Peds Neurologic Alterations from Mom
C Prepare child and parents for diagnostic procedures The child and parents should be prepared for diagnostic procedures that may confirm the suspected diagnosis. Anxiety may be able to be reduced, but is unlikely to be eliminated. Seizures are not common with infratentorial tumors, so precautions are unnecessary at this time. Introducing the child to peers can occur after admission, evaluation, and diagnostic procedures.
A 10-year-old child is admitted for suspected infratentorial brain tumor. During the child's admission, which action should the nurse anticipate doing first? A Implement seizure precautions B Introduce child to other children the same age C Prepare child and parents for diagnostic procedures D Eliminate the child's anxiety using distraction techniques
1. A computed tomography scan of the head will reveal trauma. Dilating the eyes is performed to check for retinal hemorrhages that are seen in an infant who has experienced SBS.
A 2-month-old infant is brought to the emergency room after experiencing a seizure. The infant appears lethargic with very irregular respirations and periods of apnea. The parents report the baby is no longer interested in feeding and before the seizure, rolled off the couch. What additional testing should the nurse immediately prepare for? 1. Computed tomography (CT) scan of the head and dilation of the eyes. 2. Computed tomography (CT) scan of the head and electroencephalogram (EEG). 3. X-rays of the head. 4. X-rays of all long bones. 4. X-rays of all long bones.
2. The surgery is done to reconstruct the skull to allow the brain to grow properly. Because there are potential complications associated with this surgery, such as increased ICP, the child is usually closely observed in the PICU.
A 6-month-old infant was just diagnosed with craniosynostosis. The infant's father asks the nurse for more information about reconstructive surgery. Select the nurse's best response. 1. "The surgery is done for cosmetic reasons and is without many complications." 2. "The surgery is important to allow the brain to grow properly. Although most children do well, serious complications can occur, so your child will be closely observed in the intensive care unit." 3. "The surgery is important to allow the brain to grow properly. Most surgeons wait until the child is 3 years old to minimize potential complications." 4. "The surgery is mainly done for cosmetic reasons, and most surgeons wait until the child is 3 years old as the head has finished growing at that time."
3. The helmet is worn 23 hours every day and removed only for bathing.
A 6-month-old male has been diagnosed with positional brachycephaly. The nurse is providing teaching about the use of a helmet for his therapy. Which statement indicates that the parents understand the education? 1. "We will keep the helmet on him when he is awake and remove it only for bathing and sleeping." 2. "He will start wearing the helmet when he is closer to 9 months, as he will be more upright and mobile." 3. "He will wear the helmet 23 hours every day." 4. "Most children need to wear the helmet for 6 to 12 months."
B Positive grasp reflex Positive grasp reflex would be consistent with the diagnosis. : In healthy babies, the neonatal grasp reflex begins to fade at about 3 months of age and is replaced by a voluntary grasp by about 5 months of age. A grasp reflex that does not fade is consistent with a diagnosis of CP. Pigeon chest is unrelated to a diagnosis of CP. Harlequin sign is unrelated to a diagnosis of CP. Circumoral cyanosis is unrelated to a diagnosis of CP.
A 7-month-old child has been diagnosed with cerebral palsy (CP). Which of the following signs/ symptoms would the nurse assess as consistent with the diagnosis? A Harlequin sign B Positive grasp reflex C Pigeon chest D Circumoral cyanosis
B. Lateness in walking Mild intellectual disability is minimally noticeable in young children. with one of the signs being a delay in achieving developmental milestones. such as walking at a later stage. Option A and C: Severe intellectual disability is marked by the mental age of a toddler and little or no communication skills. Option D: Children with moderate intellectual disability have noticeable developmental delays.
A child diagnosed with intellectual disability (ID) is under the supervision of Nurse Tasha. The nurse is aware that the signs and symptoms of mild ID include which of the following? A. Few communication skills B. Lateness in walking C. Mental age of a toddler D. Noticeable developmental delays
1. The child experiencing a seizure usually requires more oxygen as the seizure increases the body's metabolic rate and demand for oxygen. The seizure may also affect the child's airway, causing the child to be hypoxic. It is always appropriate to give the child blow-by oxygen immediately. The nurse should remain with the child and call for additional help.
