PEDS NEURO SHERPATH

A parent asks the nurse how her child contracted autism spectrum disorder (ASD). Which is the nurse's best response? "Your child might have contracted ASD from chemical exposure as an infant." "ASD has many different proposed causes, so pinpointing the exact cause is likely impossible." "ASD is linked to genetics, so your child contracted ASD because it must run in your family." "ASD is not an illness, so it was not contracted from anyone. It develops over time for a variety of reasons."

"ASD has many different proposed causes, so pinpointing the exact cause is likely impossible." This is a correct statement that gives the parent accurate information; therefore, this is the nurse's best response.

A parent tells the nurse, "My daughter has been diagnosed with autism spectrum disorder (ASD), but she does not act anything like my niece who also has ASD. I don't understand how they can behave so differently." How should the nurse respond? "Your daughter may have a different form of ASD and therefore does not have the same symptoms." "The behaviors associated with ASD are usually consistent, so it may be that one of the girls has been misdiagnosed." "Your daughter must have a more severe form of ASD than your niece because most children with ASD act the same." "ASD is a spectrum of disorders with a wide range of manifestations and severity. Each child is unique, and no two children have the exact same symptoms."

"ASD is a spectrum of disorders with a wide range of manifestations and severity. Each child is unique, and no two children have the exact same symptoms." The nurse should explain that children will behave differently because ASD is a spectrum of disorders with different levels of severity. Symptoms vary greatly.

A child was recently prescribed phenytoin (Dilantin) for generalized seizures. Which findings cause the nurse to hold the dose and notify the health care provider? Anorexia Hypertrophic gums An elevated blood level Decreased blood pressure

An elevated blood level Dilantin must stay within a therapeutic level. If the serum level is elevated, the drug must be held or decreased in dose to prevent adverse reactions.

Match the cerebral palsy (CP) symptoms to the nursing intervention for the hospitalized pediatric patient. Tense muscles Visible tremors Loss of coordination Involuntary movement

Tense muscles Continue to monitor Visible tremors Provide guided imagery Loss of coordination Place bed in lowest position Involuntary movement Administer a benzodiazepine

The nurse is treating a newborn and the mother confides in the nurse that she drank alcohol socially throughout the pregnancy. The nurse should be careful to assess for which specific signs and symptoms? Select all that apply. Hypotonia Excessive sleepiness Weak suck with bottle feeds Head circumference below target for age Incessant crying despite soothing attempts

Hypotonia Hypotonia is correlated with FASD, which can result from maternal alcohol ingestion during pregnancy. Weak suck with bottle feeds Feeding problems are common in an infant with FASD, which can occur as a result of maternal alcohol ingestion during pregnancy. Head circumference below target for age Microcephaly is a common manifestation of FASD. Incessant crying despite soothing attempts Difficulty in soothing the infant could be an indication of FASD, which correlates with the mother's history of alcohol ingestion throughout pregnancy.

The nurse is receiving a pediatric patient in shock who was just involved in an accident and has lost a large amount of blood. The patient should be assessed for which type of shock first? Septic shock Distributive shock Cardiogenic shock Hypovolemic shock

Hypovolemic shock This patient should be first assessed for hypovolemic shock because this is characterized by an overall decrease in circulating blood or fluid volume.

The nurse is caring for patients in the pediatric headache clinic. Which patients will the nurse assess urgently? Select all that apply. Patient reporting difficulty speaking clearly to the headache clinic receptionist. Patient diagnosed with tension headaches reporting a headache lasting three weeks. Patient diagnosed with migraine headaches reporting abdominal pain, nausea, and vomiting. Patient diagnosed with an arteriovenous malformation (AVM) reporting a brief vision loss this morning. Patient reporting pain in the neck muscles impairing movement of the head from side to side but no nuchal rigidity.

Patient reporting difficulty speaking clearly to the headache clinic receptionist. Difficulty speaking is an uncommon headache symptom and may indicate a stroke or seizure. This patient will need to be assessed urgently due to the severity of symptoms. Patient diagnosed with an arteriovenous malformation (AVM) reporting a brief vision loss this morning. An AVM causes vascular headaches and complications of the AVM include symptoms consistent with bleeding in the brain such as weakness, vision loss, difficulty speaking, and unsteadiness. This patient will need to be assessed urgently by the nurse.

A 5-year-old child presents to the emergency department and begins to exhibit neurological side effects after ingesting an unknown poison at home. Which action should the nurse take after assessing that the airway is stable? Gastric lavage Administer naloxone Initiate IV fluid resuscitation Prepare for seizure precautions

Prepare for seizure precautions Patients with neurological or metabolic side effects are prone to seizures and precautions are necessary.

A child accidentally aspirated lighter fluid after playing with a lighter. Which roles does the nurse have in managing this patient? Select all that apply. The nurse will administer IV fluids. The nurse will utilize measures to prevent emesis. The nurse will administer oxygen and support ventilation. The nurse will administer chelators and anti-coagulant medications. The nurse will monitor vital signs and observe for signs of CNS depression.

The nurse will administer IV fluids. Administration of IV fluids supports circulatory function and prevents dehydration. The nurse will utilize measures to prevent emesis. Prevention of emesis will decrease the likelihood of additional aspiration of the low-density hydrocarbons. The nurse will administer oxygen and support ventilation. Administration of oxygen and support of ventilation are essential due to potential damage to the lungs.

The pediatric patient with a moderate brain injury demonstrates decreased ability to walk normally. Which finding indicates to the nurse a severe and progressive change in intracranial pressure (ICP)? Patient often lies in the fetal position. Upper extremities are drawn in toward chest. Feet exhibit decreased sensation when touched. Patient is unable to eat without experiencing GI upset.

Upper extremities are drawn in toward chest. Flexion and decorticate posturing indicate increased ICP.

The nurse cares for a patient receiving carbamazepine for seizures. Which statement by the child's parents requires immediate follow-up? "We are getting notes from the teacher about daytime sleepiness." "The practitioner at the clinic put him on an antibiotic for bronchitis." "The after-school program director says my child became angry suddenly." "We hate having to bring him in for blood work. It interferes with school."

"The practitioner at the clinic put him on an antibiotic for bronchitis." The nurse monitoring carbamazepine levels in the patient needs to ensure the new antibiotic is not erythromycin. Erythromycin will increase Tegretol levels, thus the parents must be asked about this immediately.

A mother calls the nurse and reports that her child has ingested a toxin. Which statement by the nurse explains why inducing vomiting is contraindicated? "Vomiting can increase the toxicity of the agent." "Vomiting may cause additional damage to the esophagus." "Vomiting can increase the absorption in the oral mucosa." "Vomiting may cause bowel rupture due to the increase in pressure."

"Vomiting may cause additional damage to the esophagus." As the ingested agents makes a second trip through the esophagus, it may cause additional damage or burning of the tissue.

The nurse is caring for a child who has been struck by a car. The nurse notes a patent airway, labored breathing, and active bleeding from an open leg fracture. Which assessment should the nurse perform next? Neurologic assessment Auscultate bowel sounds Assess the cervical spine Head to toe skin assessment

Neurologic assessment After completing the primary survey, including the airway, breathing, and circulation, the nurse should assess the patient's neurologic status.

The parent of a child with intellectual disability states, "I thought she would be doing more by now. They said her condition is only mild. I think she is just difficult on purpose and doesn't try." What should be the nurse's priority assessment question? "What are your expectations for your child?" "How are you coping with your child's lack of progress?" "What is your description of a mild intellectual disability?" "Have you punished your child because of these behaviors?"

"What are your expectations for your child?" The nurse should determine whether the expectations that the parent has are realistic and appropriate for the functional level of a child with mild intellectual disability.

A nursing student asks the instructor, "How can I tell whether someone has autism spectrum disorder (ASD) or intellectual disability?" How should the instructor respond? Children with ASD have more social functioning and often initiate social contact. ASD is a type of intellectual disability so the signs and symptoms are very similar. Seizures are common in children with intellectual disability and rarely happen in children with ASD. Children with intellectual disability usually imitate others, but children with ASD lack imitative skills.

Children with intellectual disability usually imitate others, but children with ASD lack imitative skills. A child with ASD often has abnormal communication and lacks imitative skills, while a child with intellectual disability may have limited language but be able to imitate others and use gestures.

The nurse is performing a neurologic assessment on a patient with cerebral palsy (CP). The nurse notes bilateral arm spasticity and the child is unable to grip the nurse's fingers. What action should the nurse perform? Notify health care provider Assess child's gait for ataxia Complete neurologic assessment Inquire about learning difficulties

Complete neurologic assessment Spasticity is an expected finding in a child with cerebral palsy. The nurse should continue the assessment.

An eleven-year-old patient with a history of allergic rhinitis was brought to the emergency department with headache and nuchal rigidity. In addition to a lumbar puncture, for what other testing does the nurse prepare the patient? Lateral chest x-ray Urine culture for Escherichia coli Rectal swab for group B streptococci (GBS) Computed tomography (CT) scan of sinus cavities

Computed tomography (CT) scan of sinus cavities Sinusitis is often a precipitating infection in meningitis in children because olfactory nerves provide unimpeded access into central nervous system (CNS).

A child is experiencing status epilepticus. The nurse can expect to monitor which possible metabolic changes? Select all that apply. Hypoxia Hypothermia Increased glycogen stores Increased lactic acid levels Decreased blood glucose levels

Hypoxia Because of the increase in muscle contraction, oxygen is consumed in large amounts leaving the patient susceptible to hypoxia. This will therefore need to be monitored by the nurse. Increased lactic acid levels The nurse can expect to monitor for possible increases in lactic acid levels in a patient experiencing status epilepticus. Decreased blood glucose levels A decrease in blood glucose levels can be expected in a patient with status epilepticus, and therefore this is something the nurse can expect to see.

The nurse is caring for a 10-year-old child in hypovolemic shock after a liver laceration from a bicycle injury. The nurse notes delayed capillary refill, lethargy, BP 74/48, and SpO2 88%. Which orders are most important for the nurse to complete first? Select all that apply. Administer IV antibiotics Give IV normal saline bolus Provide oxygen via nasal cannula Refer parents to hospital chaplain Perform range-of-motion exercises

Give IV normal saline bolus The nurse should administer IV fluid to replace fluid volume loss. Provide oxygen via nasal cannula The nurse should provide supplemental oxygen to help maintain the patient's tissue perfusion. Refer parents to hospital chaplain Referring patients to the hospital chaplain can help provide the emotional support necessary to cope with the child's condition.

A nurse is teaching a group of parents about assessing the ABCDE's in children with toxic exposure. Which two assessment components should the nurse discuss in addition to the traditional ABC's of CPR? Select all that apply. Diuresis Disability Exposure Exudates Diaphoresis

Disability Seizure precautions should be implemented in poison exposures with neurological or metabolic side effects. The child's mental status should be assessed frequently. Exposure Treating toxic exposures and ingestions may include removal of dermal and ocular toxins, dilution of the toxin, administration of activated charcoal, and administration of an antidote. Gastric lavages are no longer recommended.

A 2-year-old child comes to the emergency department with a substantial acetaminophen overdose. Which drug-specific medication should the nurse anticipate administering to this patient? Naloxone N-acetylcysteine Activated charcoal Diluted oil of wintergreen

N-acetylcysteine N-acetylcysteine is an antidote used for significant acetaminophen ingestion.

The nurse is caring for a patient with suspected meningitis. Which interventions should need to be performed in caring for this patient? Select all that apply. Elevate head of bed to 30 degrees. Begin intravenous (IV) normal saline infusion. Administer broad-spectrum antibiotic as prescribed. Draw blood sample for a white blood cell (WBC) count. Discuss with the patient's family the importance of vaccination.

Elevate head of bed to 30 degrees. Although simple, this can be an important part of caring for a patient with suspected meningitis. It can help to control an increased intracranial pressure (ICP). Begin intravenous (IV) normal saline infusion. This can be started after antibiotic infuses to prevent dehydration and ensure tissue perfusion. Administer broad-spectrum antibiotic as prescribed. Early antibiotic therapy reduces morbidity and mortality. Draw blood sample for a white blood cell (WBC) count. This is important information and therefore the blood sample can be obtained after antibiotic is

The nurse is caring for a child who is obtunded after being struck in the head by a baseball during a game. Which artificial airway should be used to maintain airway patency? Bag, valve, mask Oropharyngeal airway Endotracheal intubation Nasopharyngeal airway

Endotracheal intubation Endotracheal intubation is a single type of artificial airway that would suffice for an unconscious child or a child who has altered mental status.

After the patient's respiratory status is stable, which action is appropriate for the nurse to perform on an unresponsive, nonverbal trauma patient? Ensure Foley catheter is patent Ensure chest tube placement secure Maintain IV fluids at maintenance therapy Ensure cervical spine protection until definitive diagnosis is made

Ensure cervical spine protection until definitive diagnosis is made All unresponsive and nonverbal trauma patients should have cervical spine protection until definitive diagnosis can be made.

Analysis of cerebrospinal fluid (CSF) obtained from lumbar puncture shows bacterial meningitis. The nurse performs what action for the nine-year-old pediatric patient? Ensure patient is receiving antibiotics. Place patient on airborne precautions. Administer the meningococcal vaccine. Provide family with home care instructions.

Ensure patient is receiving antibiotics. Patient should have been on antibiotics shortly after symptoms began, but the nurse must ensure that antibiotics are being administered as ordered based on the results of CSF findings. A delay in antibiotic administration can be fatal.

The neonatal patient exhibits odd behavior such as tongue thrusting. Which additional findings cause the nurse concern? Select all that apply. Eye deviation horizontally Apnea episode greater than 20 seconds Drooling saliva continuously Arm extension when startled Toe hyperflexes when foot is stroked

Eye deviation horizontally Eyes should never deviate. This is a sign of a neonatal seizure. Apnea episode greater than 20 seconds An episode of apnea in the neonate lasting 20 seconds or longer should be reported to the health care provider. Occasional periods of apnea lasting less than 20 seconds are considered a normal finding in the neonate. Drooling saliva continuously Drooling is not an expected behavior in the neonate. Drooling doesn't usually begin until after the second month. This is a sign of a seizure.

While assessing an infant with fetal alcohol spectrum disorder (FASD), the nurse does not see many of the characteristics that she expected to see. What is the explanation for this finding? FASD is a spectrum of disorders, so a variety of signs and symptoms is possible. The child is misdiagnosed because the lack of specific characteristics means that the child does not have FASD. Children with FASD have very specific facial characteristics, so the nurse may not be recognizing the signs of the disorder. The nurse will need to spend more time with the child to determine whether the characteristics she expected to see are present.

FASD is a spectrum of disorders, so a variety of signs and symptoms is possible. Children will not all present the same way. Some children will have mild forms, and others will have more severe forms of the disorder.

A child was recently diagnosed with adenitis. The nurse monitors for what type of seizure in this patient? Febrile Unknown Myoclonic Generalized

Febrile Febrile seizures are associated with adenitis and usually occur during a rise in body temperature rather than after a prolonged elevation in temperature.

The nurse is caring for a child who was propelled to the ground when struck by a car. The child struck the occipital region of the skull on the ground. Which other area of the head should the nurse assess for injury? Frontal Parietal Temporal Basilar

Frontal Waddell's triad says that patients sustain injuries to the contralateral side of the head. The frontal region is contralateral to the occipital region.

The nurse is caring for an infant with vomiting and diarrhea for the past week. The nurse notes a depressed anterior fontanel, decreased urine output, and lack of tears. Which prescription should the nurse complete first? Initiate oxygen Give an IV fluid bolus Administer oral antiemetic Apply barrier cream to the buttocks

Give an IV fluid bolus The patient's symptoms are indicative of hypovolemic shock. IV fluid resuscitation is the most important action.

The thirteen-month-old child had prenatal microsurgery for a myelomeningocele. Which assessment finding indicates the surgery was not completely successful? Increased head circumference Child is unable to walk or stand up A decreased ability to pick up objects Child is only saying sounds like "bah bah"

Increased head circumference Increased head circumference can indicate hydrocephalus which results from the myelomeningocele complications, meaning the surgery was not completely successful in repairing the neural tube defect.

The nurse assesses the patient's breathing patterns and laboratory values. Which findings in the pediatric patient with a head injury indicate a possible brainstem herniation? Select all that apply. Elevated arterial blood gas values. Decreased arterial blood gas values. Normal arterial blood gas (ABG) values. Breathing pattern with periods of increased rate and depth followed by periods of decreased rate and depth. Breathing pattern with long periods of decreased rate and shallow depth followed by short periods of apnea.

Normal arterial blood gas (ABG) values. A Cheyne-Stokes breathing pattern will be associated with normal arterial blood gas values which can help to differentiate this from other breathing patterns by patients experiencing respiratory distress. Breathing pattern with periods of increased rate and depth followed by periods of decreased rate and depth. Cheyne-Stokes is characterized by periods of increased rate and depth followed by periods of decreased rate and depth of breath, a pattern that will help differentiate from other breathing patterns and indicates imminent death as expected with a brainstem herniation.

A positive outcome for a child with multiple traumas depends mainly on which two factors? Rescue breathing and cardiopulmonary resuscitation (CPR) Family support and age of child Rapid assessment and intervention Administering antibiotics and hemodynamic monitoring

Rapid assessment and intervention A positive outcome for a child who has sustained multiple trauma depends on rapid assessment and intervention, which begin at the scene of the accident and continue through the trauma center emergency department, the critical care and acute care units, and the rehabilitation phase.

Which patients does the nurse monitor for increased status epilepticus risk? Select all that apply. The child who has meningitis The toddler exposed to lead paint The child with a sodium level of 112 mEq/L The child who fell from a second-story window The child with a fever of 104 degrees Fahrenheit

The child who has meningitis A child with meningitis has the potential to enter status epilepticus, and therefore this will need to be a priority in caring for the patient. The toddler exposed to lead paint A child who may have ingested a poison, such as lead paint, has the potential to enter status epilepticus. The child with a sodium level of 112 mEq/L A child with hyponatremia has the potential to enter status epilepticus, and therefore electrolytes will need to be monitored closely by the nurse. The child who fell from a second-story window A child with head trauma has the potential to enter status epilepticus, and therefore this should be a part of the care plan of the patient.

A mother brings in her 4-year-old child to the health care provider, stating that the child has marked constipation and describing the child as "sluggish." Which patient's social history is most significant? The family has recently moved into a historic house. The child has recently attended an outdoor day camp. The family has just returned from a vacation to the ocean. The child has recently started attending preschool at a newly built facility.

The family has recently moved into a historic house. A historic home may have lead paint and leaded glass which can lead to toxicity causing constipation. Exposure to lead can cause the symptoms described in this scenario.

The nurse is trying to feed a newborn with fetal alcohol spectrum disorder (FASD). The nurse is holding the baby in different positions to promote feeding, but the newborn is still spitting up the formula. What should be the nurse's next action? The nurse should try only feeding the infant small quantities at a time. Weigh the infant daily to determine whether he or she is gaining or losing weight. The nurse should decrease the frequency of feedings to allow the baby to digest each feeding. The nurse should document the intake to determine whether enough nutrition is being given.

The nurse should try only feeding the infant small quantities at a time. Decreasing the amount of each feeding can help the infant with FASD tolerate more food, which is important.

The parent of a child with autism spectrum disorder (ASD) states, "I knew that I should not have allowed her to get her vaccinations. If I had listened to my sister, this never would have happened." How can the nurse appropriately respond to this statement? "Although many people think that vaccinations are linked to ASD, the research has not shown that there is a correlation between the development of ASD and receiving vaccines." "The link between the development of ASD and receiving vaccinations has been shown to be very weak and does not outweigh the risks of not receiving recommended immunizations. "Some children do develop ASD from receiving vaccinations, but very few kids are sensitive to the thimerosal in the vaccine. It is unfortunate that your child developed ASD from the vaccine." "There is no link between vaccinations and the development of ASD. If you read the research, you will find that there is not a correlation between vaccinations and ASD and that your sister was incorrect."

"Although many people think that vaccinations are linked to ASD, the research has not shown that there is a correlation between the development of ASD and receiving vaccines." The research does not show a correlation between ASD and vaccinations, so this is a true statement. The research that originally indicated this association was later determined to be fraudulant.

A fifteen-year-old child presents to the emergency department with a severe head trauma, including herniation of the brain into the spinal column. The child is non-responsive and intubated. How will the nurse most correctly explain to the parents what is happening? "While the hydrocephalus persists, your child will not be responsive to your voice or painful stimuli." "Eventually your child will be able to squeeze your hand and will gradually begin to respond to touch." "The injury is severe, but with surgery and extended medical care in, a complete recovery can be expected." "Because of the type of injury sustained, the brain will not be able to maintain respiratory effort without the ventilator."

"Because of the type of injury sustained, the brain will not be able to maintain respiratory effort without the ventilator." The brain stem is essential to respiratory and cardiac function. Once it is compressed into the spinal column it can no longer recover the ability to maintain those vital functions.

The student nurse states, "My sister was so worried that her baby might be born with an intellectual disability. She was born healthy. I am so excited that intellectual disability is not even possible anymore." How should the nurse respond to this statement? "Childhood conditions and environmental problems can cause intellectual disability. Let's talk about ways to prevent these from causing intellectual disability." "The risk of developing intellectual disability after birth is very rare. Unless the family lives below the poverty level, development should no longer be a problem." "It is a relief when a child is born healthy and is no longer at risk for the development of intellectual disability. This is important information to share with families." "Several childhood illnesses can cause intellectual disability, but as long as a child receives immunizations, there is no risk of developing intellectual disability after birth."

"Childhood conditions and environmental problems can cause intellectual disability. Let's talk about ways to prevent these from causing intellectual disability." The nurse needs to clarify that intellectual disability can still be diagnosed after birth and that there are ways to help prevent diseases and environmental problems from affecting children.

The nurse is assessing a 3-year-old child for an intellectual disability. What questions should the nurse ask the parent(s)? Select all that apply. "Is your child physically healthy?" "Does your child have a seizure disorder?" "Can your child understand simple directions?" "Is your child developing as you would expect?" "Is your child able to verbally communicate needs?"

"Does your child have a seizure disorder?" Seizure disorders often develop in children with intellectual disability, so the presence of a seizure disorder could indicate the presence of an intellectual disability along with other signs and symptoms. "Can your child understand simple directions?" A child with intellectual disability does not have age-appropriate cognitive skills. A 3-year-old child should be able to follow a simple direction, so the inability to do so indicates a potential problem. "Is your child developing as you would expect?" This question allows the parents to bring up any concerns about the child's development, which will help the nurse gather information. "Is your child able to verbally communicate needs?" Communication is a developmental milestone that is often delayed in a child with an intellectual disability.

Parents come to the clinic with their infant who was recently diagnosed with autism spectrum disorder (ASD). The parents state that they think their child is "just fine." What questions can the nurse ask to assess for signs of ASD? Select all that apply. "Does your infant look at you when you speak to him or her?" "Has your child received the recommended immunizations?" "Does your infant seem to do the same actions over and over again with toys?" "Has your child shown behaviors that indicate that he or she misses you when you are gone?" "If your child appears distressed, does he or she come to you and climb on your lap and look for comfort?"

"Does your infant look at you when you speak to him or her?" The child with ASD may not show interest in the parents and may not show the early signs of communication expected. "Does your infant seem to do the same actions over and over again with toys?" Children with ASD may not play with toys in a way that is expected; they may engage in repetitive actions with toys instead. "Has your child shown behaviors that indicate that he or she misses you when you are gone?" Children with ASD may not show signs of attachment to the caregiver and therefore the nurse should ask this type of question. "If your child appears distressed, does he or she come to you and climb on your lap and look for comfort?" Children with ASD often do not look for comfort or soothing from their parents.

An adolescent with moderate intellectual disability states, "I want to live on my own when I become an adult." What is the nurse's best response? "You should be able to live by yourself and care for yourself if you try very hard." "Let's talk about how we can work together to prepare you for more independence." "Some of the skills you have a hard time with may make it difficult for you to live on your own." "It's tough for you to express your needs, and this will make it impossible for you to live anywhere but a group home."

"Let's talk about how we can work together to prepare you for more independence." Supervision and support that can be provided in a group home is a viable option for someone with moderate intellectual disability.

During a well-child visit, a three-year-old patient being examined exhibits unsteady gait and poorly developed speech. The health care provider suspects cerebral palsy (CP). How should the nurse guide the parents? Select all that apply. "Ensure that your home is free of sharp edges to protect the child in case of falling while walking." "Administer pain medication whenever the child shows signs of pain such as grimacing or moaning." "While we get further testing arranged, keep notes regarding any unusual behaviors or actions." "The speech-language pathologist will work with you to evaluate reasons for the poorly developed speech." "The physical therapist will show you some exercises to improve coordination and strengthen the child's muscles."

"Ensure that your home is free of sharp edges to protect the child in case of falling while walking." A three-year-old child with suspected cerebral palsy would be expected to have unsteadiness when walking due to abnormal development of the motor system. "The speech-language pathologist will work with you to evaluate reasons for the poorly developed speech." A three-year-old child with suspected cerebral palsy would be expected to have speech difficulties due to abnormal central nervous system development. Speech development can also be related to cognitive issues, autism, and hearing loss. "The physical therapist will show you some exercises to improve coordination and strengthen the child's muscles." Physical therapy and occupational therapy will work with the child to further evaluate gait and develop a plan to prevent or reduce declining strength and coordination.

A child has recently been diagnosed with Guillain- Barré syndrome. Which patient statements require follow-up by the nurse? Select all that apply. "I had a nasty cold two weeks ago, but mom said it was not a big deal." "I had a red rash a while back with a fever. It only lasted about three days." "When I get well, I'm not shaking hands with anyone, not even the pastor!" "I haven't felt well for a few days and my toes are kind of numb feeling today." "I hate getting the flu-shot, but dad insisted this year since I've been sick so much."

"I had a nasty cold two weeks ago, but mom said it was not a big deal." Enterovirus causes cold and flu-type symptoms and is associated with the development of Guillain- Barré syndrome. The child needs teaching about hand-washing techniques to prevent respiratory illnesses. "I had a red rash a while back with a fever. It only lasted about three days." A rubella infection has been associated with Guillain-Barré syndrome. The nurse follows up as the health care team works to determine a cause that could be prevented in the future. Also, if "a while back" means more than a month or so, the health care provider can rule it out as a cause. "I hate getting the flu-shot, but dad insisted this year since I've been sick so much." The influenza vaccine has a demonstrated link to the onset of Guillain-Barré. If this is the suspected cause, the child needs to avoid the flu-vaccine in the future.

The 12-year-old patient with severe headaches is being discharged from the emergency department. Which statement by the patient indicates to the nurse the need for further teaching? Select all that apply. "I hear my friends use marijuana for stress relief. I will try that." "If ibuprofen doesn't work at first, I take another one in two hours." "Since chocolate seems to trigger my headaches, I will eat less of it." "In my diary, lack of sleep is a trigger. I am going to go to bed earlier." "Football and the Spanish club are too much. I think I will drop them both."

"I hear my friends use marijuana for stress relief. I will try that." Smoke can increase headache occurrence, therefore this statement would indicate a need for further teaching. Also the nurse will want to teach about illegal substance use. "If ibuprofen doesn't work at first, I take another one in two hours." Ibuprofen will cause bleeding and other injury if taken this way, therefore this statement indicates a need for further teaching. "Since chocolate seems to trigger my headaches, I will eat less of it." The child needs to avoid, not just decrease, any trigger that has been identified. This statement would therefore indicate a need for more education on dietary habits and their connection to headaches. "Football and the Spanish club are too much. I think I will drop them both." Encourage the child to consider ways to reduce fatigue and stress without increasing isolation by dropping both activities at the same time. Perhaps there is a way to reduce involvement with one of the activities or maybe consider dropping one to evaluate headache response.

A nurse is providing care for a thirteen-year-old patient with a history of headaches. Which statements by the patient indicate further teaching is required? Select all that apply. "I just try to stay away from everyone." "I keep a diary of what I eat and how I sleep." "I dropped one of my extracurricular groups." "When I feel stressed out, I play video games." "I alternate ibuprofen and acetaminophen all day."

"I just try to stay away from everyone." Isolation is not an effective therapeutic strategy for the long-term management of headache, and therefore this statement indicates a need for further teaching. "When I feel stressed out, I play video games." The use of stress management techniques is a therapeutic strategy for the long-term nursing management of headache. However, visual stimuli can induce headaches. Alternative stress management techniques must be taught, and therefore this statement indicates a need for further teaching. "I alternate ibuprofen and acetaminophen all day." The administration of medication is a therapeutic strategy for the long-term nursing management of headache. Constant self-medicating will lead to rebound headaches. This statement indicates a need for further teaching.

A parent of two children, including a girl with an intellectual disability states, "I have a hard time working with my daughter. She just doesn't seem to understand what I'm saying like my son does." What information can the nurse provide to help the parent? "Your daughter needs more attention than your son, so make sure you spend more time with her." "Let's talk about how to use simple, concrete explanations and incorporate play while you are teaching her something new." "It is understandable that you are struggling because children with intellectual disability are often harder to work with than other children." "Are you expecting your daughter to be able to do everything that your son can do because that is not a reasonable expectation."

"Let's talk about how to use simple, concrete explanations and incorporate play while you are teaching her something new." A child with intellectual disability will do best with simple, concrete, solution-focused information and will learn best through therapeutic play and demonstrations. The nurse should provide this information to the parent to promote effective communication.

A 2-year-old child has just been diagnosed with autism spectrum disorder (ASD). The parents want to know whether their child has a serious case because it was diagnosed so early. How should the nurse respond? "The early diagnosis of ASD means that your child will have a milder form of ASD." "Recognizing that your child has ASD at an early age means that the child will need more interventions to ensure normal development." "Recognizing and treating ASD early does not determine the severity of the disorder, but it increases the chance that your child will maximize his or her potential." "The early recognition of ASD means that your child does have a severe case and will likely have a poorer prognosis than if the disorder were recognized at a later age."

"Recognizing and treating ASD early does not determine the severity of the disorder, but it increases the chance that your child will maximize his or her potential." The earlier the interventions and treatments can start, the better the prognosis for functional ability will be for the child.

The nurse is discussing the surgical closure of a myelomeningocele with the parents of a newborn patient. Which statement by the parents indicates the need for further teaching? "Surgically closing this defect will ensure my baby can walk at the right age." "This surgery makes me feel less like my baby is too fragile to hold and feed." "This surgery minimizes the problems my baby has over the course of a lifetime." "Surgically closing this defect reduces the chance my baby will develop infections."

"Surgically closing this defect will ensure my baby can walk at the right age." Surgery will decrease cord deterioration and allow for earlier physical therapy and developmental interventions. The child with spina bifida corrected by surgery still may require additional surgeries.

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." "Your child will be fine, so don't worry." "Have you considered building a fence?" "You'll need to watch your son more closely in the future."

"Tell me more about your feelings" The nurse needs to be nonjudgmental and provide the parents an opportunity to express their feelings. Saying that the child will be fine may not be true. "Have you considered building a fence?" and "You'll need to watch your child more closely in the future" are judgmental responses.

The nurse is caring for an adolescent with a moderate intellectual disability. How should the nurse best communicate with the adolescent? "Your room is a safe place, and you can find whatever you need in here. We will be around to check on you each hour." "This is your room and your bathroom. If you have any questions about where things are, please don't hesitate to ask." "You are in the hospital. We are here to help you. Stay in your room, and if you have any questions about your environment, please ask." "The floors get very slippery when they are wet, so if you spill or get water on the floor, just let me know, and we can get it cleaned up, so you don't fall."

"The floors get very slippery when they are wet, so if you spill or get water on the floor, just let me know, and we can get it cleaned up, so you don't fall." The nurse should provide safety- and solution-focused information that is simple and concrete.

The nurse cares for a five-year-old patient involved in a motor vehicle accident. The paralysis extends from the naval downward. In performing discharge teaching, the nurse knows further teaching is needed when the parents make which statements? Select all that apply. "We need to catheterize him every 8 hours for urine." "We need to turn him in the bed at least every 2 hours." "We need to make sure he has a bowel movement often." "He will need to eat every meal that we prepare for him." "He will enjoy sitting outside all morning in his wheelchair."

"We need to catheterize him every 8 hours for urine." The child should not hold urine in his bladder for an extended period of time. Since the child cannot feel the urge to urinate, catheterization does need to occur on a schedule. If urine is left in the bladder, causing bladder distention, a kidney infection may result. Catheterization should occur instead every 4-6 hours. "We need to make sure he has a bowel movement often." The parents need to make sure that the child has a bowel movement every 1-2 days, rather than stating "often." The stool should be softly formed rather than hard or loose. With little innervation to the bowels, peristalsis will be limited and constipation quickly becomes an obstruction. "He will need to eat every meal that we prepare for him." This is not the best way to make sure the child gets adequate nutrition. Five-year-olds normally ingest small portions and they can love a food one day and hate it the next. Nutritional teaching includes information about snacks, supplements, and nutrient-dense foods. "He will enjoy sitting outside all morning in his wheelchair." The child should not sit up in the wheelchair for an extended period of time. This statement needs to be clarified. Sitting for more than an hour or two can produce pressure ulcers.

The nurse is providing education to the parents of a child experiencing spinal shock after a spinal cord injury. Which statements by the nurse are correct? Select all that apply. "We will not know what permanent injuries exist for one to two months." "Currently, the child appears to have no function below the level of injury." "Limbs that are currently flaccid will remain that way for about six months." "Nurses will perform passive range of motion exercises daily to maintain muscles." "Some complications, such as low blood pressure, will resolve within a few weeks."

"We will not know what permanent injuries exist for one to two months." The injuries associated with spinal shock can cause temporary loss of function, which means regaining function can occur. This statement could therefore be used by the nurse to address concerns regarding the recovery phase. "Currently, the child appears to have no function below the level of injury." Spinal shock can cause deceased function of everything below the level of injury including musculoskeletal abilities, bladder and bowel control, and so on. When the shock resolves, some function may return. "Some complications, such as low blood pressure, will resolve within a few weeks." Complications related to spinal shock, such as inability to maintain blood pressure, control temperature, and manage heart rate should resolve when the spinal shock resolves, and therefore this information can be relayed to the parents.

The mother of a newborn with fetal alcohol spectrum disorder (FASD) appears withdrawn and depressed. The mother does not often hold or look at the infant. When she does hold the newborn, she becomes tearful. Which would be appropriate comments for the nurse to make? "You appear upset when you hold your baby. How are you feeling?" "You seem sad. Are you feeling guilty about causing your newborn to have FASD?" "How are you doing with your child's diagnosis? You seem to be upset all of the time." "Having a child with a disorder is very hard, but obstacles will be greater if you do not learn to care for your baby."

"You appear upset when you hold your baby. How are you feeling?" The nurse should point out what is observed and encourage the mother to voice feelings about the infant's condition.

The mother of young child with fetal alcohol spectrum disorder (FASD) asks, "What does this disorder mean for my plan to have a big family?" What would be the most therapeutic response? "You can have more children. Having a child with FASD does not decrease your ability to have more children." "Anyone who has had a child with FASD should not have more children because of the child endangerment that has already occurred." "Having more children is not advisable because FASD is a genetic condition, and your future children would likely have the disorder as well." "You can have more children. Let's discuss pregnancy planning and alcohol avoidance in order to prevent having another child with FASD."

"You can have more children. Let's discuss pregnancy planning and alcohol avoidance in order to prevent having another child with FASD." Having one child with FASD does not mean that the mother cannot have more children, but it does mean that the mother should receive education to decrease the likelihood that she will drink during future pregnancies.

A mother of two is adopting an infant with fetal alcohol spectrum disorder (FASD). She asks the nurse. "What can I expect my baby to be like?" What education is important for the nurse to share? Select all that apply. "Your new infant may be more irritable than the average infant." "The new baby is more likely to have a smaller head than the average infant." "The baby will likely sleep more than your other children did at the same age." "The infant may be smaller and grow at a slower rate than your other children did." "Children with FASD are usually physically healthy, so the baby will be similar to your other children until toddlerhood."

"Your new infant may be more irritable than the average infant." The nurse needs to share information that will help the new mom prepare for difficulties that might be encountered with an infant with FASD. "The new baby is more likely to have a smaller head than the average infant." Microcephaly is common in FASD. "The infant may be smaller and grow at a slower rate than your other children did." The nurse should mention that the child may have a growth deficiency.

Based on a patient's Glasgow coma scale (GCS), the nurse documents the patient's head injury as a moderate one. What might be the score of the patient? 8 11 13 15

11 If the score of GCS is 9 to 12, then the nurse documents the head injury as a moderate one. Therefore, 11 is the correct answer. If the score of GCS is 8 or less, then the nurse documents the head injury as a severe one. If the score of GCS is 13 to 15, then the nurse documents the head injury as a mild one.

The nurse is triaging patients after a mass casualty. Place the patients in the order in which they should be seen. Select all that apply. 9 year old with 74 mm Hg systolic BP 5 year old with 76 mm Hg systolic BP 8 year old with 84 mm Hg systolic BP 10 year old with 90 mm Hg systolic BP

9 year old with 74 mm Hg systolic BP Children older than 24 months: 70 mm Hg plus the number that is double the child's age in years. (9-year-old child: 70 + 18 = 88 mm Hg) 5 year old with 76 mm Hg systolic BP Children older than 24 months: 70 mm Hg plus the number that is double the child's age in years. (5-year-old child: 70 + 10 = 80 mm Hg) 8 year old with 84 mm Hg systolic BP Children older than 24 months: 70 mm Hg plus the number that is double the child's age in years. (8-year-old child: 70 + 16 = 86 mm Hg)

The nurse is caring for a four-year-old patient diagnosed with fungal meningitis. What is the most likely etiology in this child? Parents refuse to vaccinate the child Attending a child care center during the week Child has been recently diagnosed with type II diabetes A diagnosis of acquired immunodeficiency syndrome (AIDS)

A diagnosis of acquired immunodeficiency syndrome (AIDS) Infection with the virus that causes AIDS is the most likely concomitant infection in a child who has been diagnosed with fungal meningitis. Fungal meningitis occurs in those who are immunocompromised, not in children who are otherwise healthy.

The nurse assesses vital signs for the 1-year-old patient with a severe head trauma. Which findings are most concerning? Select all that apply. An oxygen saturation of 90% A temperature of 99.9 Fahrenheit A heart rate of 52 beats per minute Cheyne-Stokes respiratory pattern Blood pressure of 210/132 mm Hg

A heart rate of 52 beats per minute Bradycardia is a manifestation of Cushing's response, which can indicate an impending brain herniation. Cheyne-Stokes respiratory pattern A change in the respiratory rate and pattern is a manifestation of Cushing's response, which can indicate an impending brain herniation. Blood pressure of 210/132 mm Hg Increased systolic blood pressure and a widening pulse pressure is a manifestation of Cushing's response, which can indicate an impending brain herniation.

The nurse is assessing an infant with fetal alcohol spectrum disorder (FASD). The nurse performs a thorough head-to-toe assessment. What is the primary reason for this assessment? The nurse needs to determine what facial features the newborn has to confirm the FASD diagnosis. A head-to-toe assessment must be completed on every newborn regardless of the conditions the infant has. A thorough assessment is completed because other abnormalities are often present in an infant with FASD. The infant with FASD requires a more thorough assessment than other newborns because all the signs of complications are easily missed.

A thorough assessment is completed because other abnormalities are often present in an infant with FASD. The nurse does need to determine whether any other associated congenital conditions are present so that a plan of care can be designed.

What is the most common type of head injury in children? Deceleration injuries Deformation injuries Acceleration injuries Acceleration-deceleration injuries

Acceleration-deceleration injuries The most common type of head injury in infants is the acceleration-deceleration injury, not deceleration injury, deformation injury, or acceleration injury.

The nurse cares for a child with rapidly progressing paralysis due to Guillain-Barré syndrome (GBS). After supportive care fails, the nurse anticipates what treatment as the next step in this patient's care? Consult palliative care Administer corticosteroids Teach about plasmapheresis Administer IV immunoglobulin

Administer IV immunoglobulin A child with rapidly progressing paralysis due to Guillain-Barré syndrome should be given high-dose IVIG. The IV immunoglobulin interferes with autoantibodies causing GBS and helps restore function in the patient.

The nurse is caring for a pediatric patient admitted with seizure activity related to cerebral palsy (CP). Which interventions should the nurse perform immediately? Select all that apply. Administer intravenous diazepam (Valium). Institute safety measures such as seizure padding. Assess gait disturbances and muscle coordination. Consult speech therapy for a swallowing evaluation. Evaluate gross motor development and muscle tone.

Administer intravenous diazepam (Valium). Administering a benzodiazepine will decrease spasticity and seizure activity. This is an immediate need. Institute safety measures such as seizure padding. Safety is a primary goal, and the nurse must prevent the child from sustaining unnecessary injuries.

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 fentanyl Administer midazolam Administer naloxone Administer vecuronium

Administer naloxone

A 3-year-old child with a history of status epilepticus is brought to the emergency department and the parent's state this seizure began 14 minutes ago. Intravenous access cannot be obtained. What should the nurse do? Select all that apply. Administer rectal diazepam gel. Call for the rapid response team to come assist. Ensure that intubation equipment is at the bedside. Place a heart rate and oximetry monitor on the child. Place the monitoring equipment in the bed for transport.

Administer rectal diazepam gel. Diazepam is the preferred drug for the nursing care of this patient because it is available as a rectal gel. Ensure that intubation equipment is at the bedside. Any seizure lasting longer than five minutes places the patient at risk for being unable to maintain own airway. Place a heart rate and oximetry monitor on the child. Monitoring cardiorespiratory status is essential.

A child is brought to the emergency department with a suspected spinal cord injury at the level of C2. What is the immediate priority in the nursing care of a patient with this injury? Administer ventilatory support Assess child's visual field for spots Manage hypertension and bradycardia Provide permanent cervical stabilization

Administer ventilatory support A spinal cord injury at the level of C2 will cause the patient to be apneic and require ventilator support which is the immediate priority in the nursing care plan in this patient.

What is a priority nursing consideration for a child with suspected bacterial meningitis? Supporting the family Instituting standard precautions Administering antibiotics as soon as possible Administering pain medications around the clock

Administering antibiotics as soon as possible The priority nursing consideration in a child with suspected bacterial meningitis is to administer antibiotics as soon as possible. Supporting the family is important, but the priority nursing consideration for a child with suspected bacterial meningitis is to administer antibiotics as soon as possible. Early isolation, rather than standard precautions, is recommended. Administering pain medications around the clock is important for children who are in pain, but the priority nursing consideration for a child with suspected bacterial meningitis is to administer antibiotics as soon as possible.

A 12-year-old in the clinic reports "severe headaches." The nurse should include which focused assessments for this patient? Select all that apply. Ask about medication history. Auscultate for a bruit in the head. Assess mental status and level of consciousness. Evaluate gait, coordination, and muscle strength. Anticipate health care provider examination of optic disks for papilledema.

Ask about medication history. The nurse should ask about medication history of this child as part of evaluating this patient. Daily use of analgesics may cause rebound headaches. Auscultate for a bruit in the head. The nurse should auscultate for a bruit as an indication of an aneurysm as part of evaluating patient. Assess mental status and level of consciousness. The nurse should assess mental status of child as part of evaluating patient. Anticipate health care provider examination of optic disks for papilledema. The nurse should anticipate health care provider examination of optic disks for papilledema in child as part of evaluating patient.

The nurse is conducting an assessment of a school-aged child who has autism spectrum disorder (ASD). What should the nurse do to best assess the child's functional abilities? Select all that apply. Ask the child "Can you tell me about your morning routine?" Ask the child, "To whom could you go at home and school if you need help?" Change the child's usual routine to determine how the child can cope with minor changes. Observe the child while the child is performing activities of daily living (ADLs) to see what assistance is needed. Make an effort to interact with the child on a regular basis and talk with the child about his or her interests.

Ask the child "Can you tell me about your morning routine?" This question will allow the child to use verbalization skills as well as explain the routine that is preferred. Observe the child while the child is performing activities of daily living (ADLs) to see what assistance is needed. The nurse needs to observe the child while he or she is performing ADLs to determine whether the child has age-appropriate developmental abilities. These observations will help determine what assistance the child needs.

A 6-year-old child comes to the emergency department and presents with respiratory distress from gasoline skin exposure. Which action should the nurse take if the child becomes unconscious? Administer naloxone Administer activated charcoal Assess and support CNS function Assess and support cardiorespiratory function

Assess and support cardiorespiratory function If the child loses consciousness, assessment of the cardiorespiratory functions is necessary. If deficits are noted, provide proper support.

The nurse is caring for a child who has sustained an acceleration-deceleration head injury. Which actions should the nurse take in assessing this patient? Select all that apply. Check child's gag reflex. Assess child for retinal injury. Check child for burns and bruising. Assess for associated extremity sprain. Contact health care provider because child needs head computed tomography (CT).

Assess child for retinal injury. An acceleration-deceleration head injury occurs with "shaken baby" syndrome, which is associated with retinal tears and hemorrhaging. This child will need to be assessed for retinal damage. Check child for burns and bruising. Acceleration-deceleration injuries are associated with child abuse, and so checking for other signs of abuse will be necessary. Assess for associated extremity sprain. Extremity sprains are not an associated condition occurring with acceleration-deceleration head injuries. They may however exist separately if child has been abused. Contact health care provider because child needs head computed tomography (CT). The child has suffered from an acceleration-deceleration head injury and may have an epidural hematoma that will need to be diagnosed by a head CT scan.

The nurse is caring for a child with a rapid breathing, headache, and the smell of wintergreen on the skin and clothes. Which additional signs and symptoms would the nurse assess for? Select all that apply. Bleeding Vomiting Confusion Diaphoresis Hyperglycemia Peripheral edema

Bleeding Wintergreen is a salicylate and is often used as a safe alternative to aspirin. The nurse would assess for bleeding and bruising related to the inhibition of prothrombin, decreased platelets levels, and capillary fragility. Vomiting Wintergreen is a salicylate and is often used as a safe alternative to aspirin. Oral poisoning typically manifests nausea and vomiting related to GI irritation. Confusion Wintergreen is a salicylate and is often used as a safe alternative to aspirin. Confusion, seizures, and coma are all related to the CNS effects of salicylate poisoning. Diaphoresis Wintergreen is a salicylate and is often used as a safe alternative to aspirin. Dehydration, sweating, and decreased urine production are typical in salicylate poisoning.

A patient is admitted with Neisseria meningitidis. What should the nurse monitor for that indicates infection progression? Select all that apply. Fatigue that is not relieved by rest Blood glucose levels every 6 hours Purpura over the trunk of the patient Blood pressure and heart rate changes Vomiting, diarrhea, and abdominal cramps

Blood glucose levels every 6 hours Adrenal insufficiency is a condition that can develop with Neisseria meningitidis infection, and therefore the nurse must monitor for hypoglycemia and symptoms of it such as sweating and nausea. Purpura over the trunk of the patient Purpura and petechiae are manifestations of Neisseria meningitidis that occur at the time of presentation or shortly thereafter. Blood pressure and heart rate changes Septic shock indicates the infection is progressing rapidly. In addition to common symptoms of fever, hypotension and tachycardia are indicative of septicemia.

When caring for a fourteen-year-old child with traumatic brain injury, which complications must be addressed immediately? Select all that apply. Blood pressure 80/40 mm Hg Decreased muscle tone bilaterally Weak deep tendon reflex responses Oxygen saturation of 88% on room air Respiratory rate of 8 breaths per minute

Blood pressure 80/40 mm Hg The care for a child with traumatic brain injury includes aggressively managing hypotension of the patient because the injury could affect centers of the brain that control basic body functions such as vascular tension. Weak deep tendon reflex responses Weak deep tendon reflexes are concerning for syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and for progressive increased intracranial pressure (ICP). Oxygen saturation of 88% on room air The care for a child with traumatic brain injury includes monitoring for and correcting hypoxemia of the patient that could develop because centers of the brain that control basic body functions such as breathing are altered. Respiratory rate of 8 breaths per minute The care plan for a child with traumatic brain injury includes monitoring for hypoventilation of the patient because the injury could affect the centers of the brain that control basic body functions such as breathing.

The nurse is caring for a 12-year-old patient after a bicycle accident in which the child fell over the handlebars trying to jump a curb. Which type of injury does the child likely have? Blunt Progressive Penetrating Multisystem

Blunt A child who falls over the handlebars of a bicycle will likely sustain blunt force trauma.

What is the similarity between the diagnostic procedures of the subdural tap and the ventricular puncture? Both help to rule out subdural effusions. Both carry a risk of intracerebral hemorrhage. Both remove cerebrospinal fluid to relieve pressure. Both involve inserting a needle into the anterior fontanel.

Both remove cerebrospinal fluid to relieve pressure Both procedures, subdural tap and ventricular puncture, remove cerebrospinal fluid to relieve spinal fluid pressure. Subdural tap helps to rule out subdural effusions. Ventricular puncture carries a risk of intracerebral hemorrhage. While subdural tap involves inserting a needle into the anterior fontanel, ventricular puncture involves inserting a needle into the lateral ventricle.

The parents of a preschooler with intellectual disability are in the health care provider's office. The parents seem anxious, disheveled, and tired. What can the nurse do to be most effective when working with this family? Select all that apply. Bring up the aspects of caring for the preschooler that the parents are doing well. Provide information about local support groups for parents of children with disabilities. Ask the parents about their ability to maintain other roles, such as that of an employee or a significant other. Explain to the parents the need to put the child in a residential care facility that will provide the necessary care for the child. Discuss with the parents the need to set an example for the child by caring for their own needs, getting enough sleep, and remaining calm.

Bring up the aspects of caring for the preschooler that the parents are doing well. Positive reinforcement for the parents can help increase their self-confidence and also shows that the nurse is listening, which can help facilitate a therapeutic relationship. Provide information about local support groups for parents of children with disabilities. The parents may not choose to attend meetings of the support group, but the nurse should recognize that the parents might benefit from additional community resources and should provide this information. Ask the parents about their ability to maintain other roles, such as that of an employee or a significant other. Assessing how the parents are doing in their other roles helps the nurse to gather information about coping and recognizes the parents as individuals, as well as caregivers.

A 5-year-old child is admitted with complications related to an Arnold-Chiari malformation and myelomeningocele. What assessment findings cause the nurse to be concerned? Child is underweight for age. Child reports neck pain and stiffness. Child reports burning with urination. Child is experiencing severe headache.

Child is experiencing severe headache. Arnold-Chiari can result in hydrocephalus. A headache may indicate increasing ICP. If the child has a shunt, this may indicate a malfunction.

The nurse observes that the ten-year-old patient is becoming increasingly restless. Knowing that the child suffered a concussion playing football, what does the nurse do next? Select all that apply. Calculate Glasgow coma score. Perform bilateral pupil examination. Inspect child's skull for size and shape. Ask patient about nausea and headache. Check vital signs and oxygen saturation.

Calculate Glasgow coma score. The child's GCS will offer information about the increased restlessness and whether it is neurologic in nature. Perform bilateral pupil examination. The nurse assesses reasons for restlessness including signs of increased ICP: diplopia, papilledema, and poor pupillary response to light. Ask patient about nausea and headache. Nausea and headaches are common, early signs of increased intracranial pressure. If patient does have these, it helps direct the nurse's assessment. Check vital signs and oxygen saturation. Hypoxia can be a cause of restlessness in any population. Anytime there is a new finding in a patient, vital signs should be reevaluated as indicators of overall cardiorespiratory status.

The nurse is caring for a pediatric patient admitted with severe nausea and vomiting for several days. Which finding will help the nurse quickly evaluate peripheral tissue perfusion? Oral temp 102.3 F Flat anterior fontanel Bowel sounds hyperactive Capillary refill greater than 5 seconds

Capillary refill greater than 5 seconds Capillary refill is the best assessment method to quickly assess tissue perfusion.

Which type of poisoning might the nurse expect for a 6-year-old who has presented with a cherry-red mucosa and a history of altered mental status after playing in the garage with the car running? Lead Corrosives Hydrocarbons Carbon monoxide

Carbon monoxide Carbon monoxide (CO) binds tightly to hemoglobin, preventing the binding of oxygen. The CO makes the hemoglobin appear bright red, causing the patient to look rosy-cheeked and to have cherry-red lips.

The nurse is caring for a patient hospitalized after a crushing chest injury, leading to development of blood surrounding the pericardium. The nurse notes tachycardia, tachypnea, muffled heart sounds, weakened peripheral pulses, and delayed capillary refill. Which form of shock is the patient likely experiencing? Septic shock Cardiogenic shock Distributive shock Hypovolemic shock

Cardiogenic shock Cardiogenic shock results when the patient's heart cannot pump effectively to meet the patient's metabolic needs. In the early stages of cardiogenic shock, the child is able to compensate with tachycardia, tachypnea, and vasoconstriction to maintain cardiac output.

The nurse cares for a ten-year-old recovering from meningitis. The nurse is most concerned about which assessment finding? Child reports a persistent headache. Child fails to respond when called by name. Parents report the child is not engaging in activities. Parents insist the child complete missed schoolwork.

Child fails to respond when called by name. The child may be experiencing hearing loss secondary to neurologic damage sustained during the meningitis episode. This will not improve with time and needs to be addressed.

The nurse assesses a two-year-old child with papilledema related to hydrocephalus. Which finding causes the nurse the most concern? Child is holding head and crying Child is lethargic, responding to voice Child projectile vomits when sitting up Child has an increased head circumference

Child has an increased head circumference Sutures and fontanels close by 18 months of age. If sutures and fontanels are closed, child should not have an enlarged head circumference. This finding indicates there is an additional problem that would be most concerning to the nurse.

The nurse is caring for pediatric patients on a neurology unit. Which patient is the nurse most concerned about? Child who lost consciousness and fell to the ground during a seizure Child with a temperature of 103 degrees Fahrenheit exhibiting seizure activity Child having seizures consisting of muscle groups contracting and relaxing Child exhibiting unresponsiveness to questions and making repetitive mouth motions

Child having seizures consisting of muscle groups contracting and relaxing Muscle groups affected by this tonic-clonic activity include those that control breathing. Respirations can become irregular and stridor may occur. This child may require intubation.

An infant was brought to the emergency department (ED) after falling from a high chair, sustaining a basilar skull fracture. Which concerning assessment findings does the nurse expect? Clear drainage from the ear Pupils are unequal and sluggish Bleeding from the fractured area Intermittent confusion and lethargy

Clear drainage from the ear A basilar skull fracture is characterized with a patient who exhibits raccoon eyes, otorrhea, and hemotympanum.

An infant is brought to the emergency department with retinal hemorrhages, increased irritability, and a burn mark on the arm. Once stabilized, what is the nurse's priority intervention for this patient? Consult with child protective services. Ask the case manager to arrange home health care. Provide stress management teaching to the parents. Gather a timeline of events based on the parents' reports.

Consult with child protective services. Abusive head trauma or "shaken baby" syndrome is the most likely condition in an infant with retinal hemorrhages. The child should not go home with the parents until the cause of the traumatic brain injury is determined. If parents are not charged with abuse, someone must still make sure safeties are in place so consultation with child protective services is a priority intervention.

The nurse is caring for a comatose child with multiple injuries. The nurse should recognize which concept regarding pain? Cannot occur if the child is comatose May occur if the child regains consciousness Requires astute nursing assessment and management Is best assessed by family members who are familiar with the child

Requires astute nursing assessment and management Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain. Pain can occur in the comatose child. The child can be in pain while comatose. The family can provide insight into the child's different responses, but the nurse should be monitoring physiologic and behavioral manifestations.

A patient comes to the emergency department and is being treated for distributive shock. Which patient presentation corresponds to this diagnosis? Select all that apply. A patient suffering from profuse diarrhea Inability of a patient to maintain vascular tone A patient with septic shock who has a bacterial infection A patient with an overall decrease in circulating blood volume A patient with myocardial fluid accumulation causing insufficiency in meeting the body's demands

Inability of a patient to maintain vascular tone This patient scenario corresponds to a patient diagnosed with distributive shock, and therefore the nurse should recognize septic shock as a form for distributive shock. A patient with septic shock who has a bacterial infection This patient scenario corresponds to a patient diagnosed with distributive shock, and therefore the nurse should recognize septic shock as a form of distributive shock.

A patient presents with Guillain-Barré syndrome (GBS). What does the nurse anticipate finding in the history and physical? Select all that apply. Tuberculosis skin test that was positive Toe infection positive for staphylococcus Influenza vaccine received one month ago Upper respiratory infection two weeks ago History of frequent urinary tract infections

Influenza vaccine received one month ago The flu shot has been demonstrated to have a link to the autoimmune process triggered in Guillain-Barré. Upper respiratory infection two weeks ago Upper respiratory infection has been associated with the subsequent development of Guillain-Barré syndrome.

A child is rushed to the emergency department following a collision on the school yard impacting the left side of the head. The nurse expects which physical finding associated with this injury? Raccoon eyes Hemotympanum Left arm weakness Right leg numbness

Left arm weakness In a contrecoup injury, the weakness will occur ipsilateral to the side of injury because of the rebound of the brain within the skull. Normally an injury to the left side of the head would impact function on the right side of the body.

The nurse is caring for a fourteen-year-old patient suffering from a migraine headache. Which findings cause the nurse the most concern? Select all that apply. Left arm weakness Projectile vomiting Nausea and dizziness Urinary incontinence Sound and light intolerance

Left arm weakness This is a sign of a stroke that can occur with a severe migraine because it is a vascular headache. Though rare, this can be a complication of migraine that warrants immediate attention. Weakness should not be confused with arm tingling, which can be part of the patient's aura. Urinary incontinence This could be a sign of a seizure or even a stroke. Though rare, this can be a complication of migraine that warrants immediate attention.

The nurse is assessing a patient who fell two stories from a window. An artificial airway is in place, and the cervical spine has been stabilized. Which action is the most appropriate for the nurse to take next? Assess capillary refill Listen to lung sounds Obtain a blood pressure Evaluate the patient's Glasgow Coma Scale score

Listen to lung sounds To properly complete the primary survey, after establishing an airway and stabilizing the cervical spine, the nurse should assess the patient's breathing effort.

The nurse is caring for a patient who has sustained a gunshot shot wound to the leg. The wound is actively bleeding and the patient reports 10/10 pain. Which factor should the nurse consider a priority when assessing the severity of the patient's injury? The age of the patient The size of the patient Location of the penetration Time that the injury occurred

Location of the penetration The severity of an injury depends on the location of impact and the type of object. The nurse should consider the location of the injury and its impact on the primary survey.

A three-year-old child has a seizure while in the clinic waiting area. What actions does the nurse take? Select all that apply. Loosen clothing Restrain the child Turn child onto the side Note related manifestations Time length of seizure activity

Loosen clothing The nurse should loosen the child's clothing to prevent injury during the seizure if it can be done so without harming the patient or the nurse. Turn child onto the side The nurse should turn the child onto the side during the seizure, if it can be done so without harming the patient or the nurse. Note related manifestations The nurse should note any preceding or accompanying sensory motor manifestation that occurs at the time of the seizure activity. Time length of seizure activity The nurse should observe the length of time the seizure activity lasts.

A child presents to the emergency department with sudden bilateral ascending weakness and is diagnosed with Guillain-Barré syndrome. What should the nurse most closely monitor? Capillary refill Respiratory status Heart rate and rhythm Level of consciousness

Respiratory status Along with achieving optimal neurologic function, the nurse should prioritize monitoring the respiratory rate in a child with bilateral ascending weakness.

A child presents to the emergency department with increased intracranial pressure. Which strategies should be included in the nurse's care plan to help manage the pressure? Select all that apply. Maintain a comfortable room temperature. Administer intravenous fluids (IV) as prescribed. Elevate the child's head to 30 degrees at all times. Administer anticonvulsant medications as needed. Administer insulin for elevated blood glucose levels as prescribed.

Maintain a comfortable room temperature. Normothermia should be maintained in children with increased intracranial pressure because hyperthermia and hypothermia cause stress in the brain as it tries to maintain normothermia. Administer intravenous fluids (IV) as prescribed. Normovolemia is necessary. The nurse ensures that there is not hypervolemia or hypovolemia because decreased or increased blood flow causes stress on the brain. Elevate the child's head to 30 degrees at all times. The child with increased intracranial pressure should have the head elevated to decrease pressure caused by positioning. Administer insulin for elevated blood glucose levels as prescribed. Normal blood glucose is essential to prevent increased metabolic demands placing stress on the brain.

In a child with a complete spinal cord injury at T6, which interventions should the nurse implement to prevent complications? Select all that apply. Administer saline nose spray for nasal congestion. Maintain patient's bed position at 45-degree angle. Notify health care provider for BP of 162/89 mm Hg. Cover with blanket when goose bumps are observed. Hold steroid medications for heart rate less than 50 bpm.

Maintain patient's bed position at 45-degree angle. Angling the bed at 45 degrees promotes venous blood return, decreased intracranial pressure (ICP), and keeping child's head midline. Notify health care provider for BP of 162/89 mm Hg. The onset of autonomic dysreflexia in child with a complete spinal cord injury at T6 includes sudden increase in systolic blood pressure. Urgent intervention will be needed.

Which finding will the nurse expect to see in a 5-year-old child whom the mother suspects to have ingested the acetaminophen 3 hours ago? Jaundice Malaise, pallor, weakness Right upper quadrant (RUQ) pain Recovery from physical symptoms

Malaise, pallor, weakness During the first 24 hours, the nurse would expect to see malaise, nausea, vomiting, sweating, pallor, and weakness.

The nurse is caring for a patient who has a penetrating chest wound. The patient is unresponsive, with labored breathing and delayed capillary refill. Which factor would the nurse consider during the initial assessment in addition to the patient's signs and symptoms? Name of the patient Mechanism of injury Time of day when injury occurred Geographic location when injury occurred

Mechanism of injury Nursing intervention depends on knowing the mechanism of injury, as well as the manifesting signs and symptoms.

The nurse is caring for a child with a spinal cord injury. Which intervention is a priority? Assess each shift for characteristics of stool. Administer an antacid medication twice daily. Bathe, dry, and provide skin care to the patient. Monitor the patient's temperature and skin changes.

Monitor the patient's temperature and skin changes. A spinal cord injury can disrupt the patient's sympathetic nervous system which controls dermal vasodilation. Hyper or hypothermia causes increased stress on the healing of the neurologic system, and monitoring temperature and skin changes will be a priority.

A 3-year-old patient is diagnosed with hydrocephalus. A ventricular shunt was placed to relieve the pressure. What is the nursing care priority for a patient who had a ventricular shunt put into place? Assessing for proper bowel movements Assessing neurologic status every two hours Monitoring for fluid leaking from the incision Monitoring for headaches when the patient sits up

Monitoring for fluid leaking from the incision The main priority in the nursing care of a patient who had a ventricular shunt placed is the prevention or early detection of shunt infection, malformation, and malfunction. A leaking incision presents a high risk of infection.

The nurse is working with a new graduate in developing a plan of care for a newborn infant with spina bifida (myelomeningocele) and hydrocephalus. The nurse reminds the graduate to monitor for increased intracranial pressure (ICP). Which assessment technique should be performed to detect the presence of an increase in ICP? Measure urine specific gravity Assess for increased muscle tone Observe anterior fontanel for bulging Monitor blood pressure for signs of hypotension

Observe anterior fontanel for bulging Excessive buildup of CSF in the newborn's brain will cause expansion and fullness. The nurse can observe this through bulging (secondary to pressure) in the fontanels.

A patient who has sustained a head injury exhibits rhinorrhea. What immediate nursing intervention is appropriate for the patient? Reassure the patient, because it is an insignificant finding. Test the discharge for presence of glucose. Sedate the patient and administer antihistamine. Ask the patient to report immediately if the nose bleeds.

Test the discharge for presence of glucose Patients with head injury may have leakage of cerebrospinal fluid. The watery nasal discharge is tested for presence of glucose to rule out cerebrospinal fluid (CSF) leakage. Reassurance is given only after excluding CSF leakage. Sedating by administering an antihistamine is not appropriate in managing rhinorrhea of head injury. The patient is asked to report nasal bleeding, but priority is given to check for CSF leakage.

The nurse cares for patients in a pediatric headache clinic. Which patient should the nurse assess first? The 4-year-old child with abdominal pain and nausea. The 10-year-old child vomiting in the examination room. The 12-year-old child who reports smelling smoke and fire. The 6-year-old who screams when someone touches the child's head.

The 10-year-old child vomiting in the examination room. This child with vomiting is the most serious of these patients, indicating either a migraine in need of medicating or increased intracranial pressure (ICP).

The nurse is caring for a child who presents with blunt force trauma to the head and face, which the parents say was sustained during a fall. The nurse also notes the child is lethargic and confused and has bruises on the legs, arms, and abdomen in multiple stages of healing. Which area of body will be of most concern to the nurse? Kidneys and renal system Lungs and respiratory system The cervical spine and neurologic system Heart and cardiovascular system

The cervical spine and neurologic system The nurse should verify the stability of the cervical spine for a patient with blunt force trauma to the head and face.

The nurse is examining a child who suffered a head injury. What assessment finding does the nurse recognize as a comminuted fracture? Presence of irregular fragments of broken bones Presence of single fracture line and soft-tissue swelling Presence of multiple associated linear fractures Presence of bleeding around the eyes (raccoon eyes)

Presence of multiple associated linear fractures Comminuted fractures consist of multiple associated linear fractures as a result of intense impact from repeated blows against an object. In a depressed fracture, the bone is locally broken, usually into several irregular fragments that are pushed inward, causing pressure on the brain. The child's head appears misshapen. A linear fracture is a single fracture line that starts at the point of maximum impact but does not cross suture lines. Most linear skull fractures are associated with an overlying hematoma or soft-tissue swelling. Basilar fractures involve the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bones. Clinical features may include bleeding around the eyes.

A child who plays soccer is brought to the clinic by the mom who suggests her child is not acting right. Which associated