ICR and thermoregulation practice
As a result of hydrocephalus, 12-year-old suffers from all BUT which of the following? A. Diarrhea B. Headaches C. Seizures D. Poor grades
A
The nurse is caring for a 10-year-old with a head injury. The nurse understands which assessment finding is the earliest and most sensitive indicator for an increase in intracranial pressure? A. Change in level of consciousness B. Dilated pupils C. Loss of primitive reflexes D. Inability to focus visually
A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.
A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse expects which results for the cerebrospinal fluid that can confirm the diagnosis of meningitis? A. WBCs; glucose B. RBCs; normal WBCs C. glucose; normal RBCs D. Normal RBCs; normal glucose
A A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured and samples are obtained for culture, Gram stain, blood cell count, and determination of glucose and protein content. The findings are usually diagnostic. The patient generally has an elevated white blood cell count, often predominantly polymorphonuclear leukocytes. The glucose level is reduced, generally in proportion to the duration and severity of the infection.
he nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences.
A All these are important measures to review with the UAP, but the most important is option A. Improper use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client comfort and reduce anxiety but are of a lower priority than option A.
The nurse understands which statement to be true regarding a lumbar puncture procedure? A. The lumbar puncture is performed to obtain cerebrospinal fluid for laboratory analysis B. The lumbar puncture is performed to rule out subdural effusions C. The lumbar puncture is performed to detect electrical activity for seizures D. The lumbar puncture is performed to relieve intracranial pressure
A An LP is done to obtain cerebrospinal fluid (CSF) for laboratory analysis. A subdural tap is performed to rule out subdural effusions. It is also done to remove CSF to relieve pressure. Electrical activity or spikes are detected by an electroencephalography (EEG). This test indicates the potential for seizures. LP is contraindicated in patients with increased intracranial pressure. A subdural tap or ventricular puncture may be done to remove CSF to relieve pressure.
The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings? A. Neurologic health B. Severe brain damage C. Decorticate posturing D. Decerebrate posturing
A Moro, tonic neck, and withdrawal reflexes are three reflexes that are present in a healthy 2- month-old infant and are expected in this age group.
The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the childs care plan? A. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline. B. Maintain an active, stimulating environment. C. Perform chest percussion and suctioning every 1 to 2 hours. D. Perform active range of motion and nontherapeutic touch every 8 hours.
A Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP.
The nurse is planning care for a school-age child with bacterial meningitis. What intervention should be included? A. Keep environmental stimuli to a minimum. B. Have the child move her head from side to side at least every 2 hours. C. Avoid giving pain medications that could dull sensorium. D. Measure head circumference to assess developing complications.
A The room is kept as quiet as possible and environmental stimuli are kept to a minimum. Most children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nuchal rigidity associated with meningitis would make moving the head from side to side a painful intervention. If pain is present, the child should be treated appropriately. Failure to treat can cause increased intracranial pressure. In this age group, the head circumference does not change. Signs of increased intracranial pressure would need to be assessed.
A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child? A. Relief of discomfort B. Reassurance that illness is temporary C. Prevention of secondary bacterial infection D. Avoidance of life-threatening complications
A The principal reason for treating fever is the relief of discomfort. Relief measures include pharmacologic and environmental intervention. The most effective is the use of pharmacologic agents to lower the set point. Although the nurse can reassure the child that the illness is temporary, the child is often uncomfortable and irritable. Intervention helps the child and family minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life- threatening events are associated with fever. The use of antipyretics does not seem to reduce the incidence of febrile seizures.
In preparing the patient and family for hospital discharge, which of the following signs and symptoms of shunt malfunction and infection should the nurse include in the teaching plan? Select all that apply. A. Emesis, lethargy B. A change in neurological behavior C. Fever, Irritability D. Diarrhea or constipation E. Redness along the shunt system
A. Emesis, lethargy (Increased ICP/infection) B. A change in neurological behavior (increased ICP) C. Fever, Irritability (possible infection) E. Redness along the shunt system (possible infection) All of the above answers are s/s of increased intracranial pressure
he nurse is preparing to admit an adolescent with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) A. Fever B. Chills C. Headache D. Poor tone E. Drowsiness
ABCE Clinical manifestations of bacterial meningitis in an adolescent include, fever, chills, headache, and drowsiness. Hyperactivity is present, not poor tone
The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.) A. High-pitched cry B. Poor feeding C. Setting-sun sign D. Sunken fontanel E. Distended scalp veins F. Decreased head circumference
ABCE Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and an increased head circumference
The nurse is providing care to a 9-year-old newly admitted to the emergency department with a closed head injury. Which of the health care provider's orders will the nurse question? (Select all that apply.) A. Neuro checks every 8 hours B. Two milligrams of IV morphine x one now C. Turn off the florescent lighting in the room. D. Increase the head of the bed to 45 degrees. E. Parents at the bedside
ABD Initial neuro checks need to be performed at least hourly to detect for subtle changes. Sedating medications like morphine need to be avoided during the initial phase of assessment of a closed head injury. The head of the bed should only be elevated 15 to 30 degrees. The goal is to decrease stimulation in the room by turning off the florescent lighting. Subtle lighting can be brought into the room. Parents at the bedside will offer the child reassurance.
a 3-month-old infant, is brought to the emergency department by her parents. Parents report that Effie has been irritable and refusing feedings. What information will the nurse need to obtain from the parents? Select all that apply. A. "Is Effie in daycare?" B. "Tell me about your pregnancy and delivery." C. "How long does Effie sleep at night?" D. "Do you have any family history of cancer?" E. "Has Effie recently sustained any injuries?"
ABE
The nurse is providing care to an infant is recovering from a shunt placement for hydrocephalus. Which actions will the nurse include in the immediate postoperative care of this infant? (Select all that apply.) A. Measure head circumference. B. Place infant on the operative side. C. Assess neurological signs every hour. D. Keep the infant flat. E. Stimulate the infant to cry every hour.
ACD The infant needs to be placed on the non-operative side to prevent pressure on the shunt valve. The child does not need to cry to assess neuro signs. Provide comfort measures and decrease stimulation. The remaining actions are appropriate care for this infant.
The nurse comes upon a hospitalized child having tonic-colonic movements. The child has a history of seizure activity. What actions will the nurse take for this child? (Select all that apply.) A. Place a pillow under the child's head. B. Place an airway while the child continues to seize. C. Hold the child down during the seizure. D. Unbutton the top button of the child's shirt. E. Place the child on the side after the seizure is over. F. Leave the child to get help from the unit across the hall.
ADE Do not place anything in the child's mouth during a seizure. If an airway is available, place it after the seizure. Do not attempt to restrain the child. Remove any dangerous objects from the immediate area and allow the seizure to take its course. Never leave a seizing child. Seizures are self-limiting and the nurse needs to observe the seizure and provide post-seizure care. If clothing is restrictive, attempt to loosen the clothing.
The nurse is caring for a child with increased intracranial pressure (ICP). What interventions should the nurse plan for this child? (Select all that apply.) A. Avoid jarring the bed. B. Keep the room brightly lit. C. Keep the bed in a flat position. D. Administer prescribed stool softeners. E. Administer a prescribed antiemetic for nausea.
ADE Other measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit environment; limiting visitors; preventing any sudden, jarring movement, such as banging into the bed; and preventing an increase in ICP. The latter is most effectively achieved by proper positioning and prevention of straining, such as during coughing, vomiting, or defecating. An antiemetic should be administered to prevent vomiting, and stool softeners should be prescribed to prevent straining with bowel movements. The head of the bed should be elevated 15 to 30 degrees.
Which statement by the older school-age child indicates to the nurse the teaching was effective for seizure precautions? (Select all that apply.) A. "I will wear my helmet with my wrist and shin guards when I ride my bike." B. "I can never ride my skateboard again or watch my friends skateboard." C. "I will wear my medical ID bracelet only when I am outside of the house." D. "I will always swim with a friend or family member; I will never swim alone." E. "I will make sure I take my seizure medication when I brush my teeth at night."
ADE Skateboarding is permissible with the appropriate protection. The medical alert ID should be worn at all times. Taking it on and off increases the likelihood of forgetting to wear it. Biking, skateboarding, and in-line skating are allowable with the appropriate protection and in controlled settings. A seizure unattended in the water could be life threatening. Associate taking medication with other daily routines to increase compliance.
A 4-year-old has just been diagnosed with febrile seizures. Which treatment is appropriate? A. Phenobarbital B. Acetaminophen during fevers C. Valproic acid D. Ibuprofen daily
B
The nurse assesses vital signs for Baby Effie. Temperature 102.4 axillary; Heart Rate 98; Respiratory Rate 33; Blood pressure 122/64; Oxygen saturation 96% on Room air. Based on these vital signs, what other finding might the nurse anticipate? A. Hyperexacitability B. Shrill, high pitched cry C. Constipation D. Nystagmus
B
An infant post shunt replacement for hydrocephalus suddenly awakens with a high pitched, shrill cry and cannot be comforted. What is the next nursing action? A. Bring the parents to the infant's bedside. B. Contact the health care provider. C. Monitor the infant's intake and output. D. Pat the infant gently on its back.
B A high pitch, shrill cry is an indication of increased intracranial pressure. The shunt is not functioning as it is designed and the health care provider must be informed. While the parents can comfort the infant, they can do nothing about the malfunctioning shunt. I & O is a cardiovascular assessment and is not included in the immediate neurological focused assessment for this infant. Comfort measure to stop the crying does not address the neurologic concern in this infant.
A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will begin when? A. After the diagnosis is confirmed B. When the medication is received from the pharmacy C. After the childs fluid and electrolyte balance is stabilized D. As soon as the practitioner is notified of the culture results
B Antimicrobial therapy is begun as soon as a presumptive diagnosis is made. The choice of drug is based on the most likely infective agent. Drug choice may be adjusted when the culture results are obtained. Waiting for culture results to begin therapy increases the risk of neurologic damage. Although fluid and electrolyte balance is important, there is no indication that this child is unstable. Antibiotic therapy would be a priority intervention.
What clinical manifestations suggest hydrocephalus in an infant? A. Closed fontanel and high-pitched cry B. Bulging fontanel and dilated scalp veins C. Constant low-pitched cry and restlessness D. Depressed fontanel and decreased blood pressure
B Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. A closed fontanel, high-pitched cry, constant low-pitched cry, restlessness, a depressed fontanel, and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.
A pediatric client is found in the yard unconscious on a hot, summer day. The nurse notes that pupils are constricted and skin is dry. Vital Signs: Temperature 104°F Heart Rate 145 Blood Pressure 90/48 Respirations 28 Which of the following conditions does the nurse suspect? A. Hypothermia B. Heat stroke C. Febrile Seizure D. Increased intracranial pressure
B The client is showing signs of heat stroke due to extreme elevated temperature, absent sweating, and pupil constriction.
he nurse is performing a newborn assessment. A clicking sensation is noted when abducting the child's thigh and placing gentle pressure over the greater trochanter. How will the nurse document this finding? A. Positive Barlow's test B. Positive Ortolani maneuver C. Positive Homan's sign D. Positive Galeazzi's sign
B This movement describes the Ortolani maneuver to assess for instability of the hip. Barlow's test performs a similar maneuver only pressure is applied down and back with the examiner's thumbs. Homan's sign tests for the possibility of a blood clot in the leg. Galeazzi's sign reveals a shortening of the limb on the affected side
The CSF showed low glucose levels and elevated protein levels indicating the presence of a bacterial infection. What other lab tests would the nurse anticipate? Select all that apply. A. Lipid Profile B. Complete Blood Count (CBC) C. Blood cultures D. Antinuclear antibody (ANA) E. Hemoglobin A1C
BC
he nurse is receiving report from the emergency department on an 8-month-old child scheduled for a craniotomy. Which assessments will the nurse include in the child's care plan to evaluate for increased intracranial pressure? (Select all that apply.) A. Sunken fontanel B. Prominent sclera over the iris C. Listlessness D. Poor suck-swallow when feeding E. Increased head circumference
BDE In addition to the correct answers, the child may have a bulging and tense fontanel, as well as irritability. The cranial sutures may be separated and the child may cry with minimal stimulation.
What finding is a clinical manifestation of increased intracranial pressure (ICP) in children? A. Low-pitched cry B. Sunken fontanel C. Diplopia, blurred vision D. Increased blood pressure
C Diplopia and blurred vision are signs of increased ICP in children. A high-pitched cry and a tense or bulging fontanel are characteristic of increased ICP. Increased blood pressure, common in adults, is rarely seen in children.
The nurse at a summer camp recognizes the signs of heatstroke in an adolescent girl. Her temperature is 40 C (104 F). She is slightly confused but able to drink water. Nursing care while waiting for transport to the hospital should include what intervention? A. Administer antipyretics. B. Administer salt tablets. C. Apply towels wet with cool water. D. Sponge with solution of rubbing alcohol and water.
C Heatstroke is a failure of normal thermoregulatory mechanisms. The onset is rapid with initial symptoms of headache, weakness, and disorientation. Immediate care is relocation to a cool environment, removal of clothing, and applying of cool water (wet towels or immersion). Antipyretics are not used because they are metabolized by the liver, which is already not functioning. Salt tablets are not indicated and may be harmful by increasing dehydration. Rubbing alcohol is not used.
The nurse is assessing an 11-year-old client who presents with a temperature of 102.6°F/ 39.2ºC. Assessment findings include cool, clammy extremities, shivering, and the client reports chills. Which condition does the nurse suspect? A. Hypothermia B. Heat stroke C. Fever D. Febrile Seizure
C The client is experiencing fever.. This is indicated by the increased temperature combined with shivering and chills. This indicates the hypothalamus is controlling the temperature by shivering to generate heat and chills indicating the set point has been increased. Hypothermia would present with a decreased temperature. Hyperthermia or heat stroke would present with increased temperature with dry, hot skin.
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents? A. Febrile seizures can result. B. Antipyretics may cause malignant hyperthermia. C. Antipyretics are of no value in treating hyperthermia. D. Liver damage may occur in critically ill children.
C Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver is already compromised. Other antipyretics are available, but they are of no value in hyperthermia.
The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.) A. Fever B. Flushing C. Bradycardia D. Systemic hypertension E. Respiratory depression
CDE Cushing triad (systemic hypertension, bradycardia, and respiratory depression) is a late sign of impending brainstem herniation. Fever or flushing does not occur with Cushing triad.
The provider orders a lumbar puncture for Baby. What type of fluid would indicate the presence of a bacterial infection? A. Clear fluid with increased white blood cells (WBCs) B. Clear fluid with increased glucose and negative protein C. Milky fluid with low white blood cells (WBCs) D. Cloudy fluid with low glucose and high protein
D
Which assessment finding is most concerning for a 14-year-old who had a skiing accident? A. Tachycardia, regular respirations B. Drowsy, but responsive C. Pinpoint pupils, reactive to light D. Clear drainage from ear
D
Which assessment finding would warrant canceling the LP procedure? A. BP 75/40 B. Presence of rash along the cervical spine C. HR 122 D. Cellulitis to the lower back and buttocks
D
A 1-month-old infant is brought to the emergency department by the parents. The parents report that the child has been irritable and refusing feedings. What additional information should the nurse obtain from the parents? A. "Do you have a family history of meningitis?" B. "Does your child cry when separated from parents?" C. "Is your child grasping toys or objects?" D. "Tell me about your pregnancy and delivery."
D As part of the neurological assessment, you should gather information on the pregnancy and birth history to assess for possible exposures during pregnancy and any potential adverse events, prematurity, or birth trauma that may predispose the child to develop a neurological condition. Meningitis does not have a genetic component. This child is only 1 month old and is not developmentally appropriate for grasping objects or separation anxiety at this point
The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. What issues should be addressed? A. Most childhood activities must be restricted. B. Cognitive impairment is to be expected with hydrocephalus. C. Wearing head protection is essential until the child reaches adulthood. D. Shunt malfunction or infection requires immediate treatment.
D Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately. Limits should be appropriate to the childs developmental age. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed.
The nurse has been closely monitoring a child with a closed head injury. The child begins to exhibit decerebrate posturing. The nurse interprets this finding as an indication of which of the following? A. A change requiring every 30-minute assessments B. An improvement in the child's condition C. A decrease in intracranial pressure D. A deterioration in neurological function
D Decerebrate posturing usually indicates severe brain damage or a deterioration in neurologic function. The other answers do not indicate a progression in brain damage requiring immediate reaction.
A 4-month-old is brought to the clinic with a rectal temperature of 38.3°C (101ºF). Which intervention is most appropriate for the nurse to take? The child weighs 20kg . A. Administer Ibuprophen up to 250 mg/day B. Administer aspirin up to 800 mg/day C. Administer naproxen 400 mg/day D. Administer acetaminophen up to 800 mg/day
D Elevated temperature leads to discomfort. Providing acetaminophen helps provide comfort to the child. Acetaminophen can be dosed up to 40mg/kg/day. A child weighing 20 kg would have a max daily dose of 800mg/day. You do not give aspirin for a fever. The child is too young for ibuprophen
The nurse instructs parents about febrile seizures. Which statement made by the parent indicates understanding? A. "My child is at risk of having a febrile seizure when the temperature slowly rises above 100 degrees F." B. "My child will need to take antiepileptic medications for the rest of his life." C. "My child will have epilepsy when older due to having febrile seizures as a baby." D. "If my child's seizure lasts more than 5 minutes, I need to call 911 immediately."
D Febrile seizures are benign in nature and have no long-term sequela. Febrile seizures that last more than 5 minutes necessitate that the parent calls 911.
Which are early signs and symptoms of hydrocephalus in infants A. Confusion, headache, diplopia B. Rapid head growth, poor feeding, confusion C. Papilledema, irritability, headache D. Full fontanels, poor feeding, rapid head growth
D For infants previously undiagnosed, one of the first signs of hydrocephalus is a bulging fontanel, followed by irritability, poor feeding, and overall rapid head growth
A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary? A. Tachycardia B. Gastrointestinal upset C. Hypotension D. Alteration in level of consciousnes
D In older children, who are usually admitted to the hospital for elective or emergency shunt revision, the most valuable indicators of increasing intracranial pressure are an alteration in the childs level of consciousness, complaint of headache, and changes in interaction with the environment.
A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very irritable with a temperature of 102 F. What should the nurses care plan include? A. Observing the childs voluntary movement B. Checking the Babinski reflex every 4 hours C. Checking the Brudzinski reflex every 1 hour D. Assessing the level of consciousness (LOC) and vital signs every 2 hours
D Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is carried out at frequent intervals on a child with meningitis. The nurse should avoid actions that cause pain or increase discomfort, such as lifting the childs head, so the Brudzinski reflex should not be checked hourly. Checking the Babinski reflex or childs voluntary movements will not help with assessing the childs status.
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition? A. Posturing B. Vital signs C. Focal neurologic signs D. Level of consciousnes
D The most important nursing observation is assessment of the childs level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage.
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. How should the nurse interpret this? A. Eye trauma B. Brain death C. Severe brainstem damage D. Neurosurgical emergency
D The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. One fixed and dilated pupil is not suggestive of brain death. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain.
What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child? A. Suction the child frequently. B. Turn the childs head side to side every hour. C. Provide environmental stimulation. D. Avoid activities that cause pain or crying.
D Unrelieved pain, crying, and emotional stress all contribute to increasing the ICP. Disturbing procedures should be carried out at the same time as therapies that reduce ICP, such as sedation. Suctioning is poorly tolerated by children. When necessary, it is preceded by hyperventilation with 100% oxygen. Turning the head side to side is contraindicated for fear of compressing the jugular vein. This would block the flow of blood from the brain, raising ICP. Nontherapeutic touch and environmental stimulation increase ICP. Minimizing both touch and environmental stimuli noise reduces ICP.