A child diagnosed with meningitis is having a generalized tonic-clonic seizure. Which should the nurse do first? 1. Administer blow-by oxygen and call for additional help. 2. Reassure the parents that seizures are common in children with meningitis. 3. Call a code and ask the parents to leave the room. 4. Assess the child's temperature and blood pressure.
3. Asking specific questions will give the nurse the information needed to determine the level of care for the child.
A child fell off his bike and sustained a closed-head injury. The child is currently awake and alert, but his mother states that he "passed out" for approximately 2 minutes. The mother appears highly anxious and is very tearful. The child was not wearing a helmet. Which is a priority for the triage nurse to say at this time? 1. "Was anyone else injured in the accident?" 2. "Tell me more about the accident." 3. "Did he vomit, have a seizure, or display any other behavior that was unusual when he woke up?" 4. "Why was he not wearing a helmet?"
2. The child is experiencing diabetes insipidus, a common occurrence in children with midline brain tumors. Vasopressin is a hormone that is used to help the body retain water.
A child has been diagnosed with a midline brain tumor. In addition to showing signs of increased intracranial pressure (ICP), she has been voiding large amounts of very dilute urine. Which medication does the nurse expect to administer? 1. Mannitol. 2. Vasopressin. 3. Lasix. 4. Dopamine.
3. Pain medication promotes comfort and ultimately decreases ICP
A child in the PICU with a head injury is comatose and unresponsive. The parent asks if he needs pain medication. Select the nurse's best response. 1. "Pain medication is not necessary as he is unresponsive and cannot feel pain." 2. "Pain medication may interfere with his ability to respond and may mask any signs of improvement." 3. "Pain medication is necessary to make him comfortable." 4. "Pain medication is necessary for comfort, but we use it cautiously as it increases the demand for oxygen."
2. All forms of spinal stabilization should be continued while methylprednisolone and ranitidine are administered.
A child involved in a motor vehicle accident (MVA) is currently on a backboard with a cervical collar in place. The child is diagnosed with a cervical fracture. Which would the nurse expect to find in the child's plan of care? 1. Remove the cervical collar, keep the backboard in place, and administer high-dose methylprednisolone. 2. Continue with all forms of spinal stabilization, and administer high-dose methylprednisolone and ranitidine. 3. Remove the backboard and cervical collar, and prepare for halo traction placement. 4. Remove the cervical collar and backboard, place the child on spinal precautions, and administer high-dose methylprednisolone and ranitidine.
B Raise the head of the bed D Dim the lights in the room. E Administer intravenous antibiotics, as prescribed The head of the bed should be raised. The room lights should be dimmed. The child should be placed on droplet isolation. The child will receive IV antibiotics. The bacteria that cause meningitis are transmitted via the respiratory route. The child, therefore, should be placed on droplet isolation. Once the child has been on antibiotics for a full 24 hr or if the culture report is negative for bacteria, he or she no longer needs to remain on isolation. The nurse should refrain from moving the child's neck. The movement is very painful.
A child is admitted to the pediatric unit with a diagnosis of meningitis. Which of the following actions should the nurse perform? Select all that apply. A Perform passive range-of-motion exercises of the neck. B Raise the head of the bed. C Place the child on droplet isolation. D Dim the lights in the room. E Administer intravenous antibiotics, as prescribed.
4. Cultures of spinal fluid and blood should be obtained, followed by administration of intravenous antibiotics.
A child is being admitted with the diagnosis of meningitis. Select the procedure the nurse should do first: 1. Administration of intravenous antibiotics. 2. Administration of maintenance intravenous fluids. 3. Placement of a Foley catheter. 4. Send the spinal fluid and blood samples to the laboratory for cultures.
2. One medication is the preferred way to achieve seizure control. The child is monitored for side effects and drug levels.
A child recently diagnosed with epilepsy is being evaluated for anticonvulsant medication therapy. The child will likely be placed on which type of regimen? 1. Two to three oral anticonvulsant medications so that dosing can be low and side effects minimized. 2. One oral anticonvulsant medication to observe effectiveness and minimize side effects. 3. One rectal gel to be administered in the event of a seizure. 4. A combination of oral and intravenous anticonvulsant medications to ensure compliance.
