Ch. 16- Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder PrepU

Which of these age groups has the highest actual rate of death from drowning? A. infants B. toddlers C. preschool children D. school-aged children

B. toddlers Toddlers and older adolescents have the highest actual rate of death from drowning.

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): A. diuretic. B. antihistamine. C. steroid. D. anticonvulsant.

C. steroid. - Increased intracranial pressure (ICP) may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. - The diuretic mannitol may be used to decrease edema. - An anticonvulsant is used with increased ICP to prevent seizures. - An antihistamine would not be warranted for the treatment of a head injury.

A 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication? A. Use a soft toothbrush. B. Take medication on an empty stomach. C. Avoid excessive sunlight. D. Increase intake of citrus foods to promote absorption.

A. Use a soft toothbrush. Phenytoin is an anticonvulsant medication. It can be used in the management of seizure disorders. This medication is associated with gingival hyperplasia. This may result in tender and bleeding gums. The use of a soft toothbrush will reduce pain, bleeding and discomfort. There is no need to take this medication on an empty stomach or with citrus foods and beverages. The medication does not make an individual photosensitive.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate? A. "It's normal for this to happen, but they don't really know why." B. "The forceps used during delivery caused this to happen." C. "During delivery, your vaginal wall put pressure on the baby's head." D. "Your baby's head became blocked inside your vagina while you were pushing."

C. "During delivery, your vaginal wall put pressure on the baby's head." Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? A. Tell the parent the infant's brain is underdeveloped. B. Reassess the head circumference in 24 hours. C. Document that the infant has microcephaly. D. Report the findings to the pediatric health care provider.

D. Report the findings to the pediatric health care provider. These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain. Waiting 24 hours to reassess will delay treatment. In microcephaly, the head circumference is small, but the fontanels (fontanelles) and suture line are palpable.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? A. Risk for injury related to seizure activity B. Delayed growth and development related to physical restrictions C. Ineffective airway clearance related to history of seizures D. Risk for acute pain related to surgical procedure

A. Risk for injury related to seizure activity The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

Antibiotic therapy to treat meningitis should be instituted immediately after which event? A. Initiation of IV therapy B. Identification of the causative organism C. Admission to the nursing unit D. Collection of cerebrospinal fluid (CSF) and blood for culture

D. Collection of cerebrospinal fluid (CSF) and blood for culture Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of IV therapy aren't, by themselves, appropriate times to begin antibiotic therapy.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? A. Degree and extent of nuchal rigidity B. Occurrence of urine and fecal contamination C. Onset and character of fever D. Signs of increased intracranial pressure (ICP)

D. Signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? A. "I will give the medication to him when I first wake him up in the morning." B. "I need to watch for any new bruises or bleeding and let my health care provider know about it." C. "I'm glad to know he will only need this medication for a short time to stop his seizures." D. "This medication may cause him to have trouble sleeping. He may need something else to help him sleep."

B. "I need to watch for any new bruises or bleeding and let my health care provider know about it." Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to watch for any signs of bruising, bleed, or infection and notify their health care provider if this happens. Administer this medication with food to minimize GI upset. This medication can cause drowsiness, so do not give any sleep-inducing or other sedative type medications. Antiseizure medication does not cure seizures; it only controls the seizures. Lifelong antiseizure medication may be needed.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? A. Administer carbamazepine as prescribed. B. Administer lorazepam IV as prescribed. C. Observe and document the length of time of the seizure and type of movement observed. D. Perform a glucose finger stick to determine the child's blood sugar level.

B. Administer lorazepam IV as prescribed. A seizure lasting longer than 30 minutes is considered status epilepticus and is an emergency situation. An IV benzodiazepine such as lorazepam is administered to help stop the seizure. Checking blood glucose levels, monitoring length and type of seizure, and administration of anti-seizure medication such as carbamazepine all are correct interventions for clients with seizures, but these are not the priority action.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: A. raccoon eyes. B. rhinorrhea. C. Battle sign. D. otorrhea.

C. Battle sign. Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority? A. Left-sided heart failure B. Cerebral edema C. Cardiogenic shock D. Renal failure

B. Cerebral edema The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Renal failure and cardiogenic shock aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse will be correct in telling the parent which information in regard to seizures? A. Seizures are typically provoked by pain. B. Convulsive activity often occurs in seizures. C. The electroencephalogram (EEG) is normal during a seizure. D. Seizures are typically outgrown by 4 years of age.

B. Convulsive activity often occurs in seizures. During seizures, convulsive activity is typically noted. Breath-holding spells are typically provoked by pain or the child being upset, have a normal EEG pattern, and are typically outgrown by the time the child reaches preschool age.

A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement? A. "My stomach is upset. I feel like I might throw up." B. "I am glad that my headache is getting better." C. "You look funny. Well, both of you do. I see two of you." D. "It will be nice when you will let me take a long nap. I am sleepy."

C. "You look funny. Well, both of you do. I see two of you." The caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider.

Absence seizures are marked by what clinical manifestation? A. Brief, sudden onset of increased tone of the extensor muscle B. Loss of muscle tone and loss of consciousness C. Loss of motor activity accompanied by a blank stare D. Sudden, brief jerks of a muscle group

C. Loss of motor activity accompanied by a blank stare - An absence seizure consists of a sudden, brief arrest of the child's motor activity accompanied by a blank stare and loss of awareness. - A tonic seizure consists of a brief onset of increased tone or muscle. - A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. - An atonic seizure involves a sudden loss of muscle tone and loss of consciousness.

The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction? A. "This shunt is the only surgery my baby will need." B. "I will watch my baby for irritability and difficulty feeding." C. "My baby's cerebrospinal fluid is increasing intracranial pressure." D. "The VP shunt will help drain fluid from my baby's brain."

A. "This shunt is the only surgery my baby will need." Hydrocephalus results from an imbalance in the production and absorption of CSF. In hydrocephalus, CSF accumulates within the ventricular system and causes the ventricles to enlarge, and increases in ICP subsequently occur. A VP shunt can be used to drain excess CSF, but it will need to be replaced as the child grows, requiring shunt revision surgery at various times during the client's life. The parent should be taught to monitor for signs and symptoms of increased ICP, which include irritability and vomiting. Increased ICP indicates the shunt is not functioning properly.

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question? A. Place in an indwelling urinary catheter. B. Administer mannitol IV, dosage determined by the pharmacist. C. Administer dexamethasone, dosage determined by the pharmacist. D. Initiate an IV of 0.9% NS to run at 250 ml/hr.

D. Initiate an IV of 0.9% NS to run at 250 ml/hr. Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain? A. cerebral angiography B. video electroencephalogram C. computed tomography D. lumbar puncture

B. video electroencephalogram A video electroencephalogram can determine the precise localization of the seizure area in the brain. Cerebral angiography is used to diagnose vessel defects or space-occupying lesions. Lumbar puncture is used to diagnose hemorrhage, infection, or obstruction in the spinal canal. Computed tomography is used to diagnose congenital abnormalities such as neural tube defects.

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? A. "She always cries when the person holding her has on glasses...I guess glasses scare her." B. "She has been irritable for the last hour....seems like she is just upset for some reason." C. "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." D. "She typically breastfeeds, but lately we have had to supplement with some rice cereal."

B. "She has been irritable for the last hour....seems like she is just upset for some reason." Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The nurse is caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion? A. difficulty concentrating B. trouble focusing when reading C. bleeding from the ear D. vomiting

B. trouble focusing when reading Signs and symptoms for cerebral contusions include disturbances to vision, strength, and sensation. A child suffering a concussion will be distracted and unable to concentrate. Vomiting is a sign of a subdural hematoma. Bleeding from the ear is a sign of a basilar skull fracture.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? A. Onset and character of fever B. Occurrence of urine and fecal contamination C. Signs of increased intracranial pressure (ICP) D. Degree and extent of nuchal rigidity

C. Signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.

A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure? A. high-Fowler position while sitting on the parent's lap B. supine on a parent's lap C. semi-Fowler position with a parent at the bedside D. prone on the bed with a parent or caregiver on either side of the bed

C. semi-Fowler position with a parent at the bedside Proper positioning for an infant after a ventricular tap is to place the child in a semi-Fowler position to prevent additional drainage from the puncture site. Allow the parents or caregivers to comfort the child. Placing the child in the prone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? A. intracranial hemorrhaging B. head trauma C. positional plagiocephaly D. congenital hydrocephalus

B. head trauma - A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. - Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. - Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. - Positional plagiocephaly is caused by an infant's head remaining in the same position for too long.

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply. A. tongue blade B. oxygen gauge and tubing C. smelling salts D. padding for side rails E. suction at bedside

B. oxygen gauge and tubing D. padding for side rails E. suction at bedside When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.

The nurse is assessing a toddler for motor function. Which activity will be the most valuable? A. Let the child look at a picture book. B. Ask the child to kick the ball forward. C. Watch the child reach for a toy. D. Have the child catch a ball.

C. Watch the child reach for a toy. Watching the child reach for a toy would be most valuable for assessing motor function because the infant should be able to extend extremities to a normal stretch. Catching a ball or kicking a ball forward is too advanced for a toddler to accomplish. Looking at a picture book would help assess visual acuity and eye movement.

What information is most correct regarding the nervous system of the child? A. As the child grows, the gross and fine motor skills increase. B. The child has underdeveloped fine motor skills and well-developed gross motor skills. C. The child's nervous system is fully developed at birth. D. The child has underdeveloped gross motor skills and well-developed fine motor skills.

A. As the child grows, the gross and fine motor skills increase. As the child grows, the quality of the nerve impulses sent through the nervous system develops and matures. As these nerve impulses become more mature, the child's gross and fine motor skills increase in complexity. The child becomes more coordinated and able to develop motor skills.

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? A. frequent temperature assessment B. ketogenic diet C. use of anticonvulsant medications D. vagus nerve stimulation

C. use of anticonvulsant medications Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? A. "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose." B. "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder." C. "Since the EEG was negative there must be some other cause for the seizures. The lumbar puncture is necessary to determine what the cause is." D. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

D. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures. A normal EEG does not rule out epilepsy because seizure activity rarely occurs during the actual testing time. A 24-hour or longer EEG can help in diagnosing a seizure disorder. Just telling the parents that it needs to be done, to be patient, or it is a routine does not address the parents' concerns.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures? A. Treating the child as though she did not have epilepsy B. Instructing her teacher how to respond to a seizure C. Placing the child on her side on the floor D. Understanding the side effects of medications

D. Understanding the side effects of medications The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control.

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger? A. 11 p.m. bedtime; 6:30 a.m. wake-up B. use of nonaccented soap C. drinking three cans of diet cola D. swimming twice a week

C. drinking three cans of diet cola Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III? A. The nurse allows the child to smell objects and describe them. B. A bright-colored toy is moved in the child's visual fields. C. The nurse observes facial features and expressions for symmetry. D. The nurse talks softly to the child to note the ability to hear.

B. A bright-colored toy is moved in the child's visual fields. Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement. Cranial nerve I (olfactory nerve) controls the sense of smell. Asking the child to smell objects would be an assessment of this cranial nerve. Cranial nerve VII (facial nerve) is assessed by monitoring symmetry of facial movements. Cranial nerve VIII (acoustic nerve) is assessed by whispering.

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which as a risk factor for hemorrhagic stroke? A. meningitis B. congenital heart defect C. arteriovenous malformations (AVMs) D. sickle cell disease

C. arteriovenous malformations (AVMs) Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke. Sickle cell disease is a risk factor for ischemic stroke. Congenital heart defects are risk factors for ischemic stroke. Meningitis or other infection is a risk factor for ischemic stroke.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. A. fontanels (fontanelles) B. posture C. eye opening D. verbal response E. motor response

C. eye opening D. verbal response E. motor response The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? A. "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." B. "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." C. "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine." D. "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received."

A. "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Meningococcal conjugate vaccine protects against four types of meningitis. There is nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the infection, or that the adolescent's immune system is compromised.

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? A. Assess the level of consciousness (LOC). B. Place a patch over the client's affected eye. C. Notify the primary health care provider. D. Place the child on fall precaution.

A. Assess the level of consciousness (LOC). Decreased LOC is frequently the first sign of a major neurologic problem after head trauma. The nurse would assess the client's LOC before notifying the health care provider. The child may need to be placed on fall precaution, depending on the results of the assessment. The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary.

A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use? A. Monitor for increased intracranial pressure (ICP). B. Refer the family to an agency to assist with long-term care. C. Place a cap or similar covering on the newborn's head. D. Closely monitor neurologic status.

C. Place a cap or similar covering on the newborn's head. Using a newborn cap can help parents deal with the malformed appearance of their child so they may hold and bond with the baby. Anencephaly is incompatible with life. The newborn is missing brain hemispheres, a skull, and/or scalp. There is no forebrain or cerebrum. Monitoring for increased intracranial pressure (ICP) or neurologic status are not necessary interventions.

The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? Select all that apply. A. Time the seizure started B. Persons in attendance during seizure C. Number of seizures child has had in the last 48 hours D. Incontinence of urine or stool E. Eye position and movement F. Factors present before seizure started

A. Time the seizure started D. Incontinence of urine or stool E. Eye position and movement F. Factors present before seizure started Following a seizure, the nurse documents the following: time the seizure started; what the child was doing when the seizure began; any factor present just before the seizure (bright light, noise); part of the body where seizure activity began; movement and parts of the body involved; any cyanosis; eye position and movement; incontinence of urine or stool; time seizure ended; and child's activity after the seizure. Who was with the child or the number of seizures the child has had are not relevant to document regarding observation of this seizure.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? A. Encourage the parents to hold the child B. Decrease environmental stimulation C. Take vital signs every 4 hours D. Monitor temperature every 4 hours

B. Decrease environmental stimulation A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? A. Educate the family on the shunt. B. Measure the client's head circumference. C. Monitor the client for signs of infection. D. Assess the client's respiratory status.

D. Assess the client's respiratory status. The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway.

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? A. Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention B. Muscle tone maintained and child frozen in position C. Brief, sudden contracture of a muscle or muscle group D. Sudden, momentary loss of muscle tone, with a brief loss of consciousness

A. Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention - Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. - A sudden loss of muscle tone describes atonic seizures. - A frozen position describes the appearance of someone having akinetic seizures. - A brief, sudden contraction of muscles describes a myoclonic seizure.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? A. While assessing the child's pupils, there is no change in diameter in response to a light. B. While turning the child's head to the left, the eyes turn to the right. C. While stimulating the child's foot, the big toe points upward and other toes fan outward. D. While calling the child's name, the child stares straight ahead and does not turn to the sound.

A. While assessing the child's pupils, there is no change in diameter in response to a light. To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination.

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? A. "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." B. "I need to set an alarm to wake up and check his temperature during the night when he is sick." C. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." D. "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever."

C. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents? A. "This only happens in 1 out of 2,000 births." B. "I told you yesterday there would be facial swelling." C. "The surgery was successful. Do you have any questions?" D. "I will be watching hemoglobin and hematocrit closely."

C. "The surgery was successful. Do you have any questions?" Often what parents need most is someone to listen to their concerns. Although this is a good time for education, the parents are more concerned about the success of the surgery than their infant's appearance. Watching the hemoglobin, hematocrit and swelling are important nursing functions but they do not address the parents' psychosocial needs. The parents do not need to be taught statistics about their infant's condition. They more than likely know this from health care provider visits, the Internet, and parent support groups. Following surgery, this knowledge is not what parents are concerned about. Parents want to know their infant is safe and well.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? A. giving the infant small feedings whenever he is fussy B. massaging the scalp gently every 4 hours C. measuring the intake and output every shift D. moving the infant's head every 2 hours

D. moving the infant's head every 2 hours Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? A. Review the signs of increased intracranial pressure with parents. B. Have the child sleep without a pillow under his head. C. Have the parents call the doctor if the child vomits more than twice. D. Teach the child and his parents to keep a headache diary.

D. Teach the child and his parents to keep a headache diary. A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.

A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? A. "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." B. "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." C. "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." D. "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."

D. "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.

The nurse is reinforcing teaching with the caregivers of a child being discharged from the urgent care setting following a mild head injury that occurred in a roller skating accident. What should the caregivers be instructed to do? Select all that apply. A. Observe for and report to provider any double or blurred vision. B. Wake the child every 1 to 2 hours to check level of consciousness. C. Observe and report any vomiting that occurs within 6 hours. D. Administer acetaminophen for headache. D. Check the pupil reaction to light every 15 minutes for 12 hours.

A. Observe for and report to provider any double or blurred vision. B. Wake the child every 1 to 2 hours to check level of consciousness. C. Observe and report any vomiting that occurs within 6 hours. A child with a concussion should be observed for at least 24 hours and the caregiver should be prepared to bring the child to the hospital if symptoms worsen. The child should be awakened every 2 hours to assess that the child wakes easily and has not developed neurological symptoms. The child should be brought back to the hospital if the child vomits within 6 hours of the injury or more than two times. Other signs for parents to watch for are increased sleepiness, a worsening headache, confusion, or poor balance or walking. No analgesics or sedatives should be administered during this period of observation. In the home the parents would not be checking pupil reaction.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? A. Palpate the child's fontanels (fontanelles). B. Encourage the mother to hold and comfort the infant. B. Institute droplet precautions in addition to standard precautions. D. Educate the family about preventing bacterial meningitis.

B. Institute droplet precautions in addition to standard precautions. Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Encouraging the mother to hold and comfort the child is an intervention but not the priority one; the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread. Educating the family about preventing bacterial meningitis would be appropriate later once the initial infection has been controlled. Palpating the fontanels (fontanelles) is used to assess for hydrocephalus.

The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session? A. Her autoregulation mechanism to absorb spinal fluid has failed. B. Always keep her head raised 30º. C. Tell me your concerns about your child's shunt. D. Call the doctor if she gets a persistent headache.

C. Tell me your concerns about your child's shunt. Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.