Peds - Chapter 16: Nursing Care of the Child With a Neurologic Disorder
The nurse determines that a child is experiencing late signs of increased intracranial pressure based on which assessment findings? Select all that apply. a) Sunset eyes b) Irregular respirations c) Increased blood pressure d) Fixed dilated pupils e) Bradycardia
• Bradycardia • Fixed dilated pupils • Irregular respirations
A nurse is providing information to the parents of a child diagnosed with absence seizures. What information would the nurse expect to include when describing this type of seizure? Select all that apply. a) You might have mistaken this type of seizure for lack of attention. b) This type of seizure is more common in girls than it is in boys. c) The child will commonly report a strange odor or sensation before the seizure. d) This type of seizure is usually short, lasting for no more than 30 seconds. e) You might see a blank facial expression after a sudden stoppage of speech. f) Your child will probably sleep deeply for ½ to 2 hours after the seizure.
• This type of seizure is more common in girls than it is in boys. • You might see a blank facial expression after a sudden stoppage of speech. • This type of seizure is usually short, lasting for no more than 30 seconds. • You might have mistaken this type of seizure for lack of attention.
The nurse is collecting data from the caregivers of a child admitted with seizures. Which of the following statements indicates the child most likely had an absence seizure? a) "He kept smacking his lips and rubbing his hands." b) "He was just staring into space and was totally unaware." c) "He usually is very coordinated, but he couldn't even walk without falling." d) "His arms had jerking movements in his legs and face."
"He was just staring into space and was totally unaware."
The nurse assesses a child and finds that the child's pupils are pinpoint. What does this finding indicate? a) Intracranial mass b) Seizure activity c) Brain stem herniation d) Brain stem dysfunction
Brain stem dysfunction
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) Institute droplet precautions in addition to standard precautions. b) Educate the family about preventing bacterial meningitis. c) Encourage the mother to hold and comfort the infant. d) Palpate the child's fontanels.
Institute droplet precautions in addition to standard precautions.
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges? a) Negative Brudzinski's sign b) Positive Homans' sign c) Negative Kernig's sign d) Positive Kernig's sign
Positive Kernig's sign
Question: Put the following events of a generalized epileptic seizure in correct order: 1 Prodromal period 2 Tonic stage 3 Postictal period 4 Clonic stage
Prodromal period Tonic stage Clonic stage Postictal period
A nurse is performing a neurological examination of a preschool girl. She is testing her remote memory. Which of the following would be an appropriate type of memory to ask the girl to recall? a) What the girl had for dinner last night b) A string of three digits that the nurse has just spoken to her c) The name of an object that the nurse showed her 5 minutes ago d) Where the girl and her family went on vacation last year
What the girl had for dinner last night
When assisting a child while she is having a tonic-clonic seizure, it would be important to a) place a tongue blade between the child's teeth. b) restrain the child from all movement. c) turn the child onto her back and observe her. d) protect the child from hitting her arms against furniture.
protect the child from hitting her arms against furniture.
A school-aged girl with seizures is prescribed phenytoin sodium, 75 mg four times a day. An instruction you would want to give her parents regarding this is a) even small doses may cause noticeable dizziness. b) watching television while taking the drug may cause seizures. c) numbness of the fingers is common while taking this drug. d) their child will have to practice good tooth brushing.
their child will have to practice good tooth brushing.
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. a) The sclera of the eyes is visible above the iris. b) The child's pupils are fixed and dilated. c) The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. d) The child's heart rate is 56 beats per minute. e) 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 child's heart rate is 56 beats per minute. • The child's pupils are fixed and dilated.
The nurse is reinforcing teaching with the caregivers of a child who has had a head injury and is being discharged. Which statement made by the caregiver indicates an accurate understanding of the follow-up care for their child? a) "Even if the flashlight bothers him, we will check his eyes." b) "If he vomits again, we will bring him back immediately." c) "We can give him Tylenol for a headache, but no aspirin." d) "If he falls asleep, we will wake him up every 15 minutes."
"Even if the flashlight bothers him, we will check his eyes."
The parents of a child with a history of seizures who has been taking phenytoin (Dilantin) ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate? a) "Small increments in dosage lead to sharp increases in plasma drug levels." b) "The capacity to metabolize the drug becomes overwhelmed over time." c) "A drop in the plasma drug level will lead to a toxic state." d) "Large increments in dosage lead to a more rapid stabilizing therapeutic effect."
"Small increments in dosage lead to sharp increases in plasma drug levels."
The nurse is educating the family of a 7-year-old epilepsy patient about care and safety for this child. Which of the following comments will be most valuable in helping the parent and the child cope? a) "You'll always need a monitor in his room." b) "Use this information to teach family and friends." c) "If he is out of bed, the helmet's on the head." d) "Bike riding and swimming are just too dangerous."
"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? a) "Limit the amount of television he watches." b) "Call the doctor if he gets a headache." c) "Watch for changes in his behavior or eating patterns." d) "Always keep his head raised 30 degrees."
"Watch for changes in his behavior or eating patterns."
What information is most correct regarding the nervous system of the child? a) The child's nervous system is fully developed at birth. b) The child has underdeveloped fine motor skills and well-developed gross motor skills. c) The child has underdeveloped gross motor skills and well-developed fine motor skills. d) As the child grows, the gross and fine motor skills increase.
As the child grows, the gross and fine motor skills increase.
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent which of the following with regards to seizures? a) Convulsive activity occurs. b) The EEG is normal. c) Cyanosis occurs at the onset of the seizure. d) The patient is bradycardiac.
Convulsive activity occurs.
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) Decrease environmental stimulation b) Take vital signs every 4 hours c) Encourage the parents to hold the child d) Monitor temperature every 4 hours
Decrease environmental stimulation
A doctor orders the placement of an ICP monitor in a patient with cerebral edema. The nurse is aware that this surgery will take place in the infratentorial region of the brain. a) True b) False
False
The nurse caring for a patient with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema. a) False b) True
False
The nurse caring for a child with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema. a) True b) False
False Glucocorticoids and diuretics are used to reduce cerebral edema.
The nurse is caring for a 6-year-old child who has a history of febrile seizures and is admitted with a temperature of 102.2° F(39° C). What is the nurse's highest priority? a) Institute safety precautions. b) Provide family teaching related to the child's history. c) Offer age-appropriate activities. d) Encourage the child to do his or her own self-care.
Institute safety precautions.
Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? a) Congenital hydrocephalus b) Early closure of the fontanels c) Moderate closed-head injury d) Intracranial hemorrhaging
Intracranial hemorrhaging
The nurse is observing an infant who may have acute bacterial meningitis. Which finding might the nurse look for? a) Irritability, fever, and vomiting b) Negative Kernig's sign c) Flat fontanel d) Jaundice, drowsiness, and refusal to eat
Irritability, fever, and vomiting
The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position? a) Lying prone, with the feet higher than the head b) Lying on one side, with the back curved c) Lying prone, with the neck flexed d) Sitting up, with the back straight
Lying on one side, with the back curved
The nurse is collecting data from a child who may have a seizure disorder. Which is a description of an absence seizure? a) Brief, sudden contracture of a muscle or muscle group b) Minimal or no alteration in muscle tone, with a brief loss of consciousness c) Sudden, momentary loss of muscle tone, with a brief loss of consciousness d) Muscle tone maintained and child frozen in position
Minimal or no alteration in muscle tone, with a brief loss of consciousness
A nurse is caring for a newborn with anencephaly. Which of the following interventions will the nurse use? a) Place a cap or similar covering on the infant's head. b) Closely monitor neurologic status. c) Monitor for increased intracranial pressure (ICP). d) Refer the family to an agency to assist with long-term care.
Place a cap or similar covering on the infant's head.
Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position? a) Keeping the child in leg braces 23 hours per day b) Letting the child lie down as much as possible c) Trying to keep the child as quiet as possible d) Placing the child on your hip
Placing the child on your hip
A 10-year-old boy has been experiencing complex partial seizures and has not responded well to medication. Surgery is planned to remove brain tissue at the seizure foci. Which diagnostic test would be the most accurate in identifying the seizure foci? a) Brain scan b) Echoencephalography c) Positron emission tomography (PET) d) Myelography
Positron emission tomography (PET)
A 10-year-old child is admitted to the hospital due to history of seizure activity. As his nurse, you are called into the room by his mother, who states he is having a seizure. What would be the priority nursing intervention? 1. Prevention of injury by removing the child from his bed 2. Prevention of injury by placing a tongue blade in the child's mouth 3. Prevention of injury by restraining the child 4. Prevention of injury by placing the child on his side and opening his airway
Prevention of injury by placing the child on his side and opening his airway
A nurse is examining a boy with cerebral palsy. He has hypertonic muscles and abnormal clonus in his legs and walks on his toes. Which of the following is the type of cerebral palsy that this boy is demonstrating? a) Spastic b) Ataxic c) Athetoid d) Dyskinetic
Spastic
A nurse is performing a neurologic examination of a 5-year-old child. She asks the boy to close his eyes, and then she places a crayon in his hand and asks him to identify it. Which type of ability is the nurse testing for in this boy? a) Orientation b) Stereognosis c) Kinesthesia d) Graphesthesia
Stereognosis
The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which of the following statements is the best to use for a teaching session? a) Tell me your concerns about your child's shunt. b) Her autoregulation mechanism to absorb spinal fluid has failed. c) Call the doctor if she gets a persistent headache. d) Always keep her head raised 30º.
Tell me your concerns about your child's shunt.
A mother has brought her 5-month-old son to the clinic because he has been drowsy and unresponsive. The child has hydrocephalus and had a shunt placed about a month previously. Which symptom indicates that the shunt is infected? a) The child has a high-pitched cry. b) The child is not responding or eating well. c) The child's pupil reaction time is rapid and uneven. d) The fontanels are bulging or tense.
The child is not responding or eating well.
The nurse is caring for a child admitted with complex partial seizures. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) The child was dizzy and had decreased coordination. b) The child had shaking movements on one side of the body. c) The child was rubbing the hands and smacking the lips. d) The child had jerking movements and then the extremities stiffened.
The child was rubbing the hands and smacking the lips.
When compared with adults, why are infants and children at an increased risk of head trauma? 1. The head of the infant and young child is large in proportion to the body and the neck muscles are not well developed. 2. The development of the nervous system is complete at birth but remains immature. 3. The spine is very immobile in infants and young children. 4. The skull is more flexible due to the presence of sutures and fontanels.
The head of the infant and young child is large in proportion to the body and the neck muscles are not well developed.
After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on what evidence? a) The swelling crosses the midline of the infant's scalp. b) The infant had low-set ears and facial abnormalities. c) The swelling is limited to one small area without crossing the sagittal suture. d) The infant had a low birthweight when born at term.
The swelling crosses the midline of the infant's scalp.
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) Vomiting b) Trouble focusing when reading c) Difficulty concentrating d) Bleeding from the ear
Trouble focusing when reading
The best way to evaluate a child's level of consciousness is through conversation. a) False b) True
True
The nurse is caring for a premature infant diagnosed with intraventricular hemorrhage (IVH). Which of the following interventions best serves the needs of this client? a) Using a squeak toy to attract the child's gaze b) Stroking the child's cheek with a finger c) Placing the crib in a room by itself d) Removing toys from the crib when not in use
Using a squeak toy to attract the child's gaze
The nurse is assessing a toddler for motor function. Which of the following activities will be most valuable? a) Watch the child reach for a toy. b) Give the child some potato chips. c) Have the child catch a ball. d) Let the child look at a picture book.
Watch the child reach for a toy.
In understanding the nervous system, the nurse recognizes that the central nervous system is made up of: a) the brain and spinal cord. b) fluid that flows through the brain. c) a protective cushion for nerve cells. d) nerves throughout the upper body.
the brain and spinal cord.
An 8-year-old girl is diagnosed as having tonic-clonic seizures. You would want to teach her parents that: a) their daughter should be kept quiet late in the day when she is most likely to have a seizure. b) if their daughter shows symptoms of beginning a seizure, immediately give her medication. c) their daughter should maintain an active lifestyle. d) their daughter should carry a padded tongue blade with her at all times.
their daughter should maintain an active lifestyle.
A 9-year-old diagnosed with neurofibromatosis is being evaluated for the presence of a brain tumor. What tests may be ordered to diagnose this condition? Select all that apply. a) Radiology b) Lumbar puncture c) Positron emission tomography d) Computed tomography e) Magnetic resonance imaging f) Electroencephalogram
• Computed tomography • Magnetic resonance imaging
The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all answers that apply. a) Motor response b) Posture c) Eye opening d) Verbal response e) Fontanels
• Motor response • Eye opening • Verbal response
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 an in-line skating accident. What should the caregivers be instructed to do? Select all that apply. a) Observe and report any vomiting that occurs within six hours. b) Check the pupil reaction to light every 15 minutes for two hours. c) Wake the child every one to two hours to check level of consciousness. d) Observe for and report to provider any double or blurred vision. e) Administer acetaminophen for headache.