3. Progressing from decerebrate to decorticate posturing usually indicates an improvement in the child's condition.
A child with Reye syndrome is described in the nurse's notes as follows: 1200—comatose with sluggish pupils; when stimulated, demonstrates decerebrate posturing. 1400—unchanged except that now demonstrates decorticate posturing when stimulated. The nurse concludes that the child's condition is: 1. Worsening and progressing to a more advanced stage of Reye syndrome. 2. Worsening, and the child may likely experience cardiac and respiratory failure. 3. Improving and progressing to a less advanced stage of Reye syndrome. 4. Improving as the child's posturing reflexes are similar
A Note the time The nurse should first quickly note the time, in order to calculate how long the seizure activity lasts. Then, any standing or sitting child should be eased to the floor, with the head padded for protection, and the area cleared of any potentially harmful objects. Finally, the child should be rolled to side-lying position to protect the airway.
A child with a known seizure disorder is hospitalized for an unrelated procedure. Upon walking the child back from the restroom, the nurse notes tonic-clonic movements. Which action should the nurse take first? A Note the time B Ease the child to the floor C Clear the area of objects and pad the head D Roll the child to side-lying position to protect the airway
1. Absence seizures occur frequently and last less than 30 seconds. The child experiences a brief loss of consciousness during which she may have a change in activity. These children rarely fall, but they may drop an object. The condition is often confused with daydreaming.
A child with a seizure disorder has been having episodes during which she drops her pencil and simply appears to be daydreaming. This is most likely a/an: 1. Absence seizure. 2. Akinetic seizure. 3. Non-epileptic seizure. 4. Simple spasm seizure.
4. These are symptoms of a shunt malfunction and should be evaluated immediately.
A child with a ventriculoperitoneal (VP) shunt complains of headache and blurry vision and now experiences irritability and sleeping more than usual. The parents ask the nurse what they should do. Select the nurse's best response. 1. "Give her some acetaminophen, and see if her symptoms improve. If they do not improve, bring her to the pediatrician's office." 2. "It is common for girls to have these symptoms, especially prior to beginning their menstrual cycle. Give her a few days, and see if she improves." 3. "You are probably worried that she is having a problem with her shunt. This is very unlikely as it has been working well for 9 years." 4. "You should immediately take her to the emergency room as these may be symptoms of a shunt malfunction."
2. CP can manifest in different ways as the child grows. It does not progress, but its clinical manifestations may change
A child with cerebral palsy (CP) has been fitted for braces and is beginning physical therapy to assist with ambulation. The parents ask why he needs the braces when he was crawling without any assistive devices. Select the nurse's best response. 1. "The CP has progressed, and he now needs more assistance to ambulate." 2. "As your child grows, different muscle groups may need more assistance." 3. "Most children with CP need braces to help with ambulation." 4. "We have found that when children with CP use braces, they are less likely to fall."
2. Urinary tract infections are the most common complication of myelome - ningocele. Nearly all children with myelomeningocele have a neurogenic bladder that leads to incomplete emptying of the bladder and subsequent urinary tract infections. Frequent catheterization also increases the risk of urinary tract infection.
A parent of a newborn diagnosed with myelomeningocele asks what is a common long-term complication? The nurse's best response is: 1. Learning disabilities. 2. Urinary tract infections. 3. Hydrocephalus. 4. Decubitus ulcers and skin breakdown.
1. An atonic seizure is characterized by a loss of muscular tone, whereby the child may fall to the ground.
A preschooler has been having periods during which he suddenly falls and appears to be weak for a short time after the event. The preschool teacher asks what she should do. Select the nurse's best response. 1. "Have the parents follow up with his pediatrician as this is likely an atonic seizure." 2. "Find out if there have been any new stressors in his life, as it could be attention-seeking behavior." 3. "Have the parents follow up with his pediatrician as this is likely an absence seizure." 4. "The preschool years are a time of rapid growth, and many children appear clumsy. It would be best to watch him, and see if it continues."
C. Cognitive delays Children with seizure disorders do not necessarily have cognitive delays. Option A. B. and D: Feelings of being different from peers. poor self-image. and dependency can put additional stress on a child trying to understand and manage chronic illness.
After explaining to the parents about their child's unique psychological needs related to a seizure disorder and possible stressors. which of the following interests uttered by them would indicate further teaching? A. Feeling different from peers B. Poor self-image C. Cognitive delays D. Dependency
A Myelomeningocele. A myelomeningocele is a sac that contains a portion of the meninges, the CSF, and the nerve roots. Meningocele is a sac that contains a portion of the meninges, and cerebrospinal fluid. Spina bifida occulta is the mildest form of spina bifida in which one or more vertebrae are malformed. The child usually has no symptoms and in most cases no one knows there is a spinal defect. Anencephaly is a neural tube defect in which the bones of the skull and head do not form correctly. Infants are missing large parts of their brain and skull.
An infant is born with a sac protruding through the spine, containing cerebrospinal fluid (CSF), a portion of the meninges, and nerve roots. This condition is referred to as: A Myelomeningocele. B Spina bifida occulta. C Meningocele. D Anencephaly.
2. A myelomeningocele is a sac that contains a portion of the meninges, the CSF, and the nerve roots.
An infant is born with a sac protruding through the spine, containing cerebrospinal fluid (CSF), a portion of the meninges, and nerve roots. This condition is referred to as: 1. Meningocele. 2. Myelomeningocele. 3. Spina bifida occulta. 4. Anencephaly.
B. Seizures Seizures usually are associated with encephalopathy. a late sign of lead poisoning. Typically. lead levels have already exceeded 70 mg/dl. Option A. C. and D: Anemia. irritability. and anorexia are early signs.
Nurse Gloria is teaching the Mr. and Mrs. Diaz about the early signs and symptoms of lead poisoning; which of the following if stated by the couple would indicate the need for further understanding of the case? A. Anemia B. Seizures C. Irritability D. Anorexia
4. Decreased perfusion of the brain and increased metabolic needs of the brain.
Brain damage in a child who sustained a closed-head injury can be caused by which factor? 1. Increased perfusion to the brain and increased metabolic needs of the brain. 2. Decreased perfusion to the brain and decreased metabolic needs of the brain. 3. Increased perfusion to the brain and decreased metabolic needs of the brain. 4. Decreased perfusion of the brain and increased metabolic needs of the brain
A Hydrocephalus Myelomenigocele is commonly associated with hydrocephalus, excessive cerebrospinal fluid (CSF) within the cranial cavity. Microencephaly is associated with maternal exposure to cytomegalovirus (CMV) or rubella. Anencephaly (absence of cranial vault) is a different neural tube defect. Cranial suture overlap may occur with vaginal birth, but is not associated with myelomeningocele.
Congenital myelomeningocele is commonly associated with which of the following conditions? A Hydrocephalus B Microencephaly C Cranial suture overlap D Absence of the cranial vault
B. To reduce the risk of infection Surgical closure decreases the risk of infection stemming from damage to the fragile sac. which can lead to meningitis. Option A: Surgical repair does not help relieve hydrocephalus. In fact. some researchers believe that repair exaggerates the Arnold-Chiari malformation and decreases the absorptive surface for cerebrospinal fluid. leading to more rapid development of hydrocephalus. Option C: The neurologic deficit cannot be corrected. However. some surgeons believe that early surgery reduces risk of stretching spinal nerves and preventing further damage. Option D: Surgical repair of the sac doesn't prevent seizure disorder. an impairment of the brain neuron tissue.
Daya's child is scheduled for surgery due to myelomeningocele; the primary reason for surgical repair is which of the following? A. To prevent hydrocephalus B. To reduce the risk of infection C. To correct the neurologic defect D. To prevent seizure disorders
B. EEG The EEG recognizes abnormal electrical activity in the brain. The pattern of multiple spikes can assist in the diagnosis of particular seizure disorders. Option A: Skull radiographs can distinguish fractures and structural abnormalities. Option C: Brain scans confirm space-occupying lesions. Option D: Lumbar puncture confirms problems related to cerebrospinal fluid infection or trauma.
In diagnosing seizure disorder. which of the following is the most beneficial? A. Skull radiographs B. EEG C. Brain scan D. Lumbar puncture
B. Bilateral parachute The parachute reflex appears to about 9 months of age is normal. Option A. C. and D: All of the following are considered abnormal when evaluating infantile reflexes: reflexes that persist after they should have disappeared (rooting). reflexes are absent when they should be present (Moro). and reflexes that are unilateral (grasp).
