Pediatrics Ch. 27

A child is admitted to the pediatric intensive care unit for a submersion injury. The child's parents express guilt over the injury to the nurse. What is the most appropriate response by the nurse?

"Tell me more about your feelings."

A child has been brought to the emergency room following a car accident. The nurse observes that the patient is opening the eyes only in response to pain, is in abnormal flexion motor posture, and is uttering incomprehensive words. What is the total Glasgow Coma Scale (GCS) of the patient? Record your answer using a whole number.

7

The nurse is assessing the level of consciousness of a patient who has received a high dose of morphine. How can the nurse reverse the effects of morphine in this patient?

Administer naloxone

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is the priority of nursing care?

Administering antibiotic therapy as soon as it is ordered

What should the nurse include in the plan of care for a patient when administering intravenous phenytoin?

Administering phenytoin with normal saline solution

Six months ago a 5-year-old child started having seizures that result in a brief loss of consciousness and slight alteration in muscle tone. They sometimes go unrecognized because of the minimal change in the child's behavior. How is this seizure classified?

Absence

What is the most common type of head injury in children?

Acceleration-deceleration injuries

The nurse notes cerebrospinal fluid (CSF) leakage in a patient who has sustained a head injury. What medication is likely to benefit the patient?

Antibiotics

The temperature of an unconscious adolescent is 105° F (40.5° C). What is the priority nursing intervention?

Apply a hypothermia blanket

What nursing intervention is used to prevent increased intracranial pressure in an unconscious child?

Avoiding activities that result in pain or crying

The postoperative care of a preschool child who has had a brain tumor removed should include which nursing action?

Close supervision of the child while he or she is regaining consciousness

The nurse is providing postoperative care for a child with. hydrocephalus. Which assessment does the nurse recognize as a sign of infection of the cerebrospinal fluid?

Elevated temperature

What neurologic diagnostic procedure is used to identify shifts in midline structures from their normal positions resulting from intracranial lesions?

Encephalography

Which organism causes aseptic meningitis?

Cytomegalovirus

A nurse caring for a child with brain dysfunction notes that the child is exhibiting rigid flexion with the arms held tightly to the body and the legs extended and internally rotated. What posturing is this child demonstrating?

Decorticate

Which finding does the nurse note that is seen with severe dysfunction of the cerebral cortex or lesions to cortiocospinal tracts above the brainstem?

Decorticate posturing

The nurse is reviewing the cerebrospinal fluid (CSF) report of a patient. What finding in the CSF report is suggestive of bacterial meningitis? Select all that apply.

Decreased glucose Cloudy appearance Increased neutrophils

What is a sign of increased intracranial pressure in infants?

Irritability

What is the most appropriate nursing intervention in the care of a child experiencing a seizure?

Describing and documenting the seizure activity observed

What clinical manifestations suggest increased intracranial pressure in an infant? Select all that apply.

Drowsiness Poor feeding Tense, bulging fontanel Irritability and restlessness

The nurse assesses a child for the doll's-head maneuver. What does the absence of the doll's-head maneuver indicate?

Dysfunction of the brainstem

The nurse is caring for a 2-year-old child who is unconscious but in stable condition after a car accident. The child's parents are staying at the bedside most of the time. What is an appropriate nursing intervention?

Encouraging the parents to hold, talk to, and sing to the child as they usually would

A 3-year-old child has just undergone shunt revision for hydrocephaly. About which signs of shunt malformation should the nurse teach the parents? Select all that apply.

Fever Vomiting Personality change

The nurse is caring for a patient with seizures who was prescribed phenytoin IV. The primary health care provider has replaced this drug with fosphenytoin. What is the most likely reason for replacing phenytoin? Select all that apply.

Fosphenytoin is suitable with glucose solutions. Fosphenytoin can be administered at a higher push rate. Fosphenytoin can be given by the intramuscular route.

A nurse works in a pediatric clinic. Which routine vaccines does the nurse recommend for reducing the incidence of bacterial meningitis during infancy? Select all that apply.

H. influenza vaccine Pneumococcal vaccine

The nurse is reviewing the medical reports of a patient diagnosed with papilledema. What funduscopic findings are likely in the patient? Select all that apply.

Hemorrhage Optic disc swelling Tortuosity of vessels

A health care provider orders a positron emission tomography (PET) scan on a patient following the removal of a tumor in the skull. The patient asks the nurse about the importance of this scan. What does the nurse tell the patient? Select all that apply.

It measures the blood flow to the brain. It detects biochemical changes in tissue. It detects the metabolic activity in the brain.

The nurse is planning care for a school-age child with bacterial meningitis. Which nursing intervention should be included?

Keeping environmental stimuli to a minimum

What is the most serious complication of placement of a ventriculoperitoneal shunt used to correct hydrocephalus?

Infection

A child is administered propofol for sedation during a diagnostic test. For what effect of prolonged use of propofol is the nurse watchful?

Metabolic acidosis

The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration-deceleration head injuries because of which developmental issue?

Musculoskeletal support of the head is insufficient

The nurse is performing a neurologic assessment of a 2-month- old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest what?

Neurologic health

The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest what?

Neurologic health

What is the priority nursing action when the nurse notices increased irritability, drowsiness, and restlessness in an infant who has just undergone surgery for a brain tumor?

Notifying the health care provider immediately

The nurse is caring for a toddler who has undergone surgery for a brain tumor. During an assessment the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. What is the most appropriate nursing action?

Notifying the practitioner immediately

The nurse is caring for a young child who has sustained a head injury. During assessment the nurse notes that the child is arousable with stimulation. What level of consciousness does this finding suggest?

Obtundation

What would the nurse expect to find when assessing a child with cerebral dysfunction related to barbiturate poisoning?

Pinpoint pupils

The nurse is assessing the cerebrospinal fluid (CSF) analysis for a child. Which laboratory finding helps the nurse to distinguish bacterial meningitis from viral meningitis?

Positive Gram stain

The nurse is caring for an 8-year-old boy who has sustained a basilar skull fracture. He is becoming increasingly drowsy and now has a fever. With what complication is this response associated?

Posttraumatic meningitis

What is the priority nursing action when a nurse caring for a young child with a head injury notes that the pupils have suddenly become fixed and dilated?

Preparations for dealing with a neurologic emergency

The nurse suspects nuchal rigidity in a patient. To which findings is the nurse alert during the assessment? Select all that apply.

Presence of Kernig sign Inability to place the chin on chest

The nurse is examining a child who had a head injury. What assessment finding does the nurse recognize as a comminuted fracture?

Presence of multiple associated linear fractures

A child with status epilepticus is not responding to lorazepam and fosphenytoin. Which medications does the nurse expect to be added in the treatment plan? Select all that apply.

Propofol Midazolam Phenobarbital

The nurse is performing a neurologic assessment of a child whose level of consciousness has been variable since she sustained a cervical neck injury 12 hours What is the ago. appropriate assessment for this child?

Reactivity of pupils

The nurse is caring for a comatose child with multiple injuries. The nurse should recognize which fact about pain?

Requires astute nursing assessment and management

The parent of a 4-year-old child who experienced a single seizure at home asks the nurse what caused the seizure. What is the best response by the nurse?

Seizures are a symptom of an underlying disorder.

What is a clinical manifestation of increased intracranial pressure in infants?

Shrill, high-pitched cry

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. Which information is an important part of the discussion with the parents?

Shunt malfunction or infection requires immediate treatment

A child is having a seizure that has lasted 35 young minutes. There is a loss of consciousness. The nurse, drawing on knowledge of seizures, recognizes this as which disorder?

Status epilepticus

A patient who has sustained a head injury exhibits rhinorrhea. What immediate nursing intervention is appropriate for the patient?

Test the discharge for presence of glucose.

A mother calls the clinic to tell the nurse that her young child hit her head when she tripped and fell down three stairs. What sign of head injury, requiring immediate medical attention, is of greatest concern to the nurse?

The child becomes confused.

The term "lethargic" is used to describe a postoperative child's level of consciousness (LOC). What does this term imply? Select all that apply.

The child has sluggish speech. There is limited spontaneous movement. The child is drowsy and falls asleep quickly.

Which manifestation indicates aversive seizure in a child with partial seizure?

The child may have loss of consciousness.

What is the purpose of a lumbar puncture (LP)?

To analyze cerebrospinal fluid

A patient who had an alarming rise in intracranial pressure was administered barbiturates to induce coma. What is the purpose of inducing a coma for increased intracranial pressure? Select all that apply.

To reduce the intracranial pressure of the brain To protect the brain from the effects of low brain perfusion

What is a priority nursing consideration for the parents of a child with simple febrile seizures?

To seek medication attention if the seizure lasts more than 5 minutes

The nurse is planning to perform a caloric test on a patient. What are the correct methodologies that the nurse implements? Select all that apply.

Using 10 mL of ice water for irrigation Elevating head of bed to 30 degrees Irrigating the auditory canal for 20 seconds

The nurse is preparing a care plan for a patient who has developed diabetes insipidus (DI) following a head trauma. What treatment is included in the care plan?

Vasopressin

What are some specific signs of bacterial meningitis in neonates? Select all that apply.

Weak cry Poor tone Full, tense, bulging fontanel