Chapter 22 Neurologic and Sensory disorders Adaptive Quizzing
The mother of a 10-day-old infant reports her baby has been having "lots of eye discharge." What is the best initial response by the nurse? "Do you think this looks like an infection?" "Your baby will need to be seen by a neonatal ophthalmologist." "Tell me more about this drainage." "This is normal in infants of this age."
"Tell me more about this drainage."
The nurse is performing a neurological assessment on a child. The previous examination noted the child to be alert but answering questions inappropriately. In this exam, the child only responds to vigorous stimuli. Which action should the nurse take first? Document the findings on the hourly assessment tool. Notify the health care provider. Have another nurse verify the results. Reassess in 1 hour.
Notify the health care provider. Explanation: The level of consciousness is the earliest indicator of improvement or deterioration of the neurological status. Consciousness includes alertness, the ability to respond to stimuli, and cognition. If the child is alert but responding to questions inappropriately, then the child is said to be in a confused state. When the child only responds to vigorous stimuli, then the child is in a state of stupor. The change indicates a worsening state of consciousness.
The nurse is performing discharge teaching with the parents of a 3-month-old infant with deformational plagiocephaly (DP). Which statement by the parents requires further follow-up by the nurse? "We will limit tummy time to about 30 to 60 minutes." "We do not have a bassinet, so we will use a car seat." "We will play on the floor with toys during tummy time." "We will switch our infant's position frequently."
We do not have a bassinet, so we will use a car seat." Explanation: "We do not have a bassinet, so will we use a car seat," requires further follow-up by the nurse, because it is recommended to only use car seats while traveling in a car. Car seats can inhibit mobility and contribute to DP
The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction? "The VP shunt will help drain fluid from my baby's brain." "This shunt is the only surgery my baby will need." "I will watch my baby for irritability and difficulty feeding." "My baby's cerebrospinal fluid (CSF) is increasing intracranial pressure (ICP)."
"This shunt is the only surgery my baby will need." Explanation: Hydrocephalus results from an imbalance in the production and absorption of CSF. In hydrocephalus, CSF accumulates within the ventricular system and causes the ventricles to enlarge and increases in ICP to occur. A VP shunt can be used to drain excess CSF, but it will need to be replaced as the child grows, requiring shunt revision surgery at various times during the client's life.
The nurse will help parents of a child with amblyopia understand that occluding vision in the unaffected eye is therapeutic because: the pain of amblyopia is relieved in both eyes. use of the affected eye promotes vision development. pupil size in the affected eye will increase. occlusion relieves eye strain in the affected eye.
use of the affected eye promotes vision development.
The nurse is providing discharge teaching to the parents of a child recently diagnosed with a seizure disorder. The nurse determines learning has occurred with which statement(s) by the parents? Select all that apply. "We will keep an oral airway on hand and insert it into our child's mouth to maintain an open airway even if the teeth are clenched." "We will be sure to keep the area safe and turn our child on the side during seizure activity." "We will be sure to hold our child snugly during the seizure so no injuries occur." "We should time the seizure and write down what happens during the seizure." "We will activate EMS immediately when a seizure begins."
"We will be sure to keep the area safe and turn our child on the side during seizure activity." "We should time the seizure and write down what happens during the seizure." Explanation: The area should be made safe so injury does not occur during the seizure, and turning the child on the side helps maintain an open airway. Documentation of the seizure should be kept so the health care provider can review what occurred during the seizure. The child should not be restrained, because this will more likely lead to injury. Emergency medical services (EMS) only needs to be contacted if the child stops breathing; if any injury has occurred; if the seizure lasts for more than 5 minutes; or if the child is unresponsive to painful stimuli after the seizure.
After experiencing a head injury the child keeps falling asleep when no one is rousing him. When documenting this in the medical record which term is most appropriate? lethargic obtunded unconscious stupor
obtunded Explanation: Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided.
A nurse is providing care to a child with strabismus. The nurse understands that the most common treatment for this condition would be which of the following? Occlusion therapy Botulinum toxin injections Surgery Corrective lenses
Occlusion therapy Explanation: Although surgery and botulinum toxin may be used, the most common treatment for strabismus is occlusion therapy. Corrective lenses are used for refractive errors.
