Quiz 2
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Place multiple pillows in the room to assist with propping the child's head up. Provide information regarding policies of the unit's playroom for the parents to review. Gather appropriate equipment and signage for respiratory isolation precautions. Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized.
Gather appropriate equipment and signage for respiratory isolation precautions. Explanation: 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.
The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? "She always cries when the person holding her has on glasses...I guess glasses scare her." "She typically breastfeeds, but lately we have had to supplement with some rice cereal." "She has been irritable for the last hour....seems like she is just upset for some reason." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." TAKE ANOTHER QUIZ
She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant
A school-aged child with seizures is prescribed phenytoin sodium, 75 mg four times per day. What instruction would the nurse give the parents regarding this medication? Numbness of the fingers is common while taking this drug The child will have to adhere to good tooth brushing Watching television while taking the drug may cause seizures Even small doses may cause noticeable dizziness
The child will have to adhere to good tooth brushing Explanation: A side effect of phenytoin sodium is gingival hyperplasia. Good tooth brushing helps prevent inflammation under the hypertrophied tissue. Dizziness and tingling and numbness of the fingers are not side effects of this drug. Television watching will not elicit a seizure in a child with a known seizure disorder. A seizure occurs as an electrical interference in the brain. Reference:
4-year-old child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child, which will be the first change noted in the presence of increasing intercranial pressure? change in level of consciousness reduction in heart rate increase in heart rate decline in respiratory rate
change in level of consciousness Explanation: A change in the level of consciousness is the initial finding in the client who is experiencing an increase in intracranial pressure.
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Sudden, momentary loss of muscle tone, with a brief loss of consciousness Muscle tone maintained and child frozen in position Brief, sudden contracture of a muscle or muscle group Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention
inimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Explanation: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.
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? Institute droplet precautions in addition to standard precautions. Encourage the mother to hold and comfort the infant. Educate the family about preventing bacterial meningitis. Palpate the child's fontanels (fontanelles).
nstitute droplet precautions in addition to standard precautions. Explanation: 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 (fontanelles) is used to assess for hydrocephalus
A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which positions postoperatively? Select all that apply. prone right side lying left side lying semi-Fowler supine
rrect response: prone right side lying left side lying Explanation: Postoperatively, the nurse would position the infant in the prone or side-lying position to allow the incision to heal.
Absence seizures are marked by what clinical manifestation? Brief, sudden onset of increased tone of the extensor muscle Loss of motor activity accompanied by a blank stare Sudden, brief jerks of a muscle group Loss of muscle tone and loss of consciousness
Loss of motor activity accompanied by a blank stare Explanation: An absence seizure consists of a sudden, brief arrest of the child's motor activity accompanied by a blank stare and loss of awareness. A tonic seizure consists of a brief onset of increased tone or muscle. A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. An atonic seizure involves a sudden loss of muscle tone and loss of consciousness
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? Administer lorazepam rectally to the client. Refer the client to a neurologist. Discuss dietary therapy with the client's caregivers. Protect the child from hitting the arms against the bed.
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? Administer lorazepam rectally to the client. Refer the client to a neurologist. Discuss dietary therapy with the client's caregivers. Protect the child from hitting the arms against the bed.
To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority? Cerebral edema Renal failure Left-sided heart failure Cardiogenic shock
Correct response: Cerebral edema Explanation: The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Renal failure and cardiogenic shock aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.
What is a true statement regarding status epilepticus? Children over the age of 3 are more likely to develop status epilepticus. It is a common neurologic emergency in children. The most common cause is flashing lights. Seizure activity lasts less than 30 minutes.
It is a common neurologic emergency in children. Explanation: Status epilepticus is a common neurological emergency in children. Children younger than 3 years of age are most likely to develop status epilepticus. The most common cause of status epilepticus in children is febrile seizures. Status epilepticus occurs when seizures last longer than 30 minutes or recur without return of consciousness between seizures
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "If he is out of bed, the helmet's on the head." "Bike riding and swimming are just too dangerous." "Use this information to teach family and friends." "You'll always need a monitor in his room."
Use this information to teach family and friends." Explanation: Families need and want information they can share with relatives, child care 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 child may be able to bike ride and swim with proper precautions.
The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? While turning the child's head to the left, the eyes turn to the right. While stimulating the child's foot, the big toe points upward and other toes fan outward. While calling the child's name, the child stares straight ahead and does not turn to the sound. While assessing the child's pupils, there is no change in diameter in response to a light.
While assessing the child's pupils, there is no change in diameter in response to a light. Explanation: To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination. Reference:
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." Explanation: 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.
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 problem after 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.
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 injury Explanation: A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures are 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 an inability to swallow. All of these symptoms would make Risk for injury the highest priority
A child is brought to the emergency center after sustaining a seizure at home. When taking the child's history, which question(s) would the nurse ask the parents? Select all that apply. "What time did the seizure occur?" "Can you describe to me the movements your child experienced?" "How long did the seizure last?" "Did your child lose bladder or bowel control?" "Did you give your child any fever medicine prior to the seizure?" "Did your child stop breathing during the seizure?"
"What time did the seizure occur?" "Can you describe to me the movements your child experienced?" "How long did the seizure last?" "Did your child lose bladder or bowel control?" "Did your child stop breathing during the seizure?" Explanation: There are many types of seizures. After a child has experienced a seizure, it is helpful to know the details as much as possible so these can aid in the diagnosis. The health history becomes very important to gather this information. The nurse would obtain information from the parents as to the time the seizure occurred and note how long the seizure lasted. The parents could supply a description of the child's behavior during the seizure. This would include a description of the child's movements, any loss of bowel or bladder control, if the child became cyanotic, or any other characteristics the parents observed. The nurse would also ask the parents about any precipitating events before the seizure occurred such as a fever, a fall, anxiety, or exposure to strong stimuli. Giving an antipyretic medication to the child would not interfere with the seizure.
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Onset and character of fever Degree and extent of nuchal rigidity Signs of increased intracranial pressure (ICP) Occurrence of urine and fecal contamination
Signs of increased intracranial pressure (ICP) Explanation: Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.
he nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client? The caregivers will be prepared to care for the child at home. The child will have an understanding of the disorder. The family will understand seizure precautions. The child will remain free from injury during a seizure.
The child will remain free from injury during a seizure. Explanation: Keeping the child free from injury is the priority goal. The other choices are important, but keeping the child safe is higher than preparing for home care or knowledge deficit concerns. The physical concerns are always priority over the psychological concerns when caring for clients.
he nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? frequent temperature assessment use of anticonvulsant medications ketogenic diet vagus nerve stimulation
use of anticonvulsant medications Explanation: 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.