• Wake the child every one to two hours to check level of consciousness. • Observe and report any vomiting that occurs within six hours. • Observe for and report to provider any double or blurred vision.
The nurse is educating parents of a male infant with Chiari type II malformation. Which of the following statements about their child's condition is most accurate? a) "Take your time feeding your baby." b) "You'll see a big difference after the surgery." c) "Lay him down after feeding." d) "You won't need to change diapers often."
"Take your time feeding your baby."
After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify this as a neural tube defect. a) Anencephaly b) Spina bifida occulta c) Arnold-Chiari malformation d) Encephalocele
Arnold-Chiari malformation
In caring for the child with meningitis, the nurse recognizes that which of the following nursing diagnoses would be the most important to include in this child's plan of care? a) Delayed growth and development related to physical restrictions b) Risk for acute pain related to surgical procedure c) Ineffective airway clearance related to history of seizures d) Risk for injury related to seizure activity
Risk for injury related to seizure activity
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) Video electroencephalogram b) Computed tomography c) Cerebral angiography d) Lumbar puncture
Video electroencephalogram
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: a) ensuring the parents know how to properly give antibiotics. b) encouraging development of motor skills. c) establishing seizure precautions for the child. d) maintaining effective cerebral perfusion.
ensuring the parents know how to properly give antibiotics.
The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with? a) "How did you treat the child afterwards?" b) "Were there any jerky movements?" c) "Was the child unconscious?" d) "What happened just before the seizures?"
"What happened just before the seizures?"
At a well-child visit, hydrocephalus may be suspected in an infant if upon assessment the nurse finds: 1. Narrow sutures 2. Sunken fontanels 3. A rapid increase in head circumference 4. Increase in weight since last visit
A rapid increase in head circumference
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) Sickle cell disease b) Meningitis c) Congenital heart defect d) Arteriovenous malformations (AVMs)
Arteriovenous malformations (AVMs)
A nurse is performing a complete neurological examination of a 7-year-old boy. She will now test his cerebellar function. Which of the following tests would be appropriate for this purpose? a) Ask the boy to close his eyes and then touch his skin with a cotton wisp; ask him to point to where he was touched b) Measure the circumference of the calves and thighs with a tape measure c) Ask the boy who he is, where he is, and what day it is d) Ask the boy to touch each finger on one hand with the thumb that hand in rapid succession
Ask the boy to touch each finger on one hand with the thumb that hand in rapid succession
The nurse is assigned an infant with a possible neurological disorder. Which of the following assessment findings should you communicate to the physician as a late sign of increased intracranial pressure? a) headache and sunset eyes. b) dizziness and irritability. c) decorticate posturing and fixed and dilated pupils d) decreased pupil reaction and decreased respiration.
decorticate posturing and fixed and dilated pupils
Which statement about cerebral palsy would be accurate? a) "Cerebral palsy is a condition that runs in families." b) "Cerebral palsy means there will be many disabilities." c) "Cerebral palsy is a condition that doesn't get worse." d) "Cerebral palsy occurs because of too much oxygen to the brain."
"Cerebral palsy is a condition that doesn't get worse."
A pregnant client asks if there is any danger to the development of her fetus in the first few weeks of her pregnancy. How should the nurse respond? a) "During the first 3 to 4 weeks of pregnancy brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma." b) "The respiratory system matures during this time so good prenatal care during the first weeks of pregnancy is very important." c) "Bones begin to harden in the first 5 to 6 weeks of pregnancy so vitamin D consumption is particularly important." d) "As long as you were taking good care of your health before becoming pregnant, your fetus should be fine during the first few weeks of pregnancy."
"During the first 3 to 4 weeks of pregnancy brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma."
An otherwise healthy 18-month-old child with a history of febrile seizures is in the wellchild clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? a) "I always keep phenobarbital with me in case of a fever." b) "My child will likely outgrow these seizures by age 5." c) "The most likely time for a seizure is when the fever is rising." d) "I have ibuprofen available in case it's needed."
"I always keep phenobarbital with me in case of a fever." (Phenobarbital is used for prolonged seizures or neurologic abnormalities)
The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history? a) Incomplete myelinization b) Neonatal conjunctivitis c) Facial deformities d) A neural tube defect
A neural tube defect
Which of the following is consistent with increased ICP in the child? a) Increased appetite b) Bulging fontanel c) Emotional lability d) Narcolepsy
Bulging fontanel
The nurse is in the room when a child with a seizure disorder is having a seizure. The child is having generalized jerking muscle movement, and the nurse notes the bed appears to be wet with urine. The child is in which stage of the generalized seizure? a) Clonic b) Tonic c) Prodromal d) Postictal
Clonic
Antibiotic therapy to treat meningitis should be instituted immediately after which event? a) Identification of the causative organism b) Initiation of I.V. therapy c) Admission to the nursing unit d) Collection of cerebrospinal fluid (CSF) and blood for culture
Collection of cerebrospinal fluid (CSF) and blood for culture
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? a) Massaging the scalp gently every 4 hours b) Giving the infant small feedings whenever he is fussy c) Moving the infant's head every 2 hours d) Measuring the intake and output every shift
Moving the infant's head every 2 hours
Which of the following age groups of children have the highest actual rate of death from drowning? a) School-age children b) Toddlers c) Preschool children d) Infants
Toddlers
While observing a child, the nurse notes that the child's arms and legs are extended and pronated. The nurse interprets this as indicating damage to the: a) midbrain. b) cerebral cortex. c) meninges. d) cranial nerves.
midbrain
Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n) a) steroid. b) diuretic. c) antihistamine. d) anticonvulsant.
steroid
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the patient's ear. This would be documented as which of the following? a) Battle sign b) Otorrhea c) Rhinorrhea d) Raccoon eyes
Battle sign
The nurse is in the room when a child with a seizure disorder is having a seizure. The child is having generalized jerking muscle movement, and the nurse notes the bed appears to be wet with urine. The child is in which stage of the generalized seizure? a) Tonic b) Postictal c) Prodromal d) Clonic
Clonic
The father of a 7-year-old boy reports to the nurse that two or three times over the past weeks he has observed his son seemingly staring into space and rubbing his hands. The behavior lasts for a minute or so, followed by an inability of the child to understand what's being said to him. When the nurse asks the child about his experience, he says he doesn't know what his father is talking about. What type of seizure do these symptoms indicate the child is experiencing? a) Complex partial seizures b) Simple partial sensory seizures c) Simple partial motor seizures d) Absence seizures
Complex partial seizures
A 6-month-old infant is admitted to the hospital with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. The priority nursing intervention would be: 1. Educate the family on ways to prevent bacterial meningitis. 2. Initiate appropriate isolation precautions and begin intravenous antibiotics. 3. Assess the infant's fontanels. 4. Encourage the mother to hold the infant and feed her.
Initiate appropriate isolation precautions and begin intravenous antibiotics.
A nurse is caring for a 3-year-old girl with microcephaly. Which of the following actions is appropriate for the nurse to take? a) Playfully ask the child to touch her nose. b) Administer antipyretics as ordered. c) Prepare the child for the experience of cranial surgery. d) Teach the parents about ventriculoperitoneal (VP) shunts.
Playfully ask the child to touch her nose
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) Signs of increased intracranial pressure (ICP) c) Occurrence of urine and fecal contamination d) Onset and character of fever
Signs of increased intracranial pressure (ICP)
The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be: a) The child is having generalized seizures. b) The child's history indicates she has infantile seizures. c) The child may begin to have absence seizures every day. d) The child is in status epilepticus.
The child is in status epilepticus.
A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? a) "Did you use any medications like aspirin for the fever?" b) "Did you give your child any acetaminophen, such as Tylenol?" c) "What type of fluids did your child take when he had a fever?" d) "How high did his temperature rise when he was ill?"
"Did you use any medications like aspirin for the fever?"
Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis? a) Keep the lights on brightly so that he can see his mother b) Rock the child frequently c) Have the child's 2-year-old brother stay in the room d) Avoid making noise when in the child's room
Avoid making noise when in the child's room
A child is home with the caregivers following a treatment for a head injury. If the child makes which of the following statements, the caregiver should contact the care provider. a) "I am glad that my headache is getting better." b) "My stomach is upset. I feel like I might throw up." 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."
"You look funny. Well, both of you do. I see two of you."
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) "Your baby's head became blocked inside your vagina while you were pushing." b) "It's normal for this to happen, but they don't really know why." c) "The forceps used during delivery caused this to happen." d) "During delivery, your vaginal wall put pressure on the baby's head."
"During delivery, your vaginal wall put pressure on the baby's head."
A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)? a) Cloudy appearance b) Elevated sugar c) Decreased pressure d) Decreased leukocytes
Cloudy appearance
Question: A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the levels of consciousness in the order that reflects this progression. 1 Oriented to person, place, and time 2 Stupor 3 Disorientation 4 Obtundation 5 Coma
Oriented to person, place, and time Disorientation Obtundation Stupor Coma
The nurse is caring for an 8-year-old girl who was in a car accident. What would lead the nurse to suspect a concussion? a) The child has vomited and has bruising behind her ear. b) The child is weak and has blurry vision. c) The child is easily distracted and can't concentrate. d) The child is bleeding from the ear and draining fluid from the nose.
The child is easily distracted and can't concentrate.
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) Understanding the side effects of medications c) Instructing her teacher how to respond to a seizure d) Placing the child on her side on the floor
Understanding the side effects of medications
When assessing a neonate for seizures, what would the nurse expect to find? Select all that apply. a) Ocular deviation b) Jitteriness c) Tonic-clonic contractions d) Elevated blood pressure e) Tachycardia
• Tachycardia • Elevated blood pressure • Jitteriness • Ocular deviation
A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? a) "Did you use any medications like aspirin for the fever?" b) "What type of fluids did your child take when he had a fever?" c) "How high did his temperature rise when he was ill?" d) "Did you give your child any acetaminophen, such as Tylenol?"
"Did you use any medications like aspirin for the fever?"
In caring for a child with a seizure disorder, the highest priority goal is which of the following? a) The child will have an understanding of the disorder. b) The child will be free from injury during a seizure. c) The family will understand seizure precautions. d) The family caregivers anxiety will be reduced.
The child will be free from injury during a seizure.
The nurse is caring for a child who had a seizure, fell to the ground, and hit and injured his face, head, and shoulders. This information indicates the child likely had which type of seizures? a) Myoclonic b) Atonic c) Absence d) Infantile
Atonic Atonic or akinetic seizures cause a sudden momentary loss of consciousness, muscle tone, and postural control and can cause the child to fall. They can result in serious facial, head, or shoulder injuries. In absence seizures the child loses awareness and stares straight ahead but does not fall. Myoclonic seizures are characterized by a sudden jerking of a muscle or group of muscles, often in the arms or legs, without loss of consciousness. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes.
A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate to give in this situation? Select all that apply. a) Lorazepam b) Gabapentin c) Fosphenytoin d) Carbamazepine e) Diazepam
• Diazepam (Valuim) • Lorazepam (Ativan) • Fosphenytoin treating status epilepticus include lorazepam, diazepam, and fosphenytoin. Gabapentin and carbamazepine are anticonvulsants used to treat and prevent seizures in general.
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: a) Escherichia coli. b) Haemophilus influenza type B. c) enterovirus. d) Streptococcus group B.
enterovirus
To detect complications as early as possible in a child with meningitis who's receiving I.V. fluids, monitoring for which condition should be the nurse's priority? a) Cerebral edema b) Cardiogenic shock c) Left-sided heart failure d) Renal failure
Cerebral edema
During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents? a) The child shouldn't participate in activities that could be hazardous if a seizure occurs b) Plasma levels of the drug will be monitored on a daily basis c) Drug dosage will be adjusted depending on the frequency of seizure activity d) 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 meningococcal vaccine should be offered to high-risk populations. If never vaccinated, who has an increased risk of becoming infected with meningococcal meningitis? Select all that apply. a) 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates b) 12-year-old child with asthma c) 8-year-old child who is in good health d) 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti e) 9-year-old child who was diagnosed with diabetes mellitus when he was 7 years old
• 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates • 12-year-old child with asthma • 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti • 9-year-old child who was diagnosed with diabetes mellitus when he was 7 years old
The young child has been diagnosed with bacterial meningitis. Which nursing interventions are appropriate? Select all that apply. a) Identify close contacts of the child who will require post-exposure prophylactic medication b) Initiate seizure precautions c) Monitor the child for signs and symptoms associated with decreased intracranial pressure d) Administer antibiotics as ordered e) Initiate droplet isolation
• Initiate droplet isolation • Identify close contacts of the child who will require post-exposure prophylactic medication • Administer antibiotics as ordered • Initiate seizure precautions
When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply. a) The nurse positions the child on the side during a seizure. b) The nurse has oxygen available to use during a seizure. c) The nurse pads the crib or side rails before a seizure. d) The nurse teaches the caregivers regarding seizure precautions. e) The nurse places a washcloth in the mouth to prevent injury during seizure. f) The nurse goes for help as soon as a seizure begins.
• The nurse pads the crib or side rails before a seizure. • The nurse positions the child on the side during a seizure. • The nurse goes for help as soon as a seizure begins. • The nurse has oxygen available to use during a seizure. • The nurse teaches the caregivers regarding seizure precautions.
The treatment for children with seizures disorders is most often which of the following? a) Restricted fat diet b) Use of anticonvulsant medications c) Surgical intervention d) Strict exercise regimen
Use of anticonvulsant medications
The mother of a 12-year-old with Reye syndrome approaches the nurse wanting to know how this happened to her child, saying, "I never give my kids aspirin!" What could the nurse say to begin educating the woman? a) "Aspirin in combination with the virus will make the brain swell and the liver fail." b) "Sometimes it's hard to tell what products may contain aspirin." c) "Don't worry; you're in good hands. We have it under control now." d) "Do you think that maybe your child took aspirin on his own?"
"Sometimes it's hard to tell what products may contain aspirin."
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session? a) "Do you understand why you clamp the drain before she sits up?" b) "What questions or concerns do you have about this device?" c) "What do you know about her autoregulation mechanism failing?" d) "Why do you always keep her head raised 30 degrees?"
"What questions or concerns do you have about this device?"
The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform? a) Monitor core body temperature. b) Assess the child's level of consciousness. c) Pull up the side rails on the bed. d) Help the child cope with an altered appearance.
Assess the child's level of consciousness
An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child? Select all that apply. a) Assess child's skin for the development of distinctive rash every 4 hours b) Assess intake and output every shift c) Request order for an antiemetic d) Request order for anticonvulsant e) Monitor the child's laboratory values related to pancreatic function
• Request order for an antiemetic • Assess intake and output every shift • Request order for anticonvulsant
Preterm infants have more fragile capillaries in the periventricular area than term infants. Which problem does this put these infants at risk for? a) Moderate closed-head injury b) Congenital hydrocephalus c) Early closure of the fontanels d) Intracranial hemorrhaging
Intracranial hemorrhaging
Seven-year old Isabelle 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 Isabelle first complained of 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 of the following statements would be best for the nurse to say to this mother? a) "This is a serious problem. Aspirin is likely to cause Reye syndrome, and Isabelle should be admitted to the hospital for observation as a precaution." b) "This might or might not be a problem. Watch Isabelle 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." 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 Isabelle 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."
"This might or might not be a problem. Watch Isabelle 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."
A 9-year-old girl who is suspected of having an infection of the central nervous system is undergoing a lumbar puncture to withdraw cerebrospinal fluid for analysis. The nurse knows that the needle will be introduced into the subarachnoid space at the level of which of the following vertebrae? a) T3 or T4 b) L1 or L2 c) C1 or C2 d) L4 or L5
L4 or L5
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) Swimming twice a week b) 11 p.m. bedtime; 6:30 a.m. wake-up c) Drinking three cans of diet cola d) Use of nonscented soap
Drinking three cans of diet cola
During physical assessment of a 2-month-old infant, the nurse suspects the child may have a lesion on the brain stem. Which symptom was observed? a) Sudden increase in head circumference b) Closed posterior fontanel c) Only one eye is dilated and reactive d) Horizontal nystagmus
Horizontal nystagmus
After a difficult birth, the nurse observes that a newborn has swelling on part of his head. Which sign suggests cephalohematoma? a) Swelling crosses the midline of the infant's scalp. b) Infant had a low birth weight when born at 37 weeks. c) Infant has facial abnormalities. d) Swelling does not cross the suture lines.
Swelling does not cross the suture lines.
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) Have the child sleep without a pillow under his head. b) Review the signs of increased intracranial pressure with parents. c) Teach the child and his parents to keep a headache diary. d) Have the parents call the doctor if the child vomits more than twice.
Teach the child and his parents to keep a headache diary.