neuro

A nurse is caring for an adolescent who has sustained a closed head injury. Which of the following are clinical manifestations of increased intracranial pressure? SELECT ALL THAT APPLY A. Report of headache B. Alteration in pupillary response C. increased motor response D. Increased sleeping E. Increased sensory response

A. Report of headache B. Alteration in pupillary response D. Increased sleeping

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? a. Emergency cart b. Tracheotomy set c. Padded tongue blade d. Suctioning equipment and oxygen

d. Suctioning equipment and oxygen

The nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. A. Time the seizure. B. Restrain the child. C. Stay with the child. D. Place the child in a prone position. E. Move furniture away from the child. F. Insert a padded tongue blade in the child's mouth.

A. Time the seizure. C. Stay with the child. E. Move furniture away from the child.

The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse should include which instruction? A. Expect an increased urine output from the shunt. B. Notify the health care provider if the infant is fussy. C. Call the health care provider if the infant has a high-pitched cry. D. Position the infant on the side of the shunt when the infant is put to bed.

C. Call the health care provider if the infant has a high-pitched cry. Rationale: If the shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected. Being fussy is a concern only if other signs indicative of a complication are occurring.

A nurse is caring for a school-age client who possibly has Reye syndrome. Which of the following is a risk factor for developing Reye syndrome? A. recent hx of infectious cystitis cause by Candida B. recent hx of bacterial otitis media C. recent episode of gastroenteritis D. recent episode of Haemophilus influenza meningitis

C. recent episode of gastroenteritis

A nurse notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse should determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement should the nurse plan to include in the discharge teaching with the parents to reflect this safety need? A. "Feed your infant in a side-lying position." B. "Place a helmet on your infant when in bed." C. "Hyperextend your infant's head with a rolled blanket under the neck area." D. "When picking up your infant, support the infant's neck and head with the open palm of your hand."

D. "When picking up your infant, support the infant's neck and head with the open palm of your hand."

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? A. Maintain enteric precautions. B. Maintain neutropenic precautions. C. No precautions are required as long as antibiotics have been started. D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

The nurse is caring for a child after placement of a VP shunt. What should the nurse include in the discussion of long-term care of the child? A. Mental retardation is to be expected with hydrocephalus B. Child will need to wear a helmet at all times to protect the shunt C. Most childhood activities will need to be restricted D. Shunt malfunction or infection requires immediate treatment

D. Shunt malfunction or infection requires immediate treatment

A nurse is caring for a 4 month old infant who has meningitis. Which of the following findings is associated with this diagnosis? A. depressed anterior fontanel B. constipation C. presence of the rooting reflex D. high pitched cry

D. high pitched cry

The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem? a. Infection b. Choking c. Inability to tolerate stimulation d. Delayed growth and development

a. Infection

A newborn has signs of IICP? What is a priority nursing intervention? A. Do a head circumference measurement B. Assess pulse rate C. Monitor ability to suck D. Encourage maternal bonding

B. Assess pulse rate

A nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse should immediately test the discharge for the presence of which substance? A. Protein B. Glucose C. Neutrophils D. White blood cells

B. Glucose Rationale: After a head injury, bleeding from the nose or ears necessitates further evaluation. A watery discharge from the nose (rhinorrhea) that tests positive for glucose is likely to be cerebrospinal fluid (CSF) leaking from a skull fracture. On noting watery discharge from the child's nose, the nurse should test the drainage for glucose using reagent strips such as Dextrostix. If the results are positive, the nurse will contact the health care provider. The items in options 1, 3, and 4 are not normally found in CSF.

A nurse is caring for a child who has absence seizures. Which of the following findings can the nurse expect? SELECT ALL THAT APPLY A. loss of consciousness B. appearance of daydreaming C. dropping held objects D. falling to the floor E. having a piercing cry

A. loss of consciousness B. appearance of daydreaming C. dropping held objects

A nurse is reviewing CSF analysis for a client who has suspected meningitis. Which of the following results indicate viral meningitis? SELECT ALL THAT APPLY A. neg gram stain B. normal glucose content C. cloudy color D. decreased WBC count E. normal protein count

A. neg gram stain B. normal glucose content E. normal protein count

A nurse is caring for a client who has suspected meningitis and a decreased LOC. Which of the following actions by the nurse is appropriate? A. place the client on NPO status B. prepare the client for a liver biopsy C. position the client dorsal recumbent D. put the client in a protective environment

A. place the client on NPO status

A nurse is caring for a child was has IICP. Which of the following are appropriate actions by the nurse? SELECT ALL THAT APPLY A. Suction the endotracheal tube every 2 hours B. Maintain a quiet environment C. Use 2 pillows to elevate the head D. Admin a stool softener E. Maintain body alignment

B. Maintain a quiet environment D. Admin a stool softener E. Maintain body alignment

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? A. Test the urine for protein. B. Reposition the infant frequently. C. Provide a stimulating environment. D. Assess blood pressure every 15 minutes.