Nurse Lorna is assessing infantile reflexes in a 9-month-old baby; which of the following would she identify as normal? A. Persistent rooting B. Bilateral parachute C. Absent moro reflex D. Unilateral grasp
C. Plan for discharge in 12 to 24 hours. D. Check for electrolyte imbalances. F. Provide oxygen as ordered. Children with Category A Near Drowning are awake with minimal injury. Care includes checking electrolyte status. administering oxygen and warming. and preparing for discharge in 12 to 24 hours.
Nurse Maritza is caring for a child with Category A Near Drowning; she should do which of the following? (Select all that apply.) A. Give furosemide as ordered. B. Check for increased intracranial pressure C. Plan for discharge in 12 to 24 hours. D. Check for electrolyte imbalances. E. Keep mechanical ventilation. F. Provide oxygen as ordered.
D. Varicella Reye's syndrome has been linked with the ingestion of aspirin in children with viral infections like varicella. Option A and C: There is no association between meningitis or bacterial infections such as strep throat and the development of Reye's syndrome. Option B: Encephalitis is a component of Reye's syndrome.
Reye's syndrome is a rare and severe illness affecting children and teenagers. Its development has been linked with the use of aspirin and which of the following? A. Meningitis B. Encephalitis C. Strep throat D. Varicella
3. A quiet private room with minimal stimulation is ideal as the child with meningitis should be in a quiet environment to avoid cerebral irritation.
Select the best room assignment for a newly admitted child with bacterial meningitis. 1. Semiprivate room with a roommate who also has bacterial meningitis. 2. Semiprivate room with a roommate who has bacterial meningitis but has received intravenous antibiotics for more than 24 hours. 3. Private room that is dark and quiet with minimal stimulation. 4. Private room that is bright and colorful and has developmentally appropriate activities available.
C. Deficits in adaptive behavior with intellectual impairment Mental retardation is part of a broad category of developmental disability and is defined by the American Association of Mental Deficiency as "significantly sub-average. general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period (18 years of age)."Option A: IQ of 70 or below is considered significantly sub-average intellectual functioning. Option B: Cognitive impairment isn't part of the definition. However. the definition does states that the impairment or compromise must occur before age 18 years old.
The American Association on Mental Deficiency (AAMD). now American Association on Intellectual and Developmental Disabilities (AAIDD) definition of mental retardation emphasizes which of the following? A. An IQ level that must be below 50 B. Cognitive impairment occurring after age 22 years C. Deficits in adaptive behavior with intellectual impairment D. No responsiveness to contact
1. High fat and low carbohydrates are the components of the ketogenic diet.
The diet that produces anticonvulsant effects from ketosis consists of: 1. High-fat and low-carbohydrate foods. 2. High-fat and high-carbohydrate foods. 3. Low-fat and low-carbohydrate foods. 4. Low-fat and high-carbohydrate foods.
B Improved level of consciousness Mannitol is a controversial osmotic diuretic usually reserved for head injury cases that have not responded to other therapies. Decreased intercranial pressure is the best indication that this medication has been effective. Other listed options may or may not occur as a result of this medication.
The health care provider has ordered mannitol (Osmitrol) for a child with a head injury. The best indicator that this medication has been effective is: A Increased urine output B Improved level of consciousness C Decreased facial swelling D Decreased intercranial pressure
4. Posturing is a reflex that often indicates that the child is receiving too much stimulation.
The mother of an unconscious child has been calling her name repeatedly and gently shaking her shoulders in an attempt to wake her up. The nurse notes that the child is flexing her arms and wrists while bringing her arms closer to the midline of her body. The child's mother asks, "What is going on?" Select the nurse's best response. 1. "I think your daughter hears you, and she is attempting to reach out to you." 2. "Your child is responding to you; please continue trying to stimulate her." 3. "It appears that your child is having a seizure." 4. "Your child is demonstrating a reflex that indicates she is overwhelmed with the stimulation she is receiving."
C Irritability Irritability is the correct option. Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respiration are more often slow, deep, and irregular.
