CH 22 ?'s peds

After a tonic-clonic seizure, it would not be unusual for a child to display a. Irritability and hunger b. Lethargy and confusion c. Nausea and vomiting d. Nervousness and excitability

ANS: B Feedback A Neither irritability nor hunger is typical of the period after a tonic-clonic seizure. B In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. C Nausea and vomiting are not expected reactions in the postictal period. D The child will more likely be confused and lethargic after a tonic-clonic seizure.

The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique should be performed that will best detect the presence of an increase in intracranial pressure? 1. Check urine for specific gravity. 2. Monitor for signs of dehydration. 3. Assess anterior fontanel for bulging. 4. Assess blood pressure for signs of hypotension.

3 A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Urine concentrating ability is not well developed at the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure.

The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? 1. Increased systolic blood pressure 2. Abnormal posturing of extremities 3. Significant widening pulse pressure 4. Changes in level of consciousness

4 An altered level of consciousness is an early sign of increased intracranial pressure (ICP). Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss the teeth after every meal. b. The child will require monitoring of renal function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.

ANS: A Feedback A A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. B The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. C Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. D Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply. a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)

ANS: A, C, D Feedback Correct The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. Incorrect The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences? a. The infant has 150 mL of CSF compared with 50 mL in the adult. b. Papilledema is a common manifestation of ICP in the very young child. c. The brain of a term infant weighs less than half of the weight of the adult brain. d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses

ANS: D Feedback A An infant has about 50 mL of CSF compared with 150 mL in an adult. B Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP. C The brain of the term infant is two thirds the weight of an adult's brain. D Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the child's coordination and fine muscle movements.

The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures? a. Weight loss b. Bruising c. Anorexia d. Drowsiness

ANS: B Feedback A Weight gain, not loss, is a side effect of valproic acid. B Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. C Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications. D Anorexia is not a side effect of valproic acid.

A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the health care provider's prescriptions, which would the nurse question as inappropriate for a child with this diagnosis? 1. Administer an oral antibiotic. 2. Maintain strict intake and output. 3. Draw blood for a culture and sensitivity. 4. Place the child on droplet precautions in a private room.

1 Medication to treat acute bacterial meningitis is administered intravenously, not orally. A culture and sensitivity is done to determine if the diagnosis is bacterial or viral. Until meningitis is ruled out, the child is placed in isolation on droplet precautions because the disease is spread by airborne means. Strict intake and output should be maintained.

Which assessment noted in an infant 1 day after placement of a ventriculoperitoneal shunt is indicative of surgical complications? a.Hypoactive bowel sounds b.Congestion in upper airways c.Increasing lethargy d.Mild incisional pain

C A decreasing level of consciousness indicates a problem with shunt function and should be reported immediately to the neurosurgeon. Peristalsis is depressed during surgery. Hypoactive bowel sounds may be evident after surgery as peristalsis returns to its preoperative function. Congestion in the upper airways may be evident after surgery. Mild incisional pain is a normal finding in the postoperative period.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow

1 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? 1. Nausea 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size

1 Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. 1. Remain calm. 2. Time the seizure. 3. Ease the child to the floor. 4. Loosen restrictive clothing. 5. Keep the child on her back.

1.2.3.4 When a child is having a seizure, the nurse should remain calm, time the seizure, ease the child to the floor if the child is standing or seated, keep the child on the side (to prevent aspiration), and loosen restrictive clothing.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

1.3.5 A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective? 1. "We're glad we only have to give our child the medication for 30 days." 2. "We will make appointments for follow-up blood work and care as directed." 3. "We're glad there are no side effects from taking the antiseizure medications." 4. "After our child has been seizure free for 1 month, we can discontinue the medication."

2 Antiseizure medications are continued for a prolonged time even if seizures are controlled. Periodic reevaluation of the child is important to assess the continued effectiveness of the medication, to check serum medication levels, and to determine the need to alter the dosage if indicated. Antiseizure medications have potential side effects, and parents should be informed of such effects specific to the medication the child will be taking. Withdrawal of medication follows a predesigned protocol, usually begun when the child has been seizure free for at least 2 years. When a medication is discontinued, the dosage should be reduced gradually over 1 to 2 weeks.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

2 Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP). In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help to prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in ICP. It is not necessary to check the blood pressure every 15 minutes.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1. Enteric 2. Contact 3. Droplet 4. Neutropenic

3 A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3 Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse should include which instruction? 1. Expect an increased urine output from the shunt. 2. Notify the health care provider if the infant is fussy. 3. Call the health care provider if the infant has a high-pitched cry. 4. Position the infant on the side of the shunt when the infant is put to bed.

3 If the shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected. Being fussy is a concern only if other signs indicative of a complication are occurring.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

3 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

The nurse is monitoring an infant for signs of increased intracranial pressure. On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? 1. Increase oral fluids. 2. Document the finding. 3. Notify the health care provider. 4. Place the infant supine in a side-lying position.

3 The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased intracranial pressure (ICP) within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate ICP. Increasing oral fluids and placing the infant in a side-lying position are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider.

The nurse enters a child's room and discovers that the child is having a seizure. Which actions should the nurse take? Select all that apply. 1. Call a code. 2. Run to get the crash cart. 3. Turn the child on her side. 4. Loosen any restrictive clothing. 5. Check the child's respiratory status. 6. Place an airway into the child's mouth.

3.4, 5 During a seizure the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse loosens clothing around the child's neck and ensures a patent airway by checking respiratory status. A code is called if the child is not breathing or the heart is not beating. There are no data in the question indicating that this is the case. The nurse stays with the child to reduce the risk of injury and to allow for observation and timing of the seizure. Nothing is placed into the child's mouth during a seizure because this could injure the child's mouth, gums, or teeth.

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4 A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.

The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure? 1. "Does twitching occur in the face and neck?" 2. "Does the muscle twitching occur on one side of the body?" 3. "Does the muscle twitching occur on both sides of the body?" 4. "Does the child have a blank expression during these episodes?"

4 Absence seizures are brief episodes of altered awareness or momentary loss of consciousness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or the face or neck. Myoclonic seizures are brief, random contractions of a muscle group that can occur on one or both sides of the body.

The nurse caring for a child with suspected absence seizures is collecting data from the parents on how to manage the disorder. Which statement, if made by the parents, indicates the presence of signs congruent with this disorder? 1. "My child does well with group activities." 2. "My child leads the other children during group play." 3. "My child is doing really well in school and has high grades." 4. "My child's teacher mentioned that he seems to daydream a lot."

4 Absence seizures are very brief episodes of altered awareness. There is no muscle activity except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds but may occur one after another several times a day. The child experiencing absence seizures may appear to be daydreaming. If the child is participating in group activities, they sometimes need help catching up with the group, especially if a seizure occurs. Decreasing grades is a sign of absence seizures, as well as lowered intellectual processes.

The nurse caring for an infant with a diagnosis of hydrocephalus should monitor the infant for which sign of increased intracranial pressure? 1. Proteinuria 2. Bradycardia 3. A drop in blood pressure 4. A bulging anterior fontanel

4 An elevated or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Proteinuria, bradycardia, and a drop in blood pressure are not specific signs of increased intracranial pressure (ICP). Changes in the level of consciousness and a widened pulse pressure are additional signs of increased ICP.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

4 Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

The nurse notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse should determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement should the nurse plan to include in the discharge teaching with the parents to reflect this safety need? 1. "Feed your infant in a side-lying position." 2. "Place a helmet on your infant when in bed." 3. "Hyperextend your infant's head with a rolled blanket under the neck area." 4. "When picking up your infant, support the infant's neck and head with the open palm of your hand."

4 Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid in the cerebral ventricular system. This characteristic causes the increase in the weight of the infant's head. The infant may experience significant head enlargement. Care must be exercised so that the head is well supported when the infant is fed or moved to prevent extra strain on the infant's neck, and measures must be taken to prevent the development of pressure areas. Supporting the infant's head and neck when picking up the infant will prevent the hyperextension of the neck area and prevent the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant's head could put pressure on the neck vertebrae, causing injury.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

4 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the antibiotic as soon as it is prescribed. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings? 1. Nausea, delirium, and fever 2. Severe headache and back pain 3. Photophobia, fever, and confusion 4. Severe headache, fever, and a change in the level of consciousness

4 The classic signs/symptoms of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early manifestation and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs/symptoms.

The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse should modify the client's plan of care based on which interpretation of the client's change? 1. An insignificant finding 2. An improvement in condition 3. Decreasing intracranial pressure 4. Deteriorating neurological function

4 The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification. The remaining options are inaccurate interpretations.

The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. Which action should the nurse perform for this test? 1. Tap the child's facial nerve and assess for spasm. 2. Compress the child's upper arm and assess for tetany. 3. Bend the child's head toward the knees and hips and assess for pain. 4. Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain.

4 To test for Kernig's sign, the client's leg is raised with the knee flexed and then extended at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig's sign. This is a common finding in meningitis. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees.

A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial

ANS: A Feedback A Absence seizures are very brief episodes of altered awareness. The child has a blank expression. B Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. C Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. D There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference

ANS: A Feedback A Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. B This is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel. C A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. D By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP.

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis? a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.

ANS: A Feedback A In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. B The CSF pressure is usually increased in acute bacterial meningitis. C Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. D The CSF glucose level is usually decreased compared with the serum glucose level.

When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of a. Hydrocephalus b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Cerebral palsy d. Reye's syndrome

ANS: A Feedback A The combination of signs is strongly suggestive of hydrocephalus. B SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. C The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. D Reye's syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

The Glasgow Coma Scale consists of an assessment of a. Pupil reactivity and motor response b. Eye opening and verbal and motor responses c. Level of consciousness and verbal response d. ICP and level of consciousness

ANS: B Feedback A Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. C Level of consciousness is not a part of the Glasgow Coma Scale. D Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale.

What should be the nurse's first action when a child with a head injury complains of double vision and a headache, and then vomits? a. Immobilize the child's neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

ANS: B Feedback A Stabilizing the child's neck does not address the child's symptoms. B Any indication of ICP should be promptly reported to the physician. C This intervention may facilitate the child's comfort. It would not be the nurse's first action. D The child's episode of vomiting does not necessitate a fluid restriction.

What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if standing and go for help. b. Turn the child's body on the side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the child's wrists.

ANS: B Feedback A The child should be placed on a soft surface if he is not in bed; however, it is inappropriate to leave the child during the seizure. B Positioning the child on his side will prevent aspiration. C Nothing should be inserted into the child's mouth during a seizure to prevent injury to the mouth, gums, or teeth. D Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply. a. It must be given with D5 1/2NS. b. The child will require monitoring of therapeutic serum levels while taking this medication. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. e. It must be filtered.

ANS: B, D, E Feedback Correct The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D5 1/2NS. The IV dose must be filtered. Incorrect The IV dose must be given in normal saline, not D5 1/2NS. Dilantin has not been found to cause gastrointestinal upset, and since it is being given by the IV route, this is not a concern. The medication can be taken without food.

What is the best response to a father who tells the nurse that his son "daydreams" at home and his teacher has observed this behavior at school? a. "Your son must have an active imagination." b. "Can you tell me exactly how many times this occurs in one day?" c. "Tell me about your son's activity when you notice the daydreams." d. "He is probably overtired and needs more rest."

ANS: C Feedback The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained.

Which type of seizures involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

ANS: C Feedback A Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. B Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. D A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)

ANS: D Feedback A Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally. B Fosphenytoin can be given intravenously as a second round of medication if seizures continue. C Phenobarbital can be given intravenously as a second round of medication if seizures continue. D Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of nursing assessment to detect early signs of a worsening condition is a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

ANS: D Feedback A Neurologic posturing is indicative of neurologic damage. B Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. C Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs.

Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status

ANS: D Feedback A Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. B Temperature elevation may occur in children with ICP. C Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure. D The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema.

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. "You will be on your knees with your head down on the table." b. "You will be able to sit up with your chin against your chest." c. "You will be on your side with the head of your bed slightly raised." d. "You will lie on your side and bend your knees so that they touch your chin."

ANS: D Feedback A The knee-chest position is not appropriate for a lumbar puncture. B An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurse's body. C A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture. D The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture.