Ricci Chapter 38 Test Bank
4. The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents? A. Monitor their child's level of sedation. B. Watch for fever indicating infection. C. Gradually reduce the dosage as seizures stop. D. Monitor for an allergic reaction to the medication.
Answer: A Rationale: Diazepam is useful for home management of prolonged seizures and requires that the parents be educated on its proper administration. Monitoring the child's level of sedation is key when giving diazepam because it slows the central nervous system. Parents need to monitor the overall health of the child, including temperature when needed, but that has nothing to do with the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is necessary to prevent seizures or status epilepticus. This is not done without a physician's order. Monitoring for allergic reactions is necessary when any medications have been prescribed, but is not specific to diazepam. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 1342
11. A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands that after this treatment: A. PaCO2 levels decrease, causing vasoconstriction. B. drainage of cerebrospinal fluid occurs. C. activity is controlled via a stimulator. D. hyperexcitability of the nerves is reduced.
Answer: A Rationale: Hyperventilation decreases PaCO2, which results in vasoconstriction and therefore decreases intracranial pressure. A shunt would allow for drainage of cerebrospinal fluid. A vagal nerve stimulator is used to provide an appropriate dose of stimulation to manage seizure activity. Anticonvulsants decrease the hyperexcitability of nerves. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1340
30. A child with a seizure disorder will be discharged home from the hospital on the drug levetiracetam. What discharge instruction is the most important for the nurse to provide the parent? A. Notify the health care provider if child experiences poor coordination B. Notify the health care provider if the number of seizures increases after 4 weeks C. Return to the clinic in 3 weeks for laboratory test to determine therapeutic level of the drug D. Do not to take two doses together if one dose is missed
Answer: A Rationale: Levetiracetam is used in children to help control seizures. One major side effect of the drug is that it can cause difficulty with gait or coordination. Another major side effect is the development of psychiatric symptoms. The parent should be instructed to call the health care provider immediately if either of these side effects occur. This drug does not have a therapeutic level so there is no need for routine laboratory tests.The parent should be instructed not to give the child two doses together if one has been missed, but this is not the most important instruction. The drug takes about 4 weeks to stabilize in the blood stream, so additional seizures may be seen during this time. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 1346
23. A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes: Streptococcus group B Haemophilus influenzae type B Streptococcus pneumoniae Neisseria meningitidis What would the nurse highlight as the most common cause of meningitis in newborns? A. Streptococcus group B B. Haemophilus influenzae type B C. Streptococcus pneumoniae D. Neisseria meningitidis
Answer: A Rationale: Meningitis due to Streptococcus group B along with Escherichia coli is most common in newborns and infants. H. influenzae type B is a common cause in infants between the ages of 6 and 9 months. S. pneumoniae and N. meningitidis are common causes in children older than 3 months and in adults. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1359
3. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? A. Indications of increased intracranial pressure B. An increase in the blood glucose level C. A decrease in the liver enzymes D. A presence of protein in the urine
Answer: A Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1363
29. Phenytoin IV has been prescribed by health care provider for a child who has experienced a seizure. Before administering the drug what should the nurse do? A. Determine the IV fluid infusing is normal saline B. Assess the child's vital signs C. Monitor the electrolyte levels D. Start another IV with a large bore needle
Answer: A Rationale: The drug phenytoin can be administered PO or IV. If it is to be administered IV, the fluids needs to be normal saline solution. Any other type of fluid will cause the drug to percipitate in the IV tubing.There is no need to start an additional peripheral IV. The drug can be administered via a secondary set through the IV pump. The vital signs can be monitored after the drug is infusing. The electrolyte levels can be monitored, but treatment of the seizure is the priority. Fosphenytoin is another form of phenytoin and may be tolerated better. It can be administered through all IV fluids without precipitaion. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 1346
28. A child is in the emergency department with a head injury obtained in a motor vehicle crash. The glascow coma scale assessment is rated at 10 (3 eye opening, 3 motor, 4 verbal). How should the nurse interpret these findings? A. The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli B. The child's eyes open spontaneously, able to localize pain and uses inappropriate words C. The child's eyes open to speech, is able to obey commands but is confused D. The child's eyes open to pain, opens to extension and says incomprehensible words
Answer: A Rationale: The glascow coma scale is a widely used tool for assessing the extent of brain injury and prognosis. The scores are based on eye opening, motor response and verbal response. The perfect score is 15. The lower the score the more severe the injury and prognosis. Scores for a severe head injury are 8 or less. A moderate head injury scores between 9-12 points and a mild head injury scores between 13 and 15. With a score of 10 this child would be classified as having a moderate head injury. For answer B the eyes open spontaneously (4), localizes pain (5) and uses imcomprehensive words(2) for a total score of 11.For answer C the eyes open to speech (3), uses inappropriate words (2) and has flexion withdrawal (4) for a total score of 9. For answer D the eyes open to pain (2) extremities open to expension (2) and uses incomprehensible words (2) for a score of 6. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1330
10. A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which food selection would be most appropriate for his lunch? A. Fried eggs, bacon, and iced tea B. A hamburger on a bun, French fries, and milk C. Spaghetti with meatballs, garlic bread, and a cola drink D. A grilled cheese sandwich, potato chips, and a milkshake
Answer: A Rationale: The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 1341
24. A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children? A. Linear B. Depressed C. Diastatic D. Basilar
Answer: A Rationale: The most common type of skull fracture in children is a linear skull fracture, which can result from minor head injuries. Other, less common types of skull fractures in children include depressed, diastatic, and basilar. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1364
17. A nurse is preparing a school-aged child for a lumbar puncture. The nurse would expect to position the child in which manner? A. On her side with the head flexed forward and knees flexed to the abdomen B. Sitting upright with the head flexed forward to the chest C. Supine with arms and legs pronated and extended D. Prone with the arms flexed under the chest
Answer: A Rationale: When a lumbar puncture is performed on a child, the child is placed on his or her side with the head flexed forward and knees flexed to the abdomen. An infant would be positioned sitting upright with the head flexed forward. A supine position with the arms and legs pronated and extended suggests decerebrate posturing. A prone position is not used for a lumbar puncture. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1334
26. A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? A. Assess the client's respiratory rate B. Start cardiopulmonary resusitative measures C. Determine how long the client was face down in the water D. Apply a heart monitor to the client
Answer: A Rationale: With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway and breathing are priority. Based on this assessment, the nurse would determine if resuscitative measures were needed. Other actions such as applying a heart monitor and obtaining additional information about the event would be done once the infant's airway and breathing are assessed and emergency interventions are instituted. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1368
21. A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply. A. Complaints of stiff neck B. Photophobia C. Absent headache D. Negative Brudzinski sign E. Vomiting
Answer: A, B, E Rationale: In addition to the adolescent's complaints and history, other findings suggesting bacterial meningitis include complaints of a stiff neck, photophobia, headache, positive Brudzinski sign, and vomiting. Question format: Multiple Select Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1359
27. A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply. A. Place child in clothing with no metal B. Connect the child to a heart monitor C. Assess the IV site for patency D. Review any prescriptions for sedation E. Assess for a latex allergy
Answer: A, C, D Rationale: When preparing a child for an MRI procedure, it is important the child and parent are aware of the test procedure. No metal can be used in the MRI scanner room so all clothing, jewelry, etc. need to be removed before testing. IV contrast may be used so the IV needs to be patent and in good working order. If the child is to be sedated the nurse should review the sedation prescription and identify any discrepanies before the child goes for the examination. If the child is to be sedated a heart monitor will be used, but it is not necessary for the nurse on the unit to connect the child. A special monitor compatible with the MRI scanner will be used. If sedated the child may also receive oxygen just as a prevention because the exam take a long time in a confined space. Having a latex allergy is not a contraindication for receiving gadolinium, the MRI contrast used during testing. Question format: Multiple Select Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1335
12. The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child's level of consciousness? A. Confusion B. Obtunded C. Stupor D. Coma
Answer: B Rationale: Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1330
2. The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which problem? A. Febrile seizures B. Head trauma C. Caput succedaneum D. Posterior plagiocephaly
Answer: B Rationale: The larger head size in relation to the body, coupled with a higher center of gravity, causes children to hit their head more readily when involved in motor vehicle accidents, bicycle accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1327-1328
22. A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions? A. "Expect his headache to get worse initially and then disappear." B. "Wake him every 2 hours to check his movement and responses." C. "Call your medical provider if he vomits more than five times." D. "Any watery fluid draining from his ears is normal."
Answer: B Rationale: The nurse should instruct the parents to wake the child every 2 hours to ensure that he moves normally and wakes enough to recognize and respond appropriately to them. The parents should be instructed to call the physician or nurse practitioner or bring the child back to the emergency department if he experiences a constant headache that gets worse, vomits more than two times, or has oozing of blood or watery fluid from his ears or nose. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 1365
13. During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve? A. Olfactory B. Trigeminal C. Facial D. Accessory
Answer: B Rationale: To test the trigeminal nerve, the nurse would note the strength of the infant's suck on a pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would be assessed during spontaneous crying or smiling. The accessory nerve is assessed when the infant is in the sitting position and symmetry of the head position is noted. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 1331
19. Hydrocephalus is suspected in a 4-month-old infant. Which would the nurse expect to assess? A. Sunken fontanels B. Diminished reflexes C. Lower extremity spasticity D. Skull symmetry
Answer: C Rationale: Hydrocephalus is manifested by spasticity of lower extremities, bulging fontanels, brisk reflexes, and skull asymmetry. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1352
5. As a result of seizure activity, a computed tomography (CT) scan was performed and showed that an 18-month-old child has intracranial arteriovenous malformation. When developing the child's plan of care, what would the nurse expect to implement actions to prevent? A. Drug interactions B. Developmental disabilities C. Hemorrhagic stroke D. Respiratory paralysis
Answer: C Rationale: Intracranial hemorrhage or hemorrhagic stroke is a risk for children with intracranial arteriovenous malformation. Drug interactions are a risk for children who are treated with combinations of anticonvulsants for epilepsy. Children with hydrocephalus are at an increased risk for developmental disabilities. Respiratory paralysis is a risk of botulism that typically affects infants younger than 6 months of age. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1355
20. A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they make what statement? A. "Having the shunt put in decreases his risk for developmental problems." B. "If he doesn't get an infection in the first week, the risk is greatly reduced." C. "He will need more surgeries to replace the shunt as he grows." D. "The shunt will help to prevent any further complications from his disease."
Answer: C Rationale: Parents need to know that hydrocephalus is a chronic illness that requires lifelong follow-up and regular evaluations, including future surgeries as the child grows. The risk for infection is ever present, but is most common 1 to 2 months after shunt placement. The child with a shunt and hydrocephalus is at risk for potential growth and developmental disabilities as well as complications such as infection and malfunction of the shunt. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 1355
1. When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of what condition? A. Neonatal conjunctivitis B. Facial deformities C. Intracranial hemorrhage D. Incomplete myelinization
Answer: C Rationale: Premature infants have more fragile capillaries in the periventricular area than term infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1355
9. The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition? A. Multiple corrective surgeries to slowly remove diseased parts of his brain B. Physical, occupational, and speech therapy to maximize his potential C. Support for maintaining self-esteem because of his altered lifestyle D. Hyperventilation therapy to counteract the periods of decreased oxygenation
Answer: C Rationale: The effects of living with a seizure disorder can be devastating, and it is essential for the child to receive support to maintain self-esteem. While corrective surgery is possible, it would only be performed once. Physical, occupational, speech, and hyperventilation therapy are not indicated for treatment of epilepsy. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 1348
7. A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority? A. Hyperextending the child's head while placing him on his side B. Using a tongue blade to pry open the child's jaw C. Loosening the child's clothing to ensure a patent airway D. Protecting the child from harm during the seizure
Answer: D Rationale: During a seizure, the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is an important intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1348-1349
8. The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his breath when he gets frustrated. What will be most important to include in this plan? A. Provide cuddle time whenever the child begins to act out. B. Explain the child's behavior to the parents. C. Encourage the parents to interact more with the child. D. Stay close to prevent injury when he gets frustrated.
Answer: D Rationale: Encourage the parents to maintain a safe environment when an episode is occurring, but to avoid giving extra attention to the child after the event since this could encourage repetition of the behavior. It is important for the parents to understand what is happening, but rewarding the child with cuddle time when he is misbehaving provides incorrect reinforcement of behaviors. Encouraging the parents to interact more with the child may be helpful, but the priority is safety for the child. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1371
18. A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates? A. Tonic B. Focal clonic C. Multifocal clonic D. Myoclonic
Answer: D Rationale: Five major types of seizures have been recognized in the neonatal period: subtle, tonic, focal clonic, multifocal clonic, and myoclonic. Of these, myoclonic seizures rarely occur during the neonatal period. Subtle seizures affect preterm and full-term neonates. Tonic seizures primarily occur in preterm neonates. Focal clonic and multifocal clonic are more common in full-term neonates. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1349
25. During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response? A. Strokes in children often have an identifiable cause. B. The signs and symptoms in children are different from an adult. C. Research has identified specific treatments for children. D. Ischemic strokes are more common than hemorrhagic strokes.
Answer: D Rationale: In children, ischemic strokes are more common than hemorrhagic strokes. However, the cause of the stroke in many children remains unidentified. Signs and symptoms are similar to those in adults and will vary based on age; underlying cause, if known; and location of the stroke. Historically, children have been excluded from adult stroke studies and thus, many treatments used have had to be adapted from adult studies. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1369
16. A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion? A. The child's risk for cognitive problems is greatly increased. B. Structural damage occurs with febrile seizure. C. The child's risk for epilepsy is now increased. D. Febrile seizures are benign in nature.
Answer: D Rationale: Parents need reassurance that febrile seizures, although frightening, are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural damage or cognitive declines. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 1349
6. A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? A. Fixed and dilated pupils B. Frequent urination C. Sunset eyes D. Sunlight is "too bright"
Answer: D Rationale: Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1359
15. What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure? A. Bradycardia B. Cheyne-Stokes respirations C. Fixed, dilated pupils D. Projectile vomiting
Answer: D Rationale: Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia, Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial pressure. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1333
14. The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as: A. Decorticate posturing B. Nystagmus C. Doll's eye D. Sunsetting
Answer: D Rationale: Sunsetting is when the sclera of the eyes is showing over the top of the iris. Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements. Doll's eye is a maneuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Communication and Documentation Reference: p. 1331