nursing action should be to assess which parameter?
Pupillary responses to light
The nurse is interviewing the parents of a newborn infant who has spina bifida (myelomeningocele). Which statement by the parent would indicate the need to discuss coping issues?
Should we tell our friends about the baby?
The nurse is preparing a plan of care for a child with Reye's syndrome. When prioritizing the nursing interventions what should the nurse plan to monitor for first?
Signs of increased intracranial pressure
The nurse is conducting an assessment of a child suspected of having Reye's syndrome. Which data, as reported by the mother, should the nurse interpret as being associated with this syndrome?
The child had influenza 2 weeks ago
Which finding would indicate the presence of Kernig's sign?
The inability of the child to extend the legs fully when lying supine
The nurse is monitoring a nursing student who is caring for a child who sustained a head injury from a fall. Which action by the nursing student indicates a need for further teaching?
Forcing fluids
The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication?
If my gums become sore, i need to stop the medication
The nurse provides home care instructions to a mother of an infant who has had a surgical procedure to insert a ventriculoperitoneal shunt. Which statement by the mother indicates an understanding of the complications associated with this surgical procedure?
If my infant develops a high-pitched cry, i should call my health care provider
The registered nurse (RN) is reviewing a plan of care developed by a nursing student for a child who is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the student nurse needs further teaching and should revise the plan of care if which incorrect intervention is documented?
Restrain the child if a seizure occurs
The nurse is assessing the level of consciousness of a child with a head injury and documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?
The child has limited interaction with the environment unless aroused
A pediatrician is evaluating a school-age child after the teacher reports that the child is not paying attention during class. The teacher reports that the child appears to be daydreaming and staring off into space 40 or 50 times during the day and that the child is otherwise alert and participates in classroom activity. The nurse assisting the pediatrician expects the pediatrician to note which on physical examination?
The child is probably experiencing absence seizures and will need to have an electroencephalogram to confirm this diagnosis
A home care nurse visits a child with Reye's syndrome and plans to provide instructions to the mother regarding care of the child. Which measure should the nurse instruct the mother to take?
Check the child's skin and eyes every day for a yellow discoloration
The nurse is performing an assessment of a 9-year-old child suspected of having a brain tumor. Which question should the nurse ask to elicit data related to a characteristic sign/symptom of a brain tumor?
Do you feel sick to your stomach, and do you throw up in the morning?
The nurse provides home care instructions to the mother of an infant with a diagnosis of hydrocephalus. Which statement by the mother indicates an understanding of the care of the infant?
I need to support my infants neck and head
The nurse is caring for a child who experienced a head injury. The nurse is monitoring the child for signs of increased intracranial pressure (ICP) and informs the mother about the measures to monitor for and prevent increased ICP. Which statement by the mother would indicate a need for further teaching?
I will encourage my child to drink plenty of fluids
When providing care for a child in cervical traction with Crutchfield tongs, which actions should the nurse take?
Maintain proper alignment and prevent infection
The nurse is caring for an 8-month-old infant with a diagnosis of febrile seizures. Which item should the nurse anticipate the need for when caring for this infant?
Padded sides on the crib
A pediatric nurse is informed that a child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
Providing a quiet environment with dimmed lights
An emergency department nurse is performing an assessment on a child who has a fever of 102° F. Which finding should be of most concern to the nurse?
Stiff neck
The nurse receives a telephone call from the emergency department and is told that a 7-month-old infant with febrile seizures will be admitted to the pediatric unit. What should the nurse anticipate the need for when planning care for the admission of the infant?
Suction equipment and an airway at the bedside
A mother says to the nurse, "I am afraid that my child might have another febrile seizure." Which therapeutic communication statement is best for the nurse to make to the mother?
Tell me what frightens you the most about seizures
The nurse is caring for an 8-month-old infant with a diagnosis of febrile seizures. In planning care, the nurse should anticipate the need for which item?
Padded sides on the crib
A 12-year-old child is seen in the emergency department with a diagnosis of possible bacterial meningitis (fulminating meningococcemia). Which finding should the nurse specifically expect to note in this infection?
A fine rash with some bruising
A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
Lack of social interaction and awareness
The nurse is monitoring a child with a brain tumor for signs of complications. Which value indicates to the nurse that health care provider notification is required?
A urine specific gravity of 1.035
The nurse is measuring the head circumference of an infant on the fifth postoperative day after surgical placement of a ventricular peritoneal shunt for the correction of hydrocephalus. The nurse notes that the head circumference measurement has increased by 1 cm over the past 24 hours. The nurse analyzes this assessment data as which expectation after this surgical procedure?
A complication related to the functioning of the shunt
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, what should the nurse expect to note if this type of posturing is present?
Abnormal extension of the upper and the lower extremities
A child with a brain tumor is admitted to the hospital for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?
Initiating seizure precautions
The nurse is assigned to care for a child with juvenile idiopathic arthritis (JIA). What is the child's priority?
Acute pain
The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis?
Cloudy CSF with high protein and low glucose
The nurse assigned to care for a child with a basilar skull fracture reviews the child's record and notes that the health care provider has documented the presence of Battle's sign. Which should the nurse expect to observe in the child?
Bruising behind the ear
