Sherpath: Neurologic Conditions

The nurse is caring for a pediatric patient admitted with seizure activity related to cerebral palsy (CP). Which interventions should the nurse perform immediately? Select all that apply. Administer intravenous diazepam (Valium). Institute safety measures such as seizure padding. Assess gait disturbances and muscle coordination. Consult speech therapy for a swallowing evaluation. Evaluate gross motor development and muscle tone.

Administer intravenous diazepam (Valium). Institute safety measures such as seizure padding.

A child is brought to the emergency department with a suspected spinal cord injury at the level of C2. What is the immediate priority in the nursing care of a patient with this injury? Administer ventilatory support Assess child's visual field for spots Manage hypertension and bradycardia Provide permanent cervical stabilization

Administer ventilatory support

A child is rushed to the emergency department following a collision on the school yard impacting the left side of the head. The nurse expects which physical finding associated with this injury? Raccoon eyes Hemotympanum Left arm weakness Right leg numbness

Left arm weakness

The nurse is caring for a child who has sustained an acceleration-deceleration head injury. Which actions should the nurse take in assessing this patient? Select all that apply. Check child's gag reflex. Assess child for retinal injury. Check child for burns and bruising. Assess for associated extremity sprain. Contact health care provider because child needs head computed tomography (CT).

Assess child for retinal injury. Check child for burns and bruising. Assess for associated extremity sprain. Contact health care provider because child needs head computed tomography (CT).

A child presents to the emergency department with sudden bilateral ascending weakness and is diagnosed with Guillain-Barré syndrome. What should the nurse most closely monitor? Capillary refill Respiratory status Heart rate and rhythm Level of consciousness

Respiratory status

The twelve-year-old patient with spina bifida exhibits learning delays. What other assessment findings does the nurse anticipate? Select all that apply. Slow to follow directions Difficulty swallowing foods Upper limb discoordination Frequent respiratory infections Bowel and bladder incontinence

Slow to follow directions Difficulty swallowing foods Upper limb discoordination Bowel and bladder incontinence

The nurse cares for a child with rapidly progressing paralysis due to Guillain-Barré syndrome (GBS). After supportive care fails, the nurse anticipates what treatment as the next step in this patient's care? Consult palliative care Administer corticosteroids Teach about plasmapheresis Administer IV immunoglobulin

Administer IV immunoglobulin

When caring for a fourteen-year-old child with traumatic brain injury, which complications must be addressed immediately? Select all that apply. Blood pressure 80/40 mm Hg Decreased muscle tone bilaterally Weak deep tendon reflex responses Respiratory rate of 8 breaths per minute

Blood pressure 80/40 mm Hg Weak deep tendon reflex responses Respiratory rate of 8 breaths per minute

What are the priorities when developing a nursing plan of care for a ten-year-old patient with Guillain-Barré syndrome (GBS)? Select all that apply. Assess daily for fever, stiff neck, or confusion. Determine bilateral lower extremity strength. Check vital signs and trends every four hours. Perform tests of lower and upper sensory function. Observe chewing and swallowing of solids and liquids. Evaluate respiratory rate and use of accessory muscles.

Determine bilateral lower extremity strength. Check vital signs and trends every four hours. Perform tests of lower and upper sensory function. Observe chewing and swallowing of solids and liquids. Evaluate respiratory rate and use of accessory muscles.

The thirteen-month-old child had prenatal microsurgery for a myelomeningocele. Which assessment finding indicates the surgery was not completely successful? Increased head circumference Child is unable to walk or stand up A decreased ability to pick up objects Child is only saying sounds like "bah bah"

Increased head circumference

The nurse is working with a new graduate in developing a plan of care for a newborn infant with spina bifida (myelomeningocele) and hydrocephalus. The nurse reminds the graduate to monitor for increased intracranial pressure (ICP). Which assessment technique should be performed to detect the presence of an increase in ICP? Measure urine specific gravity Assess for increased muscle tone Observe anterior fontanel for bulging Monitor blood pressure for signs of hypotension

Observe anterior fontanel for bulging

The nurse cares for a child with Guillain-Barré syndrome. The nurse notes a frequent, weak cough and decreased bilateral hand grips. What actions should the nurse take? Select all that apply. Place a nasal cannula on the patient at 2 L/min. Obtain a pillow nurse call light for patient's use. Raise head of the bed to a semi-Fowler's position. Do not allow patient to have anything to eat or drink. Explain to patient what was assessed and the meaning.

Obtain a pillow nurse call light for patient's use. Raise head of the bed to a semi-Fowler's position. Do not allow patient to have anything to eat or drink. Explain to patient what was assessed and the meaning.

An eight-year-old child is brought to the emergency department by his parents with signs of late hydrocephalus. The nurse manages what expected findings in this patient? Select all that apply. Setting-sun sign Ongoing seizure activity Restlessness and irritability Blood pressure 140/90 mm Hg Heart rate of 45 beats per minute

Ongoing seizure activity Blood pressure 140/90 mm Hg Heart rate of 45 beats per minute

A child has recently been diagnosed with Guillain- Barré syndrome. Which patient statements require follow-up by the nurse? Select all that apply. "I had a nasty cold two weeks ago, but mom said it was not a big deal." "I had a red rash a while back with a fever. It only lasted about three days." "When I get well, I'm not shaking hands with anyone, not even the pastor!" "I haven't felt well for a few days and my toes are kind of numb feeling today." "I hate getting the flu-shot, but dad insisted this year since I've been sick so much."

"I had a nasty cold two weeks ago, but mom said it was not a big deal." "I had a red rash a while back with a fever. It only lasted about three days." "I hate getting the flu-shot, but dad insisted this year since I've been sick so much."

During a well-child visit, a three-year-old patient being examined exhibits unsteady gait and poorly developed speech. The health care provider suspects cerebral palsy (CP). How should the nurse guide the parents? Select all that apply. "Ensure that your home is free of sharp edges to protect the child in case of falling while walking." "Administer pain medication whenever the child shows signs of pain such as grimacing or moaning." "While we get further testing arranged, keep notes regarding any unusual behaviors or actions." "The speech-language pathologist will work with you to evaluate reasons for the poorly developed speech." "The physical therapist will show you some exercises to improve coordination and strengthen the child's muscles."

"Ensure that your home is free of sharp edges to protect the child in case of falling while walking." "The speech-language pathologist will work with you to evaluate reasons for the poorly developed speech." "The physical therapist will show you some exercises to improve coordination and strengthen the child's muscles."

The nurse is discussing the surgical closure of a myelomeningocele with the parents of a newborn patient. Which statement by the parents indicates the need for further teaching? "Surgically closing this defect will ensure my baby can walk at the right age." "This surgery makes me feel less like my baby is too fragile to hold and feed." "This surgery minimizes the problems my baby has over the course of a lifetime." "Surgically closing this defect reduces the chance my baby will develop infections."

"Surgically closing this defect will ensure my baby can walk at the right age."

The nurse cares for a five-year-old patient involved in a motor vehicle accident. The paralysis extends from the naval downward. In performing discharge teaching, the nurse knows further teaching is needed when the parents make which statements? Select all that apply. "We need to catheterize him every 8 hours for urine." "We need to turn him in the bed at least every 2 hours." "We need to make sure he has a bowel movement often." "He will need to eat every meal that we prepare for him." "He will enjoy sitting outside all morning in his wheelchair."

"We need to catheterize him every 8 hours for urine." "We need to make sure he has a bowel movement often." "He will need to eat every meal that we prepare for him." "He will enjoy sitting outside all morning in his wheelchair."

The nurse is providing education to the parents of a child experiencing spinal shock after a spinal cord injury. Which statements by the nurse are correct? Select all that apply. "We will not know what permanent injuries exist for one to two months." "Currently, the child appears to have no function below the level of injury." "Limbs that are currently flaccid will remain that way for about six months." "Nurses will perform passive range of motion exercises daily to maintain muscles." "Some complications, such as low blood pressure, will resolve within a few weeks."

"We will not know what permanent injuries exist for one to two months." "Currently, the child appears to have no function below the level of injury." "Some complications, such as low blood pressure, will resolve within a few weeks."

The nurse observes that the ten-year-old patient is becoming increasingly restless. Knowing that the child suffered a concussion playing football, what does the nurse do next? Select all that apply. Calculate Glasgow coma score. Perform bilateral pupil examination. Inspect child's skull for size and shape. Ask patient about nausea and headache. Check vital signs and oxygen saturation.

Calculate Glasgow coma score. Perform bilateral pupil examination. Ask patient about nausea and headache. Check vital signs and oxygen saturation.

The nurse assesses a two-year-old child with papilledema related to hydrocephalus. Which finding causes the nurse the most concern? Child is holding head and crying Child is lethargic, responding to voice Child projectile vomits when sitting up Child has an increased head circumference

Child has an increased head circumference

A 5-year-old child is admitted with complications related to an Arnold-Chiari malformation and myelomeningocele. What assessment findings cause the nurse to be concerned? Child is underweight for age. Child reports neck pain and stiffness. Child reports burning with urination. Child is experiencing severe headache.

Child is experiencing severe headache.

An infant was brought to the emergency department (ED) after falling from a high chair, sustaining a basilar skull fracture. Which concerning assessment findings does the nurse expect? Clear drainage from the ear Pupils are unequal and sluggish Bleeding from the fractured area Intermittent confusion and lethargy

Clear drainage from the ear

The nurse is performing a neurologic assessment on a patient with cerebral palsy (CP). The nurse notes bilateral arm spasticity and the child is unable to grip the nurse's fingers. What action should the nurse perform? Notify health care provider Assess child's gait for ataxia Complete neurologic assessment Inquire about learning difficulties

Complete neurologic assessment

An infant is brought to the emergency department with retinal hemorrhages, increased irritability, and a burn mark on the arm. Once stabilized, what is the nurse's priority intervention for this patient? Consult with child protective services. Ask the case manager to arrange home health care. Provide stress management teaching to the parents. Gather a timeline of events based on the parents' reports.

Consult with child protective services.

A patient presents with Guillain-Barré syndrome (GBS). What does the nurse anticipate finding in the history and physical? Select all that apply. Tuberculosis skin test that was positive Toe infection positive for staphylococcus Influenza vaccine received one month ago Upper respiratory infection two weeks ago History of frequent urinary tract infections

Influenza vaccine received one month ago Upper respiratory infection two weeks ago

In a child with a complete spinal cord injury at T6, which interventions should the nurse implement to prevent complications? Select all that apply. Administer saline nose spray for nasal congestion. Maintain patient's bed position at 45-degree angle. Notify health care provider for BP of 162/89 mm Hg. Cover with blanket when goose bumps are observed. Hold steroid medications for heart rate less than 50 bpm.

Maintain patient's bed position at 45-degree angle. Notify health care provider for BP of 162/89 mm Hg.

The nurse is caring for a child with a spinal cord injury. Which intervention is a priority? Assess each shift for characteristics of stool. Administer an antacid medication twice daily. Bathe, dry, and provide skin care to the patient. Monitor the patient's temperature and skin changes.

Monitor the patient's temperature and skin changes.

A 3-year-old patient is diagnosed with hydrocephalus. A ventricular shunt was placed to relieve the pressure. What is the nursing care priority for a patient who had a ventricular shunt put into place? Assessing for proper bowel movements Assessing neurologic status every two hours Monitoring for fluid leaking from the incision Monitoring for headaches when the patient sits up

Monitoring for fluid leaking from the incision

The eleven-year-old patient is admitted with an incomplete spinal cord injury at C4. Which findings cause the nurse the most concern? Select all that apply. Patient reports difficulty taking a deep breath. Patient is unable to lift arms or grasp eating utensils. Patient's blood pressure increases to 150/92 mm Hg. Patient has "goose bumps," small raised bumps on the skin. Patient's whole blood glucose level increases to 190 mmol/L.

Patient reports difficulty taking a deep breath. Patient's blood pressure increases to 150/92 mm Hg. Patient has "goose bumps," small raised bumps on the skin.

The hospitalized child with spina bifida has broken out in a rash. What actions should the nurse take? Select all that apply. Place a precautions sign on the door and in the room. Change out the gloves in the room and outside the door. Request that the health care provider prescribe a steroid. Check the patient's vital signs for a temperature elevation. Ask the hospital's rapid response team to evaluate the child.

Place a precautions sign on the door and in the room. Change out the gloves in the room and outside the door. Request that the health care provider prescribe a steroid. Check the patient's vital signs for a temperature elevation.

A child is diagnosed with early stage hydrocephalus. What actions should the nurse perform? Select all that apply. Place padding on all four of bed rails. Teach parents to expect high-pitched crying. Administer ondansetron (Zofran) for vomiting. Provide orientation to the room, call light, and personnel. Consult dietician for dietary supplement recommendations.

Place padding on all four of bed rails. Administer ondansetron (Zofran) for vomiting. Provide orientation to the room, call light, and personnel. Consult dietician for dietary supplement recommendations.

The health care provider examines a 7-year-old child, revealing increased deep tendon reflexes, hypertonia, flexion, and a scissors gait. Which intervention does the nurse include in this patient's plan of care? Give the parents teaching pamphlets about antiseizure medication. Ensure the child has a hospital bed and bedside commode for use at home. Provide the child with a diet plan that includes reduced-fat milk and cheeses. Teach the child and parents how to monitor for and address learning difficulties.

Teach the child and parents how to monitor for and address learning difficulties.

Match the cerebral palsy (CP) symptoms to the nursing intervention for the hospitalized pediatric patient. Tense muscles Visible tremors Loss of coordination Involuntary movement

Tense muscles - continue to monitor Visible tremors - provide guided imagery Loss of coordination - place bed in lowest position Involuntary movement - admin a benzo

A child who plays soccer is brought to the clinic by the mom who suggests her child is not acting right. Which associated finding does the nurse evaluate further? The child cannot recall yesterday's events. The child requests a drink of water and a popsicle. The mother is pacing in the triage room continuously. The mother states that the child did not eat after the game.

The child cannot recall yesterday's events.

A twelve-year-old child's spina bifida lesion affects the upper lumbar vertebrae. The nurse evaluates that the child is meeting therapeutic goals when the child demonstrates which behaviors? Select all that apply. The child participates in exercise activities daily. The child walks without using leg braces prescribed. The child has successful attempts at bladder emptying. The child chooses to play alone at school during recess. The child bathes, dresses, and puts on shoes without help.

The child participates in exercise activities daily. The child has successful attempts at bladder emptying. The child bathes, dresses, and puts on shoes without help.

The nurse evaluates a three-year-old child for developmental delays. When the nurse notes that the child has difficulty maintaining balance while walking, what other assessments does the nurse perform? Select all that apply. The nurse assesses overall muscle tone and strength. The nurse assesses for speech impairments and delays. The nurse assesses deep tendon and primitive reflexes. The nurse assesses level of consciousness and orientation. The nurse assesses for developmental milestone variances.

The nurse assesses overall muscle tone and strength. The nurse assesses for speech impairments and delays. The nurse assesses deep tendon and primitive reflexes. The nurse assesses for developmental milestone variances.