The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be MOST likely to exhibit? A Lethargy B Negative Moro C Irritability D Depressed fontanel
2. The CSF in bacterial meningitis is usually cloudy.
The nurse is aware that cloudy cerebrospinal fluid (CSF) most likely indicates: 1. Viral meningitis. 2. Bacterial meningitis. 3. No infection, as CSF is usually cloudy. 4. Sepsis.
3. The young child with encephalitis should be admitted to a PICU where close observation and monitoring are available. The child should be observed for signs of increased ICP and for cardiac and respiratory compromise.
The nurse is caring for a 1-year-old who has just been diagnosed with viral encephalitis. The parents ask if their child will be admitted to the hospital. Select the nurse's best response. 1. "Your child will likely be sent home because encephalitis is usually caused by a virus and not bacteria." 2. "Your child will likely be admitted to the pediatric floor for intravenous antibiotics and observation." 3. "Your child will likely be admitted to the PICU for close monitoring and observation." 4. "Your child will likely be sent home because she is only 1 year old. We see fewer complications and a shorter disease process in the younger child."
3. It is important to involve speech therapy to strengthen tongue and jaw movements to assist with feeding. The infant who is at risk for CP may have weakened and uncoordinated tongue and jaw movements.
The nurse is caring for a 2-month-old infant who is at risk for cerebral palsy (CP) due to extreme low birth weight and prematurity. His parents ask why a speech therapist is involved in his care. Select the nurse's best response. 1. "Your child is likely to have speech problems because of his early birth. Involving the speech therapist now will ensure vocalization at a developmentally appropriate age." 2. "The speech therapist will help with tongue and jaw movements to assist with babbling." 3. "The speech therapist will help with tongue and jaw movements to assist with feeding." 4. "Many members of the health-care team are involved in your child's care so that we will know if there are any unmet needs."
2. Asking the 3-year-old to identify her parents and state her name is a developmentally appropriate way to assess orientation.
The nurse is caring for a 3-year-old with an altered state of consciousness. The nurse determines that the child is oriented by asking the child to: 1. Name the president of the United States. 2. Identify her parents and state her own name. 3. State her full name and phone number. 4. Identify the current month but not the date.
D Moist sterile nonadherent dressing Moist sterile nonadherent dressing is the correct option. Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is? A Telfa dressing with antibiotic ointment B Dry sterile dressing C Sterile occlusive pressure dressing D Moist sterile nonadherent dressing
D Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis.
The nurse is planning care for a ten month-old infant with bacterial meningitis. Which of the following nursing measures would be appropriate for the nurse to do? A Provide active range of motion B Place in contact isolation C Provide an over-the-crib mobile D Measure head circumference
B. Increase intrathoracic pressure Head elevation decreases. not increases. intrathoracic pressure. Option A. C. and D: Elevating the head of the bed in a child with increased ICP helps to alleviate headache. maintain neutral position. and reduce intra-abdominal pressure. which may contribute to increased ICP.
Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle? A. Help alleviate headache B. Increase intrathoracic pressure C. Maintain neutral position D. Reduce intra-abdominal pressure.
C High-pitched cry A high-pitched cry may indicate increased intercranial pressure in an infant, notably in an infant with the Chiari malformation that obstructs the flow of CSF. It is normal for anterior fontanel to bulge during periods of crying. Overflow voiding is associated with neurogenic bladder, and minimal lower extremity movement is associated with spinal cord damage.
What notable sign may indicate increased intercranial pressure in an infant? A Overflow voiding B Bulging fontanel when crying C High-pitched cry D Minimal lower extremity movement
B Encouraging self-care skills in the child The primary goal for people with Down syndrome is to promote as much independence and self-care as possible. A Down syndrome child may not be able to learn new things every day, but may require repetition of previously learned skills. Parents should establish consistent disciplinary rules and habits. Age-appropriate social skills may not be attainable due to mental retardation; but socially acceptable behavior should be taught.
When talking with the parents of a Down syndrome child, which of the following goals would be most appropriate for the child and family? A Teaching the child one new thing every day B Encouraging self-care skills in the child C Establishing more lenient behavior standards D Achieving age-appropriate social skills
D Swallowing ability This child is exhibiting signs and symptoms of Guillain-Barre Syndrome (infectious polyneuritis). A sore throat often precedes the paralysis of this disorder. The nurse should evaluate swallowing ability to determine if any immediate action is necessary. After assessing swallowing, the nurse can then obtain information about exposure to illnesses. Diet and urination will not contribute to finding out the cause of these symptoms.