B. Reposition the infant frequently Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure. In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in intracranial pressure. It is not necessary to check the blood pressure every 15 minutes.

A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? SELECT ALL THAT APPLY A. inactivate polio vaccine (IPV) B. pneumococcal conjugate vaccine (PCV) C. diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)

B. pneumococcal conjugate vaccine (PCV) D. Haemophilus influenzae type B (Hib) vaccine

A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and the nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? A. Nausea B. Irritability C. Headache D. Bradycardia

D. Bradycardia Rationale: Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased intracranial pressure (ICP). In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma

A nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? A. Increased systolic blood pressure B. Abnormal posturing of extremities C. Significant widening pulse pressure D. Changes in level of consciousness (LOC)

D. Changes in level of consciousness (LOC)

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which instruction should the nurse provide to the mother? A. Increase stimuli in the home environment. B. Avoid daytime naps so that the child will sleep at night C. Give the child frequent small meals, if vomiting occurs. D. Check the skin and eyes every day for a yellow discoloration.

D. Check the skin and eyes every day for a yellow discoloration. Rationale: Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome. Decreasing stimuli and providing rest decrease stress on the brain tissue. If vomiting occurs in Reye's syndrome, it is caused by cerebral edema and is a sign of intracranial pressure.

The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which nursing action to maintain the infant's safety? A. Covering the back dressing with a binder B. Placing the infant in a head-down position C. Strapping the infant in a baby seat sitting up D. Elevating the head with the infant in the prone position

D. Elevating the head with the infant in the prone position

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? A. An infectious disease of the central nervous system B. An inflammation of the brain as a result of a viral illness C. A congenital condition that results in moderate to severe retardation D. A chronic disability characterized by impaired muscle movement and posture

D. A chronic disability characterized by impaired muscle movement and posture

A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the health care provider's prescriptions, which would the nurse question as appropriate for a child with this diagnosis? A. Administer an oral antibiotic. B. Maintain strict intake and output. C. Draw blood for a culture and sensitivity. D. Place the child on droplet precautions in a private room.

A. Administer an oral antibiotic Rationale: Medication to treat acute bacterial meningitis is administered intravenously, not orally. A culture and sensitivity is done to determine if the diagnosis is bacterial or viral. Until meningitis is ruled out, the child is placed in isolation on droplet precautions because the disease is spread by airborne means. Strict intake and output should be maintained.

A child is admitted to the pediatric unit with signs of a HA, a stiff neck, positive Kernig's sign and a fever. What intervention will the nurse employ for this client? A. Admit to an isolation room until the results of the spinal tap identify bacteria or virus B. Use TV as a distraction C. Inform parents that all children in the family will need an immediate spinal tap D. Delay pain meds until sensory system is stabilized.

A. Admit to an isolation room until the results of the spinal tap identify bacteria or virus

A nurse is caring for child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms? SELECT ALL THAT APPLY A. Baclofen (Lioresal) B. Diazepam (Valium) C. Oxybutynin chloride (Ditropan) D. Methotrexate (Rheumatrex) E. Prednisone (Deltasone)

A. Baclofen (Lioresal) B. Diazepam (Valium)

A school-age child with Down syndrome is brought to the ambulatory care center by the mother. The child has bruising all over the body. To work most effectively with this child, the nurse first addresses which complication associated with Down syndrome? A. Children with Down syndrome are more likely to develop acute leukemia than the average child. B. Children with Down syndrome fall down easily as a result of hyperflexibility and muscle weakness. C. Children with Down syndrome are at risk for physical abuse because of their low intellectual functioning. D. Children with Down syndrome scratch themselves a lot because of dry, cracked, and frequently fissuring skin.

A. Children with Down syndrome are more likely to develop acute leukemia than the average child. Rationale: Children with Down syndrome have an increased risk for developing leukemia compared with the average child. The other statements also could be true, but the nurse should first gather baseline data to determine the cause of the bruising before making other assumptions.

A child is diagnosed with Reye's syndrome. The nurse develops a nursing care plan for the child and should include which intervention in the plan? A. Assessing hearing loss B. Monitoring urine output C. Changing body position every 2 hours D. Providing a quiet atmosphere with dimmed lighting

D. Providing a quiet atmosphere with dimmed lighting Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings? A. Nausea, delirium, and fever B. Severe headache and back pain C. Photophobia, fever, and confusion D. Severe headache, fever, and a change in the level of consciousness

D. Severe headache, fever, and a change in the level of consciousness Rationale: The classic signs/symptoms of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early manifestation and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs/symptoms.

The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is characteristic of this sign? A. The child complains of muscle and joint pain. B. Petechial and purpuric rashes are noted on the child's trunk. C. Neck flexion causes adduction and flexion movements of the lower extremities. D. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.

D. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.

What is the priority nursing intervention for a child following a tonic-clonic seizure? A. check the child for injuries B. Take the child's vital signs C. reorient the child to the environment D. keep the child in a side-lying position

D. keep the child in a side-lying position