Peds Chapter 31

A 7-year-old boy is brought to the emergency room by his parents following an accident in which he was struck in the back of the head with a baseball bat. The nurse is assessing him. Which of the following would indicate increased intracranial pressure in this child? a) Decrease in pulse and pulse pressure and increase in temperature and respiratory rate b) Decrease in pulse and respiratory rate and increase in temperature and pulse pressure c) Decrease in temperature and pulse pressure and increase in pulse and respiratory rate d) Decrease in pulse and temperature and increase in respiratory rate and pulse pressure

Decrease in pulse and respiratory rate and increase in temperature and pulse pressure Explanation: All children with head trauma require a neurologic assessment as soon as they are seen and again at frequent intervals to detect signs and symptoms of increased intracranial pressure (ICP) as increasing pressure puts stress on the respiratory, cardiac, and temperature centers, causing dysfunction in these areas. The mark of increased pressure is a decrease in pulse and respiratory rate and an increase in temperature and pulse pressure (the distance between the diastolic and systolic pressure). The child's pupils also become slow or unable to react immediately. Level of consciousness and motor ability both also decrease.

An unconscious client is brought to the emergency department after ingesting too much prescribed medication. Which of the following is the highest priority nursing intervention? a) Establish a patent airway. b) Administer antacids. c) Establish IV access. d) Call family members.

Establish a patent airway

A young patient in the intensive care unit is in a coma after a severe head injury. The primary nurse is teaching a nursing student how to assess the patient's level of consciousness by using a coma scale. This scale is referred to as which of the following? a) Apgar scale b) Visual analogue scale c) Glasgow scale d) Wong-Baker FACES scale

Glasgow scale

The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? a) Palpation of the head reveals a closed posterior fontanel. b) The child is crying and looking around fearfully. c) Inspection shows a sluggish pupillary reaction. d) The child's eyes remain closed unless she is spoken to.

Inspection shows a sluggish pupillary reaction. Explanation: A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern. A closed posterior fontanel in an 11-month-old would be a normal finding. Crying and looking around are encouraging signs indicating improved neurologic status. Opening the eyes when being spoken to is an encouraging sign.

A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be next? a) Stabilize the cervical spine. b) Set up antecubital IV access. c) Check mouth for debris. d) Administer 100% oxygen.

Stabilize the cervical spine. Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and IV access occur after the C-spine is stabilized.

Fever increases the basal metabolic rate resulting in: a) Bradycardia b) Bradypnea c) Decreased oxygen demand d) Tachypnea

Tachypnea Explanation: Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand.

Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications? a) Firemen found the child sobbing silently. b) The child was trapped in a closed burning bedroom. c) The child's clothing was burned. d) The fire was caused by burning weeds.

The child was trapped in a closed burning bedroom. Explanation: When a child is confined in a closed space during a fire, he or she can inhale a great deal of smoke, causing respiratory tract burns or irritation.

The nurse is examining a 10-month-old girl who has fallen from the back porch. Which assessment will directly follow evaluation of the "ABCs?" a) Palpating the anterior fontanel b) Palpating the abdomen for soreness c) Observing skin color and perfusion d) Auscultating for bowel sounds

Palpating the anterior fontanel Explanation: Once the ABCs have been evaluated, the nurse will move on to "D" and assess for disability by palpating the anterior fontanel for signs of increased intracranial pressure. Observing skin color and perfusion is part of evaluating circulation. Palpating the abdomen for soreness and auscultating for bowel sounds would be part of the full-body examination that follows assessing for disability.

The nurse is assessing the neurologic status of an infant. Which of the following would the nurse identify as a nonreassuring finding? a) Vigorous crying b) Making eye contact with the nurse c) Soft flat anterior fontanel d) Lack of interest in surroundings

Lack of interest in surroundings

While working in the emergency room, you receive a call that a 3-year-old child sustained extensive burns in a house fire. Assuming all of the following actions are included in the standing burn-care protocol, which would be your first nursing action? a) Ask the child to drink a glass of milk. b) Give a tetanus toxoid injection. c) Insert an NG tube to empty the stomach. d) Obtain a weight.

Obtain a weight Obtaining a weight provides a base for calculating the fluid that will need to be replaced. NG placement and/or drinking milk are not actions to take at this point. Tetanus can be given later and is not critical to active management.

A 13-year-old girl suffered a serious fall while hiking with friends and injured her head. She is now being evaluated by a nurse in the emergency room. The nurse notices clear fluid flowing from the girl's nose. The girl's friend said that she had been suffering from pollen allergy recently. Which of the following interventions should the nurse implement to determine whether the fluid is cerebrospinal fluid (CSF) or rhinitis from an allergy? a) Assess the client's blood pressure b) Test the fluid with a glucose reagent strip c) Evaluate the client's level of consciousness d) Perform a skull x-ray

Test the fluid with a glucose reagent strip Explanation: Rhinorrhea or otorrhea (clear fluid draining from the nose or ear, respectively) may be noticeable. The fluid is cerebrospinal fluid (CSF) and is a serious finding because it means that the child's central nervous system is open to infection. If it's not clear if the fluid is CSF or rhinitis from an allergy, test the fluid with a glucose reagent strip. CSF will test positive for glucose, whereas the clear, watery drainage from an upper respiratory tract infection or allergy will not. The other interventions would not help determine whether the fluid was CSF or rhinitis.