Which assessment detail is most important for the clinic nurse to make regarding a school-age child who has a sore throat, arm weakness, muscle tenderness, and generally feeling unwell? A Diet intake for last 24 hours B Exposure to illnesses C Difficulty urinating D Swallowing ability
B Respiratory rate of 24 breaths per minute. A normal neonate's respiratory rate is 30 to 60 breaths per minute. Neonates' respiratory systems are immature, and the rate may initially double in response to illness. If no immediate interventions are begun when there is respiratory distress, a neonate's respiratory rate will slow down, develop worsening respiratory distress, and, eventually, respiratory arrest. Neonates with slower or faster respiratory rates are true emergency cases; they require identification of the cause of distress.With the diagnosis of suspected bacterial meningitis, the neonate is expected to be irritable, which frequently accompanies increased intracranial pressure.A rectal temperature of 38.1°C or 100.6°F indicates a low-grade fever and is not as concerning as the slower-than-normal respiratory rate of 24.The fact the infant is quieter than normal is in response to the slow respiratory rate and sepsis the neonate is experiencing.
Which clinical assessment of a neonate with bacterial meningitis would warrant immediate intervention? A Quieter than usual. B Respiratory rate of 24 breaths per minute. C Irritability. D Rectal temperature of 100.6°F (38.1°C).
B Encourage discussion of fears and concerns All parents, especially those with a child who has a disability or defect, need to hear positive comments that emphasize what is normal or beautiful about their child. Discussing fears and concerns, and reinforcing teaching are not priority on the first visit. Feeding the infant will need to wait until the open defect is repaired, usually within 24 hours of birth.
Which nursing action should be a priority when the parents first meet their infant with an open spinal defect? A Have the parents feed the infant B Encourage discussion of fears and concerns C Provide written information reinforcing health care provider education D Emphasize the infant's normal and positive features
B Hyperactive reflexes When nerve reflexes return following a spinal cord injury, they are usually overactive, resulting in spasticity and hyperactivity of the limbs and bladder. Flaccid paralysis and atonic bladder may result from spinal shock. Widened pulse pressure is not associated with resolution of spinal shock.
Which of the following findings would indicate to the nurse that spinal shock was resolving in an adolescent with a spinal cord injury? A Widening pulse pressure B Hyperactive reflexes C Atonic urinary bladder D Flaccid paralysis
C Level of consciousness Level of consciousness (response to voice or stimuli) is the best indicator of brain function. Pupil response, vital signs, and motor changes usually follow changes in consciousness.
Which of the following is the best indicator of brain function in a child with a moderate brain injury? A Pupil response B Vital signs C Level of consciousness D Gross motor strength
A Sleeping more than usual. C High-pitched cry. A high-pitched cry is often indicative of increased ICP in infants. The infant may be sleeping more than usual due to increased ICP. The anterior fontanel is usually raised and bulging in infants with increased ICP. The infant is not able to comprehend blurred vision or make any statements. The infant with increased ICP usually has a poor appetite and does not feed well.
Which signs best indicate increased intracranial pressure (ICP) in an infant? Select all that apply. A Sleeping more than usual. B Sunken anterior fontanel. C High-pitched cry. D Increased appetite. E Complaints of blurred vision
C Absence seizure. Absence seizures occur frequently and last less than 30 seconds. The child experiences a brief loss of consciousness during which she may have a change in activity. These children rarely fall, but they may drop an object. The condition is often confused with daydreaming. Akinetic seizures occur when the young child experiences a brief loss of consciousness and postural tone and falls to the ground. The child quickly regains consciousness. A non-epileptic seizure is a seizure that occurs secondary to another disorder, such as a fever or increased ICP.A simple spasm seizure is not a diagnosis
child with a seizure disorder has been having episodes during which she drops her pencil and simply appears to be daydreaming. This is most likely a/an: A Simple spasm seizure. B Non-epileptic seizure. C Absence seizure. D Akinetic seizure.