The nurse is assessing a 4-year-old child whose mother reports that the child is more irritable lately. Which of the following questions would the nurse ask to elicit information suggesting possible increased intracranial pressure (ICP)? "Has there been a change in your child's hearing?" "Does she have headaches when she gets out of bed?" "Does she vomit frequently?" "What immunizations has she had?"
"Does she have headaches when she gets out of bed?"
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? "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "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 my child having seizures for the rest of his life."
A nurse is providing discharge teaching to the parents of a child hospitalized with hydrocephalus, who had a ventriculoperitoneal (VP) shunt placed. The nurse should intervene if the parents make which statement? "We will report any changes in behavior or signs of infection immediately." "We expect our child to continue engaging in normal activities, including sports." "The shunt will need to stay in place for the rest of our child's life." "The shunt may need to be repositioned as our child grows."
"We expect our child to continue engaging in normal activities, including sports." Explanation: The nurse should intervene if the parents expect the child to engage in sports. The nurse will need to determine which type of sports the child will engage in. A child with a VP shunt should avoid contact sports such as football because of the risk of shunt damage.
The nurse is caring for a child diagnosed with aseptic meningitis. When explaining the treatment plan to the parents, which information would the nurse likely include? "We will monitor your child closely and keep your child comfortable." "We will need to move your child to the intensive care unit for care." "Until your child improves, we cannot give your child anything to eat." "Your child will need high doses of antibiotics to treat the infection."
"We will monitor your child closely and keep your child comfortable." Explanation: Aseptic meningitis is not as severe as bacterial meningitis and is usually self-limiting, requiring only supportive care. It is caused by a virus so antibiotics would not be neede
A 3-month-old infant is diagnosed with mild craniosynostosis. When teaching the parents about treatment, which information would the nurse likely include? "Your infant will need to wear a helmet after the defect is corrected for most hours of the day." "Treatment focuses on making sure to reposition your infant frequently when lying down." "It is likely your infant will need minimally invasive surgery once the infant reaches 6 months of age." "Your infant will need to be hospitalized to have open surgery to completely correct this problem."
"Your infant will need to wear a helmet after the defect is corrected for most hours of the day." Explanation: Craniosynostosis is treated by surgery to release the fused suture(s) and to achieve cosmetic improvements for facial and head deformities. Surgery is done before the infant is 6 months of age to achieve the best outcome.
The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child? Inability to articulate the sounds of the letter 'R' and "S" when vocalizing A delay or lack of clear, understandable speech pattern Purulent draining from one or both ears associated with pain behaviors A history of supplemental oxygen use at birth or shortly after birth
A delay or lack of clear, understandable speech pattern Explanation: A hearing impairment will often cause a delay or absence of normal speech and language development in a child.
The nurse is assessing the vision of 9-year-old boy. His vision appears normal on a vision screening test, although the nurse notices that he has to tilt his head occasionally as he is reading the chart. His mother tells the nurse that he has trouble reading and reports having a headache after doing his homework. Which condition should the nurse suspect in this boy? Amblyopia Myopia Astigmatism Nystagmus
Astigmatism
A group of nursing students are reviewing information about the different types of hearing impairment. The students demonstrate understanding of the information when they identify which of the following as a possible cause of a conductive hearing impairment? Select all that apply. Brain injury Fluid in the middle ear Cerumen blockage Injury to the inner ear Tympanic membrane scarring
Cerumen blockage Fluid in the middle ear Tympanic membrane scarring Explanation: Possible causes of conductive hearing impairment include blockage by cerumen or a foreign object, fluid in the middle ear, and tympanic membrane scarring. Damage to the inner ear by disease or injury is a possible cause of sensorineural hearing impairment. Brain injury is a cause of central hearing impairment.
The nurse is assessing a 9-year-old child who is suspected of having meningitis. The nurse assesses the child for meningeal irritation using the Kernig sign. Which result would the nurse interpret as positive? Child reports pain behind the knee when leg is extended. Child immediately flexes the knees when chin touches chest. Child flexes hips when placed in the supine position. Child reports pain when head is raised toward the chest.
Child reports pain behind the knee when leg is extended. Explanation: When testing for the Kernig sign, the nurse would lay the child supine with the hips flexed and then try to straighten a leg out. The test is positive if pain behind the knee is experienced when the leg is extended. Younger children may cry out or resist leg extension.
Antibiotic therapy to treat meningitis should be instituted immediately after which event? Initiation of IV therapy Collection of cerebrospinal fluid (CSF) and blood for culture Identification of the causative organism Admission to the nursing unit
Collection of cerebrospinal fluid (CSF) and blood for culture Explanation: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate
The nurse is assessing a child with a suspected traumatic brain injury. The child is disoriented to place and time, but not person, and is having difficulty following commands. The nurse would use which terminology to document the child's level of consciousness? Confusion Clouding of consciousness Obtundation Stupor
Confusion
A nurse is caring for a 1-year-old child with a head injury. The child was previously unconscious but is now alert and oriented. Oral feedings are prescribed. The nurse determines that the child's risk for aspiration is low based on the presence of which reflex(es)? Select all that apply. Babinski Swallow Moro Cough Gag
Gag Cough Swallow
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. 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 chil
A parent calls the nurse triage line to say the child accidentally got hit in the eye and the parent believes the child will have a black eye. Which instruction is important for the nurse to provide this parent? Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours. Assure the parent that the scleral hemorrhages will resolve. Administer acetaminophen if needed for pain. Refer the child to an ophthalmologist for further evaluation.
Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours.
The nurse is assessing a child who has suffered a head injury. Which assessment finding would indicate loss of midbrain functioning? no response to verbal statements arms adducted and flexed on the chest with hands fisted loss of deep tendon reflexes arms adducted and extended with pronation of wrists with fingers flexed
arms adducted and extended with pronation of wrists with fingers flexed Explanation: Decerebrate posturing, rigid extension, and adduction of the arms and pronation of the wrists with flexed fingers occurs when the midbrain is not functional.
Which of the following is a physical sign of abusive head trauma (shaken baby syndrome)? often there are no physical signs bruising on the shoulders and neck periorbital edema edema near the base of the neck
often there are no physical signs
The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine." "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received."
"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."
The nurse is performing discharge teaching for parents with a child with congenital microcephaly. Which statement by the parents requires further follow-up by the nurse? "Respite care may be available." "There is no cure for my child's condition." "My child may have a shorter lifespan." "Physical therapy may be needed for my child."
"My child may have a shorter lifespan."
The nurse is caring for a child with hearing loss due to damage from chronic inner ear infections. The nurse knows that the child most likely has which type of hearing loss? Conductive Mixed hearing loss Central auditory dysfunction Sensorineural
Conductive Explanation: Otitis media, middle ear infection, can cause damage to the structures of the middle ear, which can result in conductive hearing loss. Sensorineural hearing loss involves the dysfunction of the nerves and central auditory dysfunction involves dysfunction within the central nervous system.
A young child in the clinic has watery eyes and reddened conjunctiva. The child keeps the eyes closed a lot, because it hurts to have them open. Which problem does the nurse suspect for this client? A. Stye B. Blepharitis marginalis C. Conjunctivitis D. Chalazion
Conjunctivitis Explanation: Conjunctivitis is inflammation of the conjunctiva and is demonstrated by watery eyes with reddened conjunctiva and sensitivity to light. Sticking of eyelids with pustular drainage is also a sign. It is very contagious and requires antibiotics for treatment.
The nurse is providing care to an infant with microcephaly. When reviewing the prenatal and birth history, the nurse would identify the mother's exposure to which infection as a potential contributing factor? Cytomegalovirus Gonorrhea Candida Chlamydia
Cytomegalovirus Explanation: Microcephaly is diagnosed as either primary, in which a genetic, chromosomal, or hereditary cause is implicated, or secondary, in which the defect occurs as a result of exposure to irradiation, maternal infection with toxoplasmosis, rubella, or cytomegalovirus, or maternal use of alcohol or tobacco.
A 1-year-old comes to the clinic for a routine visit. The eye examination reveals an enlarged, edematous, and hazy cornea. The child appears sensitive to light. What should the nurse suspect? Cataract Infantile glaucoma Stye Conjunctivitis
Infantile glaucoma Explanation: Glaucoma is increased intraocular pressure caused by inadequate or blocked drainage of aqueous humor. The cornea, which appears enlarged, may be edematous and hazy. In addition there may be tearing, pain, and photophobi
After teaching a group of nursing students about seizures, the instructor determines that the teaching was successful when the students identify which of the following about status epilepticus? Children older than the age of 3 years are more likely to develop status epilepticus. The most common cause is flashing lights. It is a common neurologic emergency in children. Seizure activity lasts less than 30 minutes.
It is a common neurologic emergency in children. Explanation: Status epilepticus is a common neurologic 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
A 9-year-old child with a history of epilepsy is brought to the emergency department. The child has been having a series of tonic-clonic seizures over the past 5 minutes and has not recovered from them between episodes. Which medication would the nurse anticipate being used to control the child's seizures? Carbamazepine Gabapentin Ethosuximide Lorazepam
Lorazepam Explanation: Although carbamazepine, gabapentin, and ethosuximide may be used to treat seizures, the child is experiencing status epilepticus. The agents of choice in this situation would be lorazepam or diazepam.
A nurse suspects that a child has developed pneumococcal meningitis based on assessment of which of the following? Otitis media Chills Nuchal rigidity Productive cough
Nuchal rigidity Explanation: Pneumococcal meningitis is manifested by fever, irritability, and nuchal rigidity.
The nurse is caring for a 4-year-old child who is unconscious. Which action by the nurse is priority? Keep the side rails up and padded. Administer IV fluids. Position on the side with the chin extended. Cushion bony prominences.
Position on the side with the chin extended. Explanation: Maintaining the child's airway and breathing is the priority; therefore, the nurse should position an unconscious child to maintain the airway, such as on the side with the chin extended, which will prevent the tongue from obstructing the airway if the child is not receiving artificial ventilation
A nurse is preparing a presentation on neurologic development in children. What information should the nurse include in the presentation? Poverty and caregiver mental illness are shown to contribute to developmental delays in children. The ratio of body surface area to body weight is much less in children than in adults. Teratogens have little effect on a child's neurologic development. Only a small portion of the body's total blood supply is needed to support cerebral metabolism in children.
Poverty and caregiver mental illness are shown to contribute to developmental delays in children.
A child has been diagnosed with strabismus. After further examination, the client is told that the resting position of the right eye is convergent. The nurse further explains that this means which of the following? The resting position of the eye is turned out. The same eye deviates constantly. One pupil is higher than the other. The resting position of the eye is turned in.
The resting position of the eye is turned in. Explanation: In strabismus, the resting position of one eye may be divergent (turned out) or convergent (turned in). One pupil may be higher than the other (vertical strabismus). Strabismus may be monocular, in which the same eye deviates constantly.
A 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication? Use a soft toothbrush. Increase intake of citrus foods to promote absorption. Avoid excessive sunlight. Take medication on an empty stomach.
Use a soft toothbrush. Explanation: Phenytoin is an anticonvulsant medication. It can be used in the management of seizure disorders. This medication is associated with gingival hyperplasia. This may result in tender and bleeding gums. The use of a soft toothbrush will reduce pain, bleeding and discomfort.
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? white blood cell count hemoglobin level serum glucose level urinalysis
serum glucose level Explanation: Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expend energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review.
A child has recently been diagnosed with cataracts. The treatment for cataracts is: wearing a patch until the cloudiness clears. there is no treatment for childhood cataracts. eye drops to lower the pressure. surgery.
surgery. Explanation: A cataract is marked opacity of the lens. It can be present at birth. Treatment for childhood cataracts is surgical removal of the cloudy lens, followed by insertion of an internal intraocular lens.
A toddler is prescribed amoxicillin for bilateral otitis media. The parent reports that the toddler refuses to take the oral medication. The nurse knows that more education is needed when the parent makes which statement? "I will shake the medication well, and draw up the amount prescribed in the syringe you gave me. I will hold my toddler upright so he does not choke, and I will squirt the medication along the gum line." "I will shake the medication well, and draw up the medication to the top of the syringe. My spouse and I will hold our toddelr down and force the medication down his throat." "I will shake the medication well, and draw up the amount prescribed in the medicine spoon you gave me. I will hold my toddler upright so he does not choke, and I will let him drink the medicine off the spoon." "I will shake the medication well, and draw up the amount prescribed. I will allow my toddler to suck in the medication while I hold him."
"I will shake the medication well, and draw up the medication to the top of the syringe. My spouse and I will hold our toddelr down and force the medication down his throat."
The nurse has finished teaching the mother of a 5-year-old male diagnosed with bacterial conjunctivitis how to manage her son's infection at home. Which statement by the mother would indicate a need for further education? "I will use a warm compress to help loosen crust that accumulated on his eyelid overnight." "I will wash my hands immediately after caring for him." "I will encourage my son to not touch his eyes." "I will use Visine drops in his infected eye to help reduce redness."
"I will use Visine drops in his infected eye to help reduce redness."
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 Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Brief, sudden contracture of a muscle or muscle group Muscle tone maintained and child frozen in position
Minimal 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 1-year-old has just undergone surgery to correct craniosynostosis. When talking with the parents, which of the following would be most appropriate? "I'll be watching his hemoglobin and hematocrit closely." "This condition only happens in 1 out of 2,000 births." "I told you yesterday there would be facial swelling." "Now that the surgery was successful, do you have any questions?"
Now that the surgery was successful, do you have any questions?" Explanation: Often what parents need most is someone to listen to their concerns. Although this is a good time for education, let the parents adjust to their baby's appearance
To give eardrops to a 4-year-old child, what would be the best technique to use? Pull the pinna of the ear up and back. Press the pinna of the ear forward. Pull the pinna of the ear downward. Lift the pinna of the ear down and back.
Pull the pinna of the ear up and back. Explanation: Pulling the pinna upward and back straightens the ear canal in the child older than 3 years of age.
The nurse is planning care for a preschool-age child diagnosed with meningitis. What should the nurse identify as a priority goal for this patient's care? Inspect the teeth for obvious caries. Increase stimulation opportunities to prevent coma. Provide an opportunity for therapeutic play. Reduce the pain related to nuchal rigidity.
Reduce the pain related to nuchal rigidity.
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. tongue blade padding for side rails smelling salts oxygen gauge and tubing suction at bedside
oxygen gauge and tubing suction at bedside padding for side rails
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 an infant car seat after feeding the infant placing the infant in a Sims position in the crib after feeding the infant placing the infant supine in the crib after feeding the infant placing the infant prone in the crib after feeding the infant
placing the infant in an infant car seat after feeding the infant Explanation: Placing a child or infant in the semi-Fowler position can help reduce cerebral edema and pressure. Using an infant child seat helps to simulate the raised head of the bed.
The nurse is reviewing discharge planning instructions with the parents of a child who had a ventriculoperitoneal (VP) shunt placed. Which statement by the parents requires further follow-up by the nurse? "Our child should be monitored for poor feeding." "If our child has vomiting, something may be wrong with the shunt." "Our child may have occasional lethargy." "We will watch for changes in behavior at home."
"Our child may have occasional lethargy." Explanation: Lethargy, changes in behavior, poor feeding, and nausea and vomiting may indicate that the shunt has become infected, clogged, or kinked or has developed a blood clot
The nurse is providing care to an infant with hydrocephalus who has had a ventriculoperitoneal shunt inserted. The nurse documents the infant's assessment. Which finding(s) would lead the nurse to notify the health care provider about the possibility that the child has developed a paralytic ileus? Select all that apply. Level of consciousness Bowel sounds Abdomen Incisional sites Temperature Abdominal circumference
Abdomen Bowel sounds Abdominal circumference
During physical assessment of a 2-year-old child, the nurse suspects that the child may have a cataract in one eye based on assessment of which of the following? Excess watering of the eyes Edema of the eyelids Absence of the red reflex Sclera appears to be blue
Absence of the red reflex Explanation: The absence of the red reflex and a white, opaque appearance of the lens are telltale signs of a cataract. A blue tinge to the sclera and excess watering of the eyes are signs of glaucoma. Edema of the eyelids is a sign of allergic conjunctivitis.
The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? Perform a glucose finger stick to determine the child's blood sugar level. Administer carbamazepine as prescribed. Administer lorazepam IV as prescribed. Observe and document the length of time of the seizure and type of movement observed.
Administer lorazepam IV as prescribed.
The child has conjunctivitis with much mattering of the eyes. What instruction should the nurse give the family? Select all that apply. Consider the child contagious until treated with prescribed medication for 24 hours. Use measures (such as distraction) to keep the child from rubbing the eyes. All family members should use frequent and proper hand hygiene. Wipe mattering from the eyes from the outer canthus inward (temple to nose). Avoid sharing towels, clothing, pillow cases and other personal items with others.
All family members should use frequent and proper hand hygiene. Use measures (such as distraction) to keep the child from rubbing the eyes. Consider the child contagious until treated with prescribed medication for 24 hours. Avoid sharing towels, clothing, pillow cases and other personal items with others.
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? Decrease environmental stimulation Encourage the parents to hold the child Take vital signs every 4 hours Monitor temperature every 4 hours
Decrease environmental stimulation Explanation: 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
A nurse is providing care for a 6-year-old child admitted to the hospital for meningitis. The child's past medical history shows recent mild-to-moderate hearing loss secondary to recurrent ear infections. Which intervention is most important for the nurse to implement? Determine an effective method of communicating with the child. Provide the family with information on community support groups. Coordinate hearing rehabilitation and speech therapy services. Educate the parents about antibiotics to treat infection.
Determine an effective method of communicating with the child.
The nurse is performing a neurologic assessment on a 7-month-old infant. Which task should the nurse perform last? Move a toy through the field of vision. Elicit the gag reflex. Shine a penlight in each eye. Palpate the anterior fontanelle.
Elicit the gag reflex. Explanation: Eliciting the gag reflex is the most invasive task and should be performed last
A 17-year-old is brought to the emergency department with a fever, headache, and stiff neck. Bacterial meningitis is suspected. The nurse would anticipate preparing the adolescent for which test to confirm the diagnosis? Magnetic resonance imaging Lumbar puncture Complete blood count Computed tomography
Lumbar puncture Explanation: Although a complete blood count may be done to evaluate for an elevated white blood cell count and clotting deficiencies, bacterial meningitis is diagnosed with a lumbar puncture to analyze the cerebrospinal fluid and identify the organism
A nurse is providing care for a 14-year-old child hospitalized after a motor vehicle accident that resulted in blunt head trauma. The nurse notes that the client appears to be sleeping and is lying with upper limbs flexed at the elbow and wrists while lower limbs are extended. Which action should the nurse take next? Reposition the client. Notify the health care provider. Allow the client to sleep undisturbed. Utilize the Glasgow Coma scale (GCS).
Utilize the Glasgow Coma scale (GCS). Explanation: The nurse should further assess the client using the GCS, which will determine level of consciousness. The client's positioning suggests decorticate posturing, which indicates brain injury to the corticospinal tracts. Performing this assessment will provide additional important information that the nurse can provide when notifying the health care provider
The nurse is conducting a class at a local community center for parents of preschool-aged and school-aged children. One of the topics is Reye syndrome. The nurse emphasizes the need to avoid the use of aspirin in children with a viral illness. Which virus(es) would the nurse address as commonly associated with this syndrome? Select all that apply. Influenza Epstein-Barr virus Varicella Cytomegalovirus Hepatitis
Varicella Influenza Explanation: Reye syndrome occurs when aspirin is administered to a child during a viral illness. Influenza A and B and varicella are the viruses most commonly associated with Reye syndrome.
An infant is diagnosed with nasolacrimal duct obstruction. The nurse is instructing the parents on how to perform lacrimal massage. The nurse determines the need for additional teaching based on which statement by the parents? "We will press on the outer corner of the eye for several seconds." "We should stroke the area about 10 times with each session." "We should do the massage along with warm compresses." "We should do the massage every morning and every evening."
We will press on the outer corner of the eye for several seconds." Explanation: Caregivers can perform lacrimal massage at home in conjunction with applying warm compresses to open the membrane. Caregivers should place the index finger between the inner corner of the child's eye and the side of the nose and press in and down over the lacrimal sac for a few seconds
The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing in the figure. The nurse is aware that this type of posturing is the result of injury to what area? frontal lobe mid-cervical brain stem cerebral cortex
brain stem Explanation: Decerebrate posturing is seen with injuries occurring at the level of the brain stem.
The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? hyperthermia hypertension tachypnea poor handwriting
hypertension Explanation: Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia.
The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the child questions. How should the nurse document the child's level of consciousness? decreased level of consciousness obtunded fully conscious stupor
obtunded Explanation: Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided
