Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder

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. - oxygen gauge and tubing - suction at bedside - tongue blade - padding for side rails - smelling salts

Answer: - oxygen gauge and tubing - suction at bedside - padding for side rails

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. - eye opening - verbal response - motor response - fontanels (fontanelles) - posture

Answer: - eye opening - verbal response - motor response

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? A.) Assess the level of consciousness (LOC). B.) Notify the primary health care provider. C.) Place the child on fall precaution. D.) Place a patch over the client's affected eye.

Answer: A.) Assess the level of consciousness (LOC).

A 4-year-old child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child, which will be the first change noted in the presence of increasing intercranial pressure? A.) change in level of consciousness B.) reduction in heart rate C.) increase in heart rate D.) decline in respiratory rate

Answer: A.) change in level of consciousness

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? A.) head trauma B.) intracranial hemorrhaging C.) congenital hydrocephalus D.) positional plagiocephaly

Answer: A.) head trauma

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): A.) diuretic. B.) antihistamine. C.) anticonvulsant. D.) steroid.

Answer: D.) steroid.

A 6-year-old child with hydrocephalus had a ventriculoperitoneal (VP) shunt placed 6 weeks ago and now has experienced a seizure, vomiting, and loss of appetite. Which intervention will target the child's priority need? A.) Administer intravenous antibiotics as prescribed. B.) Pad and raise the rails on the child's bed. C.) Educate the parents about seizure precautions. D.) Prepare a menu with the child's favorite foods.

Answer: A.) Administer intravenous antibiotics as prescribed. Rationale: The major complications associated with shunts are infection and malfunction. When a shunt malfunctions the child experiences vomiting, drowsiness, and headache. When infection has occurred the child experiences increased vital signs, poor feeding, vomiting, decreased responsiveness, seizure activity and signs of local inflammation along the shunt tract. When an infection occurs the priority of care is to treat the infection with IV antibiotics. The seizures and the poor eating will resolve once the infection is cleared. The parents can be taught about seizure precautions and the bed can be padded but these are not the priority of care.

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect? A.) hydrocephalus B.) anencephaly C.) encephalocele D.) spina bifida occulta

Answer: A.) hydrocephalus Rationale: Hydrocephalus results from an imbalance in the production and absorption of cerebrospinal fluid. In hydrocephalus, cerebrospinal fluid accumulates within the ventricular system and causes the ventricles to enlarge and increases in intracranial pressure. Anencephaly, encephalocele and spina bifida occulta are all neural tube defects.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: A.) raccoon eyes. B.) Battle sign. C.) rhinorrhea. D.) otorrhea.

Answer: B.) Battle sign. Rationale: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

Which of these age groups has the highest actual rate of death from drowning? A.) infants B.) toddlers C.) preschool children D.) school-aged children

Answer: B.) toddlers

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? A.) Sudden, momentary loss of muscle tone, with a brief loss of consciousness B.) Muscle tone maintained and child frozen in position C.) Brief, sudden contracture of a muscle or muscle group D.) Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

Answer: D.) Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

The nurse has performed discharge teaching for parents of a child diagnosed with epilepsy. The child has been prescribed Zonegran (zonisamide). Which comments by the parents indicate the need for further discharge teaching regarding this medication? Select all that apply. - "I hope this medicine doesn't upset our child's stomach when taking it since the medication should be given on an empty stomach." - "Since our child also takes Dilantin (phenytoin), the dosages will likely be adjusted since it increases the metabolism of the Zonegran (zonisamide)." - "This medication can make our child very sedated so we need to monitor for this side effect." - "We need to watch our child's gums for swelling since this commonly happens with this medicine." - "We may need to add B-complex vitamin supplementation to our child's medications because this can help mange side effects."

Answer: - "This medication can make our child very sedated so we need to monitor for this side effect." - "We need to watch our child's gums for swelling since this commonly happens with this medicine." - "We may need to add B-complex vitamin supplementation to our child's medications because this can help mange side effects." Rationale: Presence of food will delay absorption of the medication so it should not be administered with food. Phenytoin, phenobarbital, and carbamazepine all increase the metabolism of this drug. A side effect of phenobarbital is excessive sedation and gingival hyperplasia. B-complex vitamin supplementation can help manage side effects of levetiracetam.

The parents of a 10-month-old child bring the infant to the emergency department after finding the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone." Which assessments are priority for the nurse to complete? Select all that apply. - airway - respiratory status - level of consciousness - vital signs - circulation - pupillary response - sgns of child abuse (child mistreatment)

Answer: - airway - respiratory status - circulation Rationale: With a submersion injury, hypoxia is the primary problem. Therefore, assessment of the airway, breathing, and circulation (ABCs) are the primary assessments the nurse will complete. These guide implementation of resuscitative measures. Other assessments such as level of consciousness, vital signs, and pupillary response would be done once the child is stable. The nurse would also perform a complete assessment, looking for signs of child abuse (child mistreatment) once the child is stable.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? A.) Onset and character of fever B.) Degree and extent of nuchal rigidity C.) Signs of increased intracranial pressure (ICP) D.) Occurrence of urine and fecal contamination

Answer: C.) Signs of increased intracranial pressure (ICP) Rationale: Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? A.) While turning the child's head to the left, the eyes turn to the right. B.) While stimulating the child's foot, the big toe points upward and other toes fan outward. C.) While calling the child's name, the child stares straight ahead and does not turn to the sound. D.) While assessing the child's pupils, there is no change in diameter in response to a light.

Answer: D.) While assessing the child's pupils, there is no change in diameter in response to a light.

The meningococcal vaccine should be offered to high-risk populations. If never vaccinated, who has an increased risk of becoming infected with meningococcal meningitis? Select all that apply. - 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates - 12-year-old child with asthma - 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti - 9-year-old child who was diagnosed with diabetes when he was 7 years old - 8-year-old child who is in good health

Answer: - 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates - 12-year-old child with asthma - 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti - 9-year-old child who was diagnosed with diabetes when he was 7 years old Rationale: The following people have an increased risk of becoming infected with meningococcal meningitis: college freshman living in dormitories, children 11 years old or older, children who travel to high risk areas, and children with chronic health conditions.

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? A.) "Did you use any medications, like aspirin, for the fever?" B.) "Did you give your child any acetaminophen, such as Tylenol?" C.) "What type of fluids did your child take when he had a fever?" D.) "How high did his temperature rise when he was ill?"

Answer: A.) "Did you use any medications, like aspirin, for the fever?" Rationale: Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

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? A.) "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." B.) "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." C.) "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." D.) "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine."

Answer: A.) "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? A.) "I will cradle her in my arms after the procedure for at least 30 minutes." B.) "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things." C.) "My child may have a headache after the procedure. If she does, she can have something for the pain." D.) "I need to encourage my child to drink at least 1 glass of water after the procedure."

Answer: A.) "I will cradle her in my arms after the procedure for at least 30 minutes." Rationale: During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? A.) Teach the child and his parents to keep a headache diary. B.) Review the signs of increased intracranial pressure with parents. C.) Have the child sleep without a pillow under his head. D.) Have the parents call the doctor if the child vomits more than twice.

Answer: A.) Teach the child and his parents to keep a headache diary.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? A.) moving the infant's head every 2 hours B.) measuring the intake and output every shift C.) massaging the scalp gently every 4 hours D.) giving the infant small feedings whenever he is fussy

Answer: A.) moving the infant's head every 2 hours Rationale: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? A.) Delayed growth and development related to physical restrictions B.) Risk for injury related to seizure activity C.) Risk for acute pain related to surgical procedure D.) Ineffective airway clearance related to history of seizures

Answer: B.) Risk for injury related to seizure activity Rationale: The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

The nurse is caring for a child admitted with focal onset motor seizures (simple partial motor seizures). Which clinical manifestation would likely have been noted in the child with this diagnosis? A.) The child had jerking movements in the legs and facial muscles. B.) The child had shaking movements on one side of the body. C.) The child was rubbing the hands and smacking the lips. D.) The child was dizzy and had decreased coordination.

Answer: B.) The child had shaking movements on one side of the body. Rationale: Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part. A focal onset sensory seizure may include sensory symptoms called an aura, which signals an impending attack. Myoclonic seizures are characterized by a sudden jerking of a muscle or group of muscles, often in the arms or legs, without loss of consciousness. Complex partial seizures may cause nonpurposeful movements, such as hand rubbing and lip smacking. During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination.

A school-aged child with seizures is prescribed phenytoin sodium, 75 mg four times per day. What instruction would the nurse give the parents regarding this medication? A.) Numbness of the fingers is common while taking this drug B.) The child will have to adhere to good tooth brushing C.) Watching television while taking the drug may cause seizures D.) Even small doses may cause noticeable dizziness

Answer: B.) The child will have to adhere to good tooth brushing Rationale: A side effect of phenytoin sodium is gingival hyperplasia. Good tooth brushing helps prevent inflammation under the hypertrophied tissue. Dizziness and tingling and numbness of the fingers are not side effects of this drug. Television watching will not elicit a seizure in a child with a known seizure disorder. A seizure occurs as an electrical interference in the brain.

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? A.) "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." B.) "I need to set an alarm to wake up and check his temperature during the night when he is sick." C.) "I hate to think that I will need to be worried about my child having seizures for the rest of his life." D.) "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."

Answer: C.) "I hate to think that I will need to be worried about my child having seizures for the rest of his life." Rationale: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? A.) "I will give the medication to him when I first wake him up in the morning." B.) "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." C.) "I need to watch for any new bruises or bleeding and let my health care provider know about it." D.) "I'm glad to know he will only need this medication for a short time to stop his seizures."

Answer: C.) "I need to watch for any new bruises or bleeding and let my health care provider know about it."

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain? A.) cerebral angiography B.) lumbar puncture C.) video electroencephalogram D.) computed tomography

Answer: C.) video electroencephalogram

Antibiotic therapy to treat meningitis should be instituted immediately after which event? A.) Admission to the nursing unit B.) Initiation of IV therapy C.) Identification of the causative organism D.) Collection of cerebrospinal fluid (CSF) and blood for culture

Answer: D.) Collection of cerebrospinal fluid (CSF) and blood for culture

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? A.) "Watch for changes in his behavior or eating patterns." B.) "Call the doctor if he gets a headache." C.) "Always keep his head raised 30 degrees." D.) "Limit the amount of television he watches."

Answer: A.) "Watch for changes in his behavior or eating patterns." Rationale; Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? A.) Dramatic increase in head circumference B.) Pupil of one eye dilated and reactive C.) Vertical nystagmus D.) Posterior fontanel (fontanelle) is closed

Answer: A.) Dramatic increase in head circumference Rationale: A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain. Only one pupil that is dilated and reactive is a sign of an intracranial mass. Vertical nystagmus indicates brain stem dysfunction. A closed posterior fontanel (fontanelle) would be frequently seen by this age.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? A.) Institute droplet precautions in addition to standard precautions. B.) Encourage the mother to hold and comfort the infant. C.) Educate the family about preventing bacterial meningitis. D.) Palpate the child's fontanels (fontanelles).

Answer: A.) Institute droplet precautions in addition to standard precautions.

A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use? A.) Place a cap or similar covering on the newborn's head. B.) Monitor for increased intracranial pressure (ICP). C.) Refer the family to an agency to assist with long-term care. D.) Closely monitor neurologic status.

Answer: A.) Place a cap or similar covering on the newborn's head. Rationale; Using a newborn cap can help parents deal with the malformed appearance of their child so they may hold and bond with the baby. Anencephaly is incompatible with life. The newborn is missing brain hemispheres, a skull, and/or scalp. There is no forebrain or cerebrum. Monitoring for increased intracranial pressure (ICP) or neurologic status are not necessary interventions.

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? A.) Report the findings to the pediatric health care provider. B.) Reassess the head circumference in 24 hours. C.) Document that the infant has microcephaly. D.) Tell the parent the infant's brain is underdeveloped.

Answer: A.) Report the findings to the pediatric health care provider.

The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session? A.) Tell me your concerns about your child's shunt. B.) Call the doctor if she gets a persistent headache. C.) Her autoregulation mechanism to absorb spinal fluid has failed. D.) Always keep her head raised 30º.

Answer: A.) Tell me your concerns about your child's shunt. Rationale; Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures? A.) Understanding the side effects of medications B.) Treating the child as though she did not have epilepsy C.) Placing the child on her side on the floor D.) Instructing her teacher how to respond to a seizure

Answer: A.) Understanding the side effects of medications Rationale: The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control.

The nurse is preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child? A.) Use a doll with electrodes attached to the head. B.) Show the child a video of the procedure. C.) Tell the child he or she can take a nap during the procedure. D.) Assure the child the procedure will not hurt.

Answer: A.) Use a doll with electrodes attached to the head. Rationale: An electroencephalogram (EEG) is a test to measure the electrical activity of the brain. It is conducted by attached electrodes over sections of the head and obtains an electrical reading via a monitor. There is no pain involved in the procedure, but the child must lie still. The best way for the nurse to explain the procedure to the child is via a doll with attached electrodes that the child can play with, feel, and manipulate. This helps to reduce the child's anxiety and aids in cooperation. Videos can help with the education process but they do not allow for interaction and physical touching. The child can take a nap during the procedure but this does not prepare the child for the procedure. Assuring the child that the procedure will not hurt is not the best way to prepare the child.

A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure? A.) semi-Fowler position with a parent at the bedside B.) supine on a parent's lap C.) prone on the bed with a parent or caregiver on either side of the bed D.) high-Fowler position while sitting on the parent's lap

Answer: A.) semi-Fowler position with a parent at the bedside Rationale: Proper positioning for an infant after a ventricular tap is to place the child in a semi-Fowler position to prevent additional drainage from the puncture site. Allow the parents or caregivers to comfort the child. Placing the child in the prone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure.

The nurse is collecting data from the caregivers of a child admitted with seizures. Which statement indicates the child most likely had an absence seizure? A.) "His arms had jerking movements in his legs and face." B.) "He was just staring into space and was totally unaware." C.) "He kept smacking his lips and rubbing his hands." D.) "He usually is very coordinated, but he couldn't even walk without falling."

Answer: B.) "He was just staring into space and was totally unaware."

The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority? A.) Risk for delayed development B.) Risk for injury C.) Risk for ineffective tissue perfusion: cerebral D.) Risk for self-care deficit: bathing and dressing

Answer: B.) Risk for injury

The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is: A.) maintaining effective cerebral perfusion. B.) ensuring the parents know how to properly give antibiotics. C.) establishing seizure precautions for the child. D.) encouraging development of motor skills.

Answer: B.) ensuring the parents know how to properly give antibiotics.

The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse? A.) "You probably don't have anything to worry about. It is common for toddlers to fall." B.) "I understand your concern, but toddlers fall and hit their heads a lot since they are not very coordinated yet." C.) "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." D.) "Most mothers are concerned because their toddlers fall a lot. As long as your child seems to be developmentally normal it shouldn't be a concern."

Answer: C.) "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Rationale: The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? A.) "I have ibuprofen available in case it's needed." B.) "My child will likely outgrow these seizures by age 5." C.) "I always keep phenobarbital with me in case of a fever." D.) "The most likely time for a seizure is when the fever is rising."

Answer: C.) "I always keep phenobarbital with me in case of a fever."

Gabapentin has been prescribed for a pediatric client. Which statement by the client indicates an understanding of teaching related to the medication? A.) "This medication can be sprinkled on my food." B.) "This medication should be taken in the evening before I go to bed." C.) "I can't take this medication within 2 hours of taking my antacid medication." D.) "This medication will make me extremely hungry."

Answer: C.) "I can't take this medication within 2 hours of taking my antacid medication."

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? A.) Take vital signs every 4 hours B.) Monitor temperature every 4 hours C.) Decrease environmental stimulation D.) Encourage the parents to hold the child

Answer: C.) Decrease environmental stimulation Rationale: 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. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position? A.) Lying prone, with the neck flexed B.) Sitting up, with the back straight C.) Lying on one side, with the back curved D.) Lying prone, with the feet higher than the head

Answer: C.) Lying on one side, with the back curved

The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns? A.) VI B.) VII C.) VIII D.) IX

Answer: D.) IX Rationale: Cranial nerve IX (glossopharyngeal) would be assessed to test the swallowing and gag reflex. Cranial nerve VIII is the acoustic nerve which is involved in hearing. Cranial nerve VII is the facial nerve and controls facial muscles, salivation and taste. Cranial nerve VI is the abducens nerve and controls and is related to eye movements.

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question? A.) Place in an indwelling urinary catheter. B.) Administer dexamethasone, dosage determined by the pharmacist. C.) Administer mannitol IV, dosage determined by the pharmacist. D.) Initiate an IV of 0.9% NS to run at 250 ml/hr.

Answer: D.) Initiate an IV of 0.9% NS to run at 250 ml/hr. Rationale: Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.

During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents? A.) Plasma levels of the drug will be monitored on a daily basis B.) Drug dosage will be adjusted depending on the frequency of seizure activity C.) The drug must be discontinued immediately if even the slightest problem occurs D.) The child shouldn't participate in activities that could be hazardous if a seizure occurs

Answer: D.) The child shouldn't participate in activities that could be hazardous if a seizure occurs

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? A.) tachypnea B.) hyperthermia C.) poor handwriting D.) hypertension

Answer: D.) hypertension Rationale: Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP.