ex 3 PED Prepu cHapter 16

The nurse is collecting data on an 18-month-old child admitted with a diagnosis of possible seizures. When interviewing the caregivers, which questions would be most important for the nurse to ask? "Is your child up to date on his immunizations?" "Has anyone in your family been sick recently" "What type of activities was your child doing today?" "Have you checked your child's temperature?"

"Have you checked your child's temperature?"

46. A nurse should expect which cerebrospinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis (Select all that apply)? a. Elevated white blood cell (WBC) count b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBCs)

ANS: A, C, D

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)? a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations

ANS: B, D, E

A 6-year-old child with hydrocephalus had a ventriculoperitoneal (VP) shunt placed 6 weeks ago and now has experienced a seizure, vomiting, and loss of appetite. Which intervention will target the child's priority need? Administer intravenous antibiotics as prescribed. Pad and raise the rails on the child's bed. Educate the parents about seizure precautions. Prepare a menu with the child's favorite foods.

Administer intravenous antibiotics as prescribed.

The community health nurse is preparing a presentation on safety measures to prevent injuries in children. Which example of proper safety guidelines should the nurse include? Select all that apply. a child wearing a helmet while ice skating an infant in a car seat a child riding a scooter with elbow and knee pads a preschool-age child sitting on the lap of a caregiver in the back seat of a car a child wearing a helmet, knee pads, and elbow pads while riding a skateboard

a child wearing a helmet while ice skating an infant in a car seat a child wearing a helmet, knee pads, and elbow pads while riding a skateboard

A child is diagnosed with aseptic meningitis. The child's mother states, "I don't know where she would have picked this up." The nurse prepares to respond to the mother based on the understanding that this disorder is most likely caused by: enterovirus. Escherichia coli. Haemophilus influenzae type B. group B streptococcus.

enterovirus.

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? semi-Fowler position with a parent at the bedside supine on a parent's lap prone on the bed with a parent or caregiver on either side of the bed high-Fowler position while sitting on the parent's lap

semi-Fowler position with a parent at the bedside

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? "I will watch my baby for irritability and difficulty feeding." "My baby's cerebrospinal fluid is increasing intracranial pressure." "The VP shunt will help drain fluid from my baby's brain." "This shunt is the only surgery my baby will need."

"This shunt is the only surgery my baby will need."

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? Assess the level of consciousness (LOC). Notify the primary health care provider. Place the child on fall precaution. Place a patch over the client's affected eye.

Assess the level of consciousness (LOC). Explanation: 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.

Which clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure

a. Bulging fontanel and dilated scalp veins

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands the need for this treatment is based on what? 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.

a. PaCO2 levels decrease, causing vasoconstriction.

. Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. Your head will be restrained during the procedure. b. You will have to drink a special fluid before the test. c. You will have to lie flat after the test is finished. d. You will have electrodes placed on your head with glue.

a. Your head will be restrained during the procedure.

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. Eye trauma. c. Severe brainstem damage. b. Neurosurgical emergency. d. Indication of brain death.

b. Neurosurgical emergency.

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

toddlers

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? Take vital signs every 4 hours Monitor temperature every 4 hours Decrease environmental stimulation Encourage the parents to hold the child

Decrease environmental stimulation

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

Signs of increased intracranial pressure (ICP) Explanation: 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.

During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents? Plasma levels of the drug will be monitored on a daily basis Drug dosage will be adjusted depending on the frequency of seizure activity The drug must be discontinued immediately if even the slightest problem occurs The child shouldn't participate in activities that could be hazardous if a seizure occurs

The child shouldn't participate in activities that could be hazardous if a seizure occurs

Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol c. Atropine sulfate b. Epinephrine hydrochloride d. Sodium bicarbonate

a. Mannitol

7. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan c. Computed tomography (CT) scan b. Echoencephalography d. Magnetic resonance imaging (MRI)

c. Computed tomography (CT) scan

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 priority condition? a. Neonatal conjunctivitis b. Facial deformities c. Intracranial hemorrhage d. Incomplete myelinization

c. Intracranial hemorrhage

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. eye opening verbal response motor response fontanels (fontanelles) posture

eye opening verbal response motor response

A 3-year-old child is hospitalized after a near-drowning accident. The childs mother complains to the nurse, This seems unnecessary when he is perfectly fine. The nurses best reply is: a. He still needs a little extra oxygen. b. Im sure he is fine, but the doctor wants to make sure. c. The reason for this is that complications could still occur. d. It is important to observe for possible central nervous system problems.

c. The reason for this is that complications could still occur.

The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is: maintaining effective cerebral perfusion. ensuring the parents know how to properly give antibiotics. establishing seizure precautions for the child. encouraging development of motor skills.

ensuring the parents know how to properly give antibiotics.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? moderate closed-head injury early closure of the fontanels (fontanelles) congenital hydrocephalus intracranial hemorrhaging

intracranial hemorrhaging Explanation: Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels (fontanelles) has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity, which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection.

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent indicates to the nurse that additional teaching is needed? "I have ibuprofen available in case it is needed." "My child will likely outgrow these seizures by age 5." "I always keep phenobarbital with me in case of a fever." "The most likely time for a seizure is when the fever is rising."

"I always keep phenobarbital with me in case of a fever."

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? "I will cradle her in my arms after the procedure for at least 30 minutes." "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things." "My child may have a headache after the procedure. If she does, she can have something for the pain." "I need to encourage my child to drink at least 1 glass of water after the procedure."

"I will cradle her in my arms after the procedure for at least 30 minutes."

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "If he is out of bed, the helmet's on the head." "Bike riding and swimming are just too dangerous." "Use this information to teach family and friends." "You'll always need a monitor in his room."

"Use this information to teach family and friends."

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? "Watch for changes in his behavior or eating patterns." "Call the doctor if he gets a headache." "Always keep his head raised 30 degrees." "Limit the amount of television he watches."

"Watch for changes in his behavior or eating patterns."

A 13-year-old adolescent is being released from the hospital following examination for a concussion. The parent has agreed to monitor the adolescent at home for the next 24 hours. Which instruction(s) should the nurse provide? Select all that apply. Assess the adolescent's level of consciousness every 1 to 2 hours while awake. Wake the adolescent once during the night to assess consciousness. Ask the adolescent to name a familiar object. Ask the adolescent to state where he or she lives. Wake the adolescent every hour during the night to assess for consciousness. Do not let the adolescent sleep during the first 24 hours.

Assess the adolescent's level of consciousness every 1 to 2 hours while awake. Wake the adolescent once during the night to assess consciousness. Ask the adolescent to name a familiar object. Ask the adolescent to state where he or she lives.

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

Collection of cerebrospinal fluid (CSF) and blood for culture

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? Seizures are typically outgrown by 4 years of age. Convulsive activity often occurs in seizures. Seizures are typically provoked by pain. The electroencephalogram (EEG) is normal during a seizure.

Convulsive activity often occurs in seizures. Explanation: 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.

The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? Decorticate posturing and fixed and dilated pupils Decreased pupil reaction and decreased respiration. Headache and sunset eyes Dizziness and irritability

Decorticate posturing and fixed and dilated pupils

A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate for administration? Select all that apply. Diazepam Lorazepam Fosphenytoin Gabapentin Carbamazepine

Diazepam Lorazepam Fosphenytoin Commonly used medications for treating status epilepticus include lorazepam, diazepam, and fosphenytoin. Gabapentin and carbamazepine are anticonvulsants used to treat and prevent seizures in general.

The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns? VI VII VIII IX

IX Explanation: Cranial nerve IX (glossopharyngeal) would be assessed to test the swallowing and gag reflex. Cranial nerve VIII is the acoustic nerve which is involved in hearing. Cranial nerve VII is the facial nerve and controls facial muscles, salivation and taste. Cranial nerve VI is the abducens nerve and controls and is related to eye movements.

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

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

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

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

Place a cap or similar covering on the newborn's head. Explanation: 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 is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse? Place the child in a bathtub filled with cool water. Apply ice packs to the child's axillary and groin area. Administer acetaminophen by mouth as prescribed. Remove any blankets or heavy clothing and replace with a thin sheet

Remove any blankets or heavy clothing and replace with a thin sheet

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? Delayed growth and development related to physical restrictions Risk for injury related to seizure activity Risk for acute pain related to surgical procedure Ineffective airway clearance related to history of seizures

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

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? Tell me your concerns about your child's shunt. Call the doctor if she gets a persistent headache. Her autoregulation mechanism to absorb spinal fluid has failed. Always keep her head raised 30º.

Tell me your concerns about your child's shunt. Explanation: 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.

The nurse is preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child? Use a doll with electrodes attached to the head. Show the child a video of the procedure. Tell the child he or she can take a nap during the procedure. Assure the child the procedure will not hurt.

Use a doll with electrodes attached to the head.

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

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.

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. Wake the child every 1 to 2 hours to check level of consciousness. Observe and report any vomiting that occurs within 6 hours. Observe for and report to provider any double or blurred vision. Check the pupil reaction to light every 15 minutes for 12 hours. Administer acetaminophen for headache.

Wake the child every 1 to 2 hours to check level of consciousness. Observe and report any vomiting that occurs within 6 hours. Observe for and report to provider any double or blurred vision.

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the childs postoperative care (Select all that apply)? a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.

a. Observe closely for signs of infection. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.

A nurse is preparing a presentation for an expectant parent group about neural tube defects and how to prevent them. Which would the nurse emphasize? a. Smoking cessation b. Aerobic exercise c. Increased calcium intake d. Folic acid supplementation

d. Folic acid supplementation

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? drinking three cans of diet cola swimming twice a week use of nonaccented soap 11 p.m. bedtime; 6:30 a.m. wake-up

drinking three cans of diet cola Explanation: 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 knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? head trauma intracranial hemorrhaging congenital hydrocephalus positional plagiocephaly

head trauma

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? tachypnea hyperthermia poor handwriting hypertension

hypertension Explanation: Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP

The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply. increased head circumference pulse rate of 60 beats/min and regular vomiting blood pressure decreased from baseline parent states, "My infant does not act right."

increased head circumference vomiting pulse rate of 60 beats/min and regular parent states, "My infant does not act right."

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. oxygen gauge and tubing suction at bedside tongue blade padding for side rails smelling salts

oxygen gauge and tubing suction at bedside padding for side rails

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? cerebral angiography lumbar puncture video electroencephalogram computed tomography

video electroencephalogram Explanation: 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.

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 meningitides

ANS: A Feedback: Meningitis due to Streptococcus group B along with Escherichia coli is most common in newborns and infants. H. influenzae type B, S. pneumoniae and N. meningitides are common causes in children older than 3 months and in adults.

The young boy was involved in a motor vehicle accident and was admitted to the pediatric intensive care unit with changes in level of consciousness and a high-pitched cry. Which are late signs of increased intracranial pressure? Select all that apply. The child states that he feels a little "dizzy." The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. The sclera of the eyes is visible above the iris. The child's heart rate is 56 beats per minute. The child's pupils are fixed and dilated.

The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. The child's heart rate is 56 beats per minute. The child's pupils are fixed and dilated.

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

d. Projectile vomiting

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? "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." "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." "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose." "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder."

"The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Explanation: 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 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? Administer lorazepam IV as prescribed. Perform a glucose finger stick to determine the child's blood sugar level. Administer carbamazepine as prescribed. Observe and document the length of time of the seizure and type of movement observed.

Administer lorazepam IV as prescribed.

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. You will be on your knees with your head down on the table. b. You will be able to sit up with your chin against your chest. c. You will be on your side with the head of your bed slightly raised. d. You will lie on your side and bend your knees so that they touch your chin.

d. You will lie on your side and bend your knees so that they touch your chin.

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

moving the infant's head every 2 hours Explanation: 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.

The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse? "You probably don't have anything to worry about. It is common for toddlers to fall." "I understand your concern, but toddlers fall and hit their heads a lot since they are not very coordinated yet." "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." "Most mothers are concerned because their toddlers fall a lot. As long as your child seems to be developmentally normal it shouldn't be a concern."

Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Explanation: The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.

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

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.

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? Place in an indwelling urinary catheter. Administer dexamethasone, dosage determined by the pharmacist. Administer mannitol IV, dosage determined by the pharmacist. Initiate an IV of 0.9% NS to run at 250 ml/hr.

Initiate an IV of 0.9% NS to run at 250 ml/hr. Explanation: 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.

While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? Administer lorazepam rectally to the client. Refer the client to a neurologist. Discuss dietary therapy with the client's caregivers. Protect the child from hitting the arms against the bed.

Protect the child from hitting the arms against the bed.

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply. The nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse places a washcloth in the mouth to prevent injury during seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions.

The nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions

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

The surgery was successful. Do you have any questions?" Explanation: 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 is completing a nursing history on a female client who has just found out she is 6 weeks' pregnant. She reports that over the last 2 months she has been drinking excessive amounts of alcohol every weekend and smokes a half-pack of cigarettes per day. What is the nurse concerned with given this information? Select all that apply. brain development in the fetus spinal cord development in the fetus solid bone formation in the fetus development of gastrointestinal organs in the fetus reproductive organ development in the fetus

brain development in the fetus spinal cord development in the fetus

he nurse assesses a child and finds that the child's pupils are pinpoint. What does this finding indicate? brain stem dysfunction seizure activity brain stem herniation intracranial mass

brain stem dysfunction Pinpoint pupils are commonly observed in poisonings, brain stem dysfunction, and opiate use. Dilated but reactive pupils are seen after seizures. Fixed and dilated pupils are associated with brain stem herniation. A single dilated but reactive pupil is associated with an intracranial mass.

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect? hydrocephalus anencephaly encephalocele spina bifida occulta

hydrocephalus