Peds: PrepU Ch. 16
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? -"Were there any jerky movements?" -"What happened just before the seizures?" -"Was the child unconscious?" -"How did you treat the child afterwards?"
"What happened just before the seizures?" Asking what happened just before the seizure will suggest whether the episode was a seizure or a breath-holding event, which is frequently precipitated by an expression of anger or frustration. Cyanotic breath holding can be accompanied by clinic movements, as can seizures. Both types of events render the child unconscious. One would expect concerned, caring treatment from the parents regardless of the cause.
What finding is consistent with increased ICP in the child? -Emotional lability -Narcolepsy -Bulging fontanelle -Increased appetite
-Bulging fontanelle Children with increased ICP exhibit bulging fontanels. They typically have a decreased appetite, are restless, and have trouble sleeping.
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 -Posture
Eye opening Verbal response Motor response The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.
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? -VIII -VII -VI -IX
-IX 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.
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-Coma 2-Stupor 3-Oriented to person, place, and time 4-Disorientation 5-Obtundation
3, 4, 5, 2, 1 Levels of consciousness in order from most alert to least alert are orientated to person, place, and time (full consciousness); confusion (disorientation); obtundation; stupor; and finally coma.
A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)? -Decreased pressure -Elevated sugar -Cloudy appearance -Decreased leukocytes
Cloudy appearance In the CSF of clients diagnosed with bacterial meningitis, the pressure is elevated, the appearance is cloudy, and the leukocytes are elevated. A decreased sugar content is noted.
While in a pediatric client's room, the nurse notes the client begin to have a tonic-clonic seizure. Which nursing action is priority? -Administer lorazepam rectally to the client -Protect the child from hitting the arms against the bed -Refer the client to a neurologist -Discuss dietary therapy with the client's caregivers
-Protect the child from hitting the arms against the bed Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other near by objects. If the seizure continues, lorazepam may be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care; however, this is not priority. Dietary therapy is considered for clients with chronic seizure disorders who do not respond to medication therapy.
A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority? -Urinalysis -Serum glucose level -Hemoglobin level -White blood cell count
-Serum glucose level Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expends energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review.
Any individual taking phenobarbital for a seizure disorder should be taught: -to brush his or her teeth four times a day. -never to discontinue the drug abruptly. -never to go swimming. -to avoid foods containing caffeine.
-never to discontinue the drug abruptly. Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child&'s dependency on the drug can result.
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 -Congenital hydrocephalus -Intracranial hemorrhaging
Intracranial hemorrhaging Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels 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 father would indicate to the nurse that additional teaching should be done? -"My child will likely outgrow these seizures by age 5." -"The most likely time for a seizure is when the fever is rising." -"I have ibuprofen available in case it's needed." -"I always keep phenobarbital with me in case of a fever."
-"I always keep phenobarbital with me in case of a fever." Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature because seizures occur as the temperature rises.
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 -Computed tomography -Lumbar puncture -Video electroencephalogram
Video electroencephalogram A video electroencephalogram can determine the precise localization of the seizure area in the brain. Cerebral angiography is used to diagnose vessel defects or space-occupying lesions. Lumbar puncture is used to diagnose hemorrhage, infection, or obstruction in the spinal canal. Computed tomography is used to diagnose congenital abnormalities such as neural tube defects.
The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate? -"You won't need to change diapers often." -"You'll see a big difference after the surgery." -"Take your time feeding your baby." -"Lay him down after feeding."
"Take your time feeding your baby." One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations.
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? -"Bike riding and swimming are just too dangerous." -"If he is out of bed, the helmet's on the head." -"You'll always need a monitor in his room." -"Use this information to teach family and friends."
"Use this information to teach family and friends." Families need and want information they can share with relatives, childcare providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The boy may be able to bike ride and swim with proper precautions.
The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing (decerebrate) in the figure. The nurse is aware that this type of posturing is the result of injury to what area? -Cerebral cortex -Mid-cervical -Brain stem -Frontal lobe
-Brain stem Decerbrate posturing is seen with injuries occurring at the level of the brain stem. Decorticate posturing occurs with damage of the cerebral cortex. Both types of posturing are characterized by extremely rigid muscle tone. Injuries to the frontal lobe of the brain and the mid-cervical spine would not cause these types of posturing.
The nurse is caring for a child diagnosed with hydrocephalus following ventriculopertoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? -Educate the family on the shunt -Monitor the client for signs of infection -Assess the client's respiratory status -Measure the client's head circumference
Assess the client's respiratory status The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains an airway.
The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? -Congenital hydrocephalus -Intracranial hemorrhaging -Head trauma -Positional plagiocephaly
Head trauma A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Positional plagiocephaly is caused by an infant's head remaining in the same position for too long.
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? -The infant had low-set ears and facial abnormalities. -The infant had a low birthweight when born at term. -The swelling is limited to one small area without crossing the sagittal suture. -The swelling crosses the midline of the infant's scalp.
The swelling crosses the midline of the infant's scalp. The fact that the swelling crosses the midline of the infant's scalp indicates caput succedaneum. If the swelling is limited and does not cross the midline or suture lines, it would suggest cephalohematoma. Low birthweight does not suggest caput succedaneum. Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele.
The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant? -placing the infant in a Sims position in the crib after feeding the infant -placing the infant prone in the crib after feeding the infant -placing the infant supine in the crib after feeding the infant -placing the infant in an infant car seat after feeding the infant
placing the infant in an infant car seat after feeding the infant Placing a child or infant in the semi-Fowler's position can help reduce cerebral edema and pressure. Using an infant child seat helps to simulate the raised head of the bed. In the supine position, the client is completely flat on his or her spine. Prone is face down and flat. Sims is a side-lying position with one leg flexed. All of the described positions place the client flat and not with the head raised as that would be in the semi-Fowler's position.
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 -Tongue blade -Suction at bedside -Smelling salts. -Padding for side rails
-Oxygen gauge and tubing -Suction at bedside -Padding for side rails When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority? -Risk for self-care deficit: bathing and dressing -Risk for ineffective tissue perfusion: cerebral -Risk for injury -Risk for delayed development
-Risk for injury A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures is the most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to inability to swallow. All of these symptoms would make Risk for injury the highest priority.
The nurse is assessing a toddler for motor function. Which activity will be the most valuable? -Have the child catch a ball. -Watch the child reach for a toy. -Let the child look at a picture book. -Give the child some potato chip
-Watch the child reach for a toy. Watching the child reach for a toy would be most valuable for assessing motor function because the infant should be able to extend extremities to a normal stretch. Catching a ball is too advanced for a toddler to accomplish. Looking at a picture book would help assess visual acuity and eye movement. Eating potato chips would help assess sensor function for taste.
The nurse has just admitted a 17-year-old diagnosed with bacterial meningitis. The parents of the adolescent tell the nurse, "We just don't understand how this could have happened. Our child has always been healthy and also just received a booster vaccine last year?" How should the nurse respond? -"Your child was likely exposed to a strain of bacteria not covered with the meningitis vaccine received." -"Maybe your child's immune system isn't strong enough to fight off the infection, even with having received the vaccine." -"Are you sure your child received a vaccine for meningitis? Maybe it was a flu vaccine." -"I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection."
"I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection." Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Questioning them about being sure would not be the best response unless there was reason to believe their information was not accurate. There is nothing to lead the nurse to believe that a different strain of bacteria caused the infection, or that the the child's immune system is compromised.
A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? -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) Decreased LOC is frequently the first sign of a major neurologic problems after a head trauma. The nurse would assess the client's LOC before notifying the health care provider. The child may need to be placed on fall precaution, depending on the results of the assessment. The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary.
A 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 A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.
The nurse is caring for a child 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. Rapid administration of IV fluids may increase ICP. An IV rate of 250 mL/hr 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.
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: -rhinorrhea. -otorrhea. -Battle sign. -raccoon eyes.
Battle sign. Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.
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? -Educate the family about preventing bacterial meningitis. -Encourage the mother to hold and comfort the infant. -Palpate the child's fontanelles. -Institute droplet precautions in addition to standard precautions.
Institute droplet precautions in addition to standard precautions. Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Encouraging the mother to hold and comfort the child is an intervention but not the priority one: the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread. Educating the family about preventing bacterial meningitis would be appropriate later once the initial infection has been controlled. Palpating the fontanels is used to assess for hydrocephalus.
Which of these age groups has the highest actual rate of death from drowning? -Toddlers -School-aged children -Preschool children -Infants
Toddlers Toddlers and older adolescents have the highest actual rate of death from drowning.
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? -Signs of increased intracranial pressure (ICP) -Degree and extent of nuchal rigidity -Onset and character of fever -Occurrence of urine and fecal contamination
-Signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? -"The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." -"I need to set an alarm to wake up and check his temperature during the night when he is sick." -"I hate to think that I will need to be worried about his having seizures for the rest of his life." -"When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever."
"I hate to think that I will need to be worried about his having seizures for the rest of his life." Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.
At 36 weeks' gestation a client is scheduled for a biophysical profile. Before the client has the ultrasound examination, which component of the biophysical profile does the nurse complete? -Nonstress test -Doppler flow study -Fetal movement evaluation -Contraction stress test
Nonstress test A nonstress test is the one component of a biophysical profile not performed during the ultrasound examination. Fetal movement evaluation is performed by the client, at home on a daily basis. A contraction stress test involved the induction of uterine contractions and is not part of a biophysical profile. Doppler flow studies are performed during an ultrasound examination, but are not part of a biophysical profile.
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? -Understanding the side effects of medications -Treating the child as though she did not have epilepsy -Placing the child on her side on the floor -Instructing her teacher how to respond to a seizure
Understanding the side effects of medications The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control.
The nurse is assisting to position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? -"The child will be held by the mother on her lap with his back towards the health care provider." -"The child will be placed in the prone position with the nurse holding the child still." -"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." -"When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible."
For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." Correct positioning for a lumbar puncture is to place the child on his or her side with their neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.
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? -Arteriovenous malformations (AVMs) -Sickle cell disease -Congenital heart defect -Meningitis
Arteriovenous malformations (AVMs) Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke. Sickle cell disease is a risk factor for ischemic stroke. Congenital heart defects are risk factors for ischemic stroke. Meningitis or other infection is a risk factor for ischemic stroke.
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? -Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized. -Provide information regarding policies of the unit's playroom for the parents to review. -Gather appropriate equipment and signage for respiratory isolation precautions. -Place multiple pillows in the room to assist with propping the child's head up.
Gather appropriate equipment and signage for respiratory isolation precautions. Children with meningitis are placed on respiratory precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the infection to other family members or health care providers. While a child is on respiratory isolation, they will typically not be allowed out of their rooms to play. Due to pain when their neck is flexed, most children are most comfortable without a pillow. Reducing stimulation can help to promote rest for the child.
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? -Risk for injury related to seizure activity -Delayed growth and development related to physical restrictions -Ineffective airway clearance related to history of seizures -Risk for acute pain related to surgical procedure
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 the history of seizures does not impact the airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.
A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? -"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." 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.
A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement? -"You look funny. Well, both of you do. I see two of you." -"My stomach is upset. I feel like I might throw up." -"I am glad that my headache is getting better." -"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 caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider.
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? -"It's normal for this to happen, but they don't really know why." -"The forceps used during delivery caused this to happen." -"Your baby's head became blocked inside your vagina while you were pushing." -"During delivery, your vaginal wall put pressure on the baby's head."
-"During delivery, your vaginal wall put pressure on the baby's head." Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.
A nursing instructor has completed a class session on Guillain-Barré syndrome. Which statement by a student indicates a need for further education? -"Paralysis peaks at about 3 weeks before recovery, but most do not completely recover from the paralysis." -"Children with this disorder may need mechanical ventilation as the disease progresses." -"There is no medication available to treat this disorder." -"These children may need nutritional support if they are unable to eat."
-"Paralysis peaks at about 3 weeks before recovery, but most do not completely recover from the paralysis." Despite the length of this disorder, most children recover completely without any residual effects. A small number may have some residual weakness but not necessarily paralysis. The paralysis peaks at about 3 weeks and then slowly reverses. Supportive care such as mechanical ventilation, nutritional support, passive ROM, and every 2 hour turning and repositioning are the focus of care for children with this syndrome. There is no medication specific for this syndrome.
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 -11 p.m. bedtime; 6:30 a.m. wake-up -Swimming twice a week -Use of nonscented soap
-Drinking three cans of diet cola Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.
The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III? -The nurse observes facial features and expressions for symmetry. -A bright-colored toy is moved in the child's visual fields. -The nurse talks softly to the child to note the ability to hear. -The nurse allows the child to smell objects and describe them.
A bright-colored toy is moved in the child's visual fields. Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement. Cranial nerve I (olfactory nerve) controls the sense of smell. Asking the child to smell objects would be an assessment of this cranial nerve. Cranial nerve VII (facial nerve) is assessed by monitoring symmetry of facial movements. Cranial nerve VIII (acoustic nerve) is assessed by whispering.
A 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? -Prepare a menu with the child's favorite foods. -Pad and raise the rails on the child's bed. -Administer intravenous antibiotics as prescribed. -Educate the parents about seizure precautions.
Administer intravenous antibiotics as prescribed. The major complications associated with shunts are infection and malfunction. When a shunt malfunctions the child experiences vomiting, drowsiness, and headache. When infection has occurred the child experiences increased vital signs, poor feeding, vomiting, decreased responsiveness, seizure activity and signs of local inflammation along the shunt tract. When an infection occurs the priority of care is to treat the infection with IV antibiotics. The seizures and the poor eating will resolve once the infection is cleared. The parents can be taught about seizure prcautions and the bed can be padded but these are not the priority of 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? -"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." -"I understand your concern, but toddlers fall and hit their heads a lot since they are not very coordinated yet." -"You probably don't have anything to worry about. It is common for toddlers to fall."
Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." 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.
A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? -Teach the child and his parents to keep a headache diary. -Have the child sleep without a pillow under his head. -Have the parents call the doctor if the child vomits more than twice. -Review the signs of increased intracranial pressure with parents.
Teach the child and his parents to keep a headache diary. A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.
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. Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected. Maintaining cerebral perfusion is important for a child with hydrocephalus, but the priority intervention for the parents at this time is in regards to the infection. Establishing seizure precautions is an intervention for a child with a seizure disorder. Encouraging development of motor skills would be appropriate for a microcephalic child.
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? -"Even if the flashlight bothers him, we will check his eyes." -"If he falls asleep, we will wake him up every 15 minutes." -"If he vomits again, we will bring him back immediately." -"We can give him acetaminophen for a headache, but no aspirin."
"Even if the flashlight bothers him, we will check his eyes." The child's pupils are checked for reaction to light every 4 hours for 48 hours. If the child falls asleep, he or she should be awakened every 1 to 2 hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The caregiver should observe the child for at least 6 hours for vomiting or a change in the child's level of consciousness. The caregiver should notify the health care provider immediately if the child vomits more than three times, but if the child vomits once, returning to the care provider immediately is not needed.
Isabelle, age 7, 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 said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be best for the nurse to say to this mother? -"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." -"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 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." -"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."
"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." Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent what information in regard to seizures? -The child is bradycardiac. -Convulsive activity occurs. -The EEG is normal. -Cyanosis occurs at the onset of the seizure.
-Convulsive activity occurs. During seizures convulsive activity is typically noted. During a breath-holding spell, the child is bradycardiac, cyanosis occurs at the onset, and the EEG is normal.
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? -Her autoregulation mechanism to absorb spinal fluid has failed. -Call the doctor if she gets a persistent headache. -Tell me your concerns about your child's shunt. -Always keep her head raised 30º.
-Tell me your concerns about your child's shunt. Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical—base information on the parents' level of understanding.
The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the healthcare provider as a late sign of increased intracranial pressure? -Headache and sunset eyes -Dizziness and irritability -Decreased pupil reaction and decreased respiration. -Decorticate posturing and fixed and dilated pupils
Decorticate posturing and fixed and dilated pupils Decerebrate or decorticate posturing and fixed and dilated pupils are late signs of increased intracranial pressure. Decreased pupil reaction, decreased respirations, headache, sunset eyes, dizziness, and irritability are early signs of increased intracranial pressure.
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 -Encourage the parents to hold the child -Decrease environmental stimulation
Decrease environmental stimulation A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.
The nurse caares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? -Ketogenic diet -Use of anticonvulsant medications -Frequent temperature assessment -Vagus nerve stimulation
Use of anticonvulsant medications Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.
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? "Why do you always keep her head raised 30 degrees?" "Do you understand why you clamp the drain before she sits up?" "What do you know about her autoregulation mechanism failing?" "What questions or concerns do you have about this device?"
What questions or concerns do you have about this device?" Always start by assessing the family's knowledge. Ask them what they need to know. Knowing when to clamp the drain is important, but they might not be listening if they have another question on their minds. Autoregulation is too technical. Teaching should be based on the parents' level of understanding. Keeping her head elevated is not part of the information which would be taught regarding the drainage system.
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: -establishing seizure precautions for the child. -maintaining effective cerebral perfusion. -ensuring the parents know how to properly give antibiotics. -encouraging development of motor skills.
ensuring the parents know how to properly give antibiotics. Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected. Maintaining cerebral perfusion is important for a child with hydrocephalus, but the priority intervention for the parents at this time is in regards to the infection. Establishing seizure precautions is an intervention for a child with a seizure disorder. Encouraging development of motor skills would be appropriate for a microcephalic child.
Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): -antihistamine. -diuretic. -anticonvulsant. -steroid.
steroid. Increased intracranial pressure (ICP) may be caused from several factors: head trauma, birth trauma, hydrocephalus, infection and/or tumors. Whatever the reason the brain swells and becomes inflammed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. The diuretic mannitol may be used to decrease edema. An anticonvulsant is used with increased ICP to prevent seizures. An antihistamine would not be warranted in for treatment of a head injury.
