Chapter 46 Review Questions
The nurse is caring for a 2-year-old girl who is unconscious but stable following a car accident. Her parents are staying at the bedside most of the time. An appropriate nursing intervention is to: suggest that the parents go home until she is alert enough to know that they are present. use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns. encourage the parents to hold, talk, and sing to her as they usually would. position her with proper body alignment and head of bed lowered 15 degrees.
c
The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain: cannot occur if the child is comatose. may occur if the child regains consciousness. requires astute nursing assessment and management. is best assessed by family members who are familiar with the child.
c
The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. In the discussion the nurse should include that: parental protection is essential until the child reaches adulthood. cognitive impairment is to be expected with hydrocephalus. shunt malfunction or infection requires immediate treatment. most usual childhood activities must be restricted.
c
The temperature of an adolescent who is unconscious is 105° F. The PRIORITY nursing action is to: continue to monitor temperature. initiate a pain assessment. apply a hypothermia blanket. administer acetaminophen or ibuprofen.
c
The MOST appropriate nursing interventions when caring for a child experiencing a seizure include: Select all that apply. restraining the child when a seizure occurs to prevent bodily harm. placing a padded tongue between the teeth if they become clenched. avoid suctioning the child during the seizure. describing and documenting the seizure activity observed. applying supplemental oxygen after inserting an artificial oral airway.
c, d
What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? Suctioning child frequently Providing environmental stimulation Turning head side to side every hour Avoiding activities that cause pain or crying
d
Why are infants particularly vulnerable to acceleration-deceleration head injuries? The anterior fontanel is not yet closed. The nervous tissue is not well developed. The scalp of the head has extensive vascularity. Musculoskeletal support of head is insufficient.
d
The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and pupils are unequal and sluggish. The MOST appropriate nursing action is to: notify the health care provider immediately. document level of consciousness. observe closely for signs of increased intracranial pressure (ICP). administer pain medication and assess for response.
a
The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest: neurologic health. severe brain damage. decorticate posturing. decerebrate posturing.
a
The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. The MOST appropriate nursing assessment in this case is: reactivity of pupils. doll's head maneuver. oculovestibular response. funduscopic examination to identify papilledema.
a
The nurse is planning care for a school-age child with bacterial meningitis. The plan should include: keeping environmental stimuli at a minimum. avoiding giving pain medications that could dull sensorium. measuring head circumference to assess developing complications. having child move head side to side at least every 2 hours.
a
The nurse who is concerned about increased intracranial pressure in an infant should assess for: irritability. photophobia. pulsating anterior fontanel. vomiting and diarrhea.
a
A 3-year-old child is status postshunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? Select all that apply. Personality change Bulging anterior fontanel Vomiting Dizziness Fever
a, b, e
The postoperative care of a preschool child who has had a brain tumor removed should include which information? Clear drainage is to be expected. Close supervision is needed while the child is regaining consciousness. Positioning is on the side in the Trendelenburg position. Analgesics are contraindicated because of altered consciousness.
b
A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is: absence seizure. generalized seizure. status epilepticus. simple partial seizure.
c
The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. The PRIORITY of nursing care is to: initiate isolation precautions as soon as the diagnosis is confirmed. initiate isolation precautions as soon as the causative agent is identified. administer antibiotic therapy as soon as it is ordered. administer sedatives/analgesics on a preventive schedule to manage pain.
c
