CHAPTER 13 AND 20 TEST

identification of the causative organism

Antibiotic therapy to treat meningitis should be instituted immediately after which event?

an aura

Most epileptic generalized seizures are preceded by:

6 minutes

The maximum time a near-drowning victim can be without O2 with resultant brain damage is:

is not uncommon during the first 2 days after trauma

The mother of a 3 y.o. who received a mild concussion during a fall from his tricycle the previous day tells the nurse that she is worried about his temperature elevation of 100. The nurse's best response will be based on the knowledge that the temperature elevation

have a poor sucking reflex

The newborn nursery nurse takes special care in feeding a child with a possible intracranial hemorrhage b/c these children

does not turn the head toward a sound

The nurse assesses an indication of hearing loss when a 3-month-old baby

Petechiae over the trunk

The nurse caring for a child with suspected meningitis assesses a cardinal indicator of meningococcal infection, which is:

membranes, CSF, and the spinal cord

The nurse clarifies that the difference between a myelomeningocele and a meningocele is that the cyst of a myelomeningocele contains:

is on the rise

The nurse clarifies to the frightened mother of a child who has had a febrile seizure that these seizures usually occur when the temperature

absorbed into the circulating volume and excreted

When the mother of a child who has just received a VP shunt for the relief of hydrocephalus asks the nurse what happens to all the fluid that is pumped into the peritoneal space, the nurse bases the response on the knowledge that the fluid is

cloudy CSF with high protein and low glucose levels

Which of the following lab results would verify the diagnosis of bacterial meningitis?

folic acid

studies have shown that the incidence of neural tube defects has been greatly reduced by the use of:

palpating the anterior fontanel

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's LOC diminishes a priority nursing intervention is:

are twice of that of the adult

The nurse is aware that during early childhood cerebral blood flow and oxygen consumption:

lack of social interaction and awareness

Which of the following represent a primary characteristic of autism?

T:98.4, P:50, BP: 118/68, R:8

A 12 year old is admitted to the E.R. after a head injury. His admission VS are T:98.2, P:68, BP:96/56 and R:16. Select the set of VS that would indicate to the nurse that there is increasing ICP:

Sodium: 124 mmol/L

A mother brings her infant to the E.R. and say he had a seizure. While the nurse is obtaining a history, the mother says she was running out of formal so she stretched the formula by adding three times the normal amount of water. Electrolyte and blood glucose levels are drawn on the infant. The nurse would expect which lab value?

Check what the child's LOC has been

A nurse notes the below chart entry concerning a school-age child who has had brain tumor removed. Which nursing action should be performed first? "10/31/12: Patient's pupil equal and reactive to light, motor strength equal, aware of name, date, but not location, complaining of headache...Nurse Smith, LPN"

taking daily head measurements, taking daily abdominal measurements, positioning on the opposite sides from surgery

In caring for an infant who has had a VP shunt, the nurse will include in the plan of care:

hypothermia

The nurse explains that b/c of high body surface area to mass and small amount of subcutaneous fat, a child after submersion is at risk for

placement of a one-way pressure valve

The nurse explains that once a VP shunt is in place the CSF is prevented from back-flowing by:

received at least 24 hours of antibiotic therapy

The nurse explains to the mother of a child with meningitis that the child will remain in isolation until the child has

change the baby's position every 2 hours

The nurse includes in the plan of care for a 5-month-old hydrocephalic baby an intervention to prevent hypostatic pneumonia, which would be

tonic phase

The nurse is aware that most convulsive seizures begin with a:

flat on the back

The nurse is aware that the most appropriate position for 1-day post-op child with a VP shunt is

bulging fontanels, irritability, high-pitched cry

The nurse is caring for a 1 month old infant who fell from the changing table during a diaper change. Which s/sx of increased ICP is the nurse likely to assess in this client?

forceful vomiting, high-pitched shrill cry, inability to move normally

The nurse is caring for a newborn who was born after a long labor. Because of the length of labor, the nurse is alert for signs of intracranial hemorrhage, which would include:

decorticate-cerebral cortex; decebrate- midbrain

The nurse recognizes this posture in a child with a head injury as being indicative of injury to the:

protect the sac

The nurse takes special caution in positioning the infant with a myelomeningocele in order to:

placing a hand or small cushion under the child's head support

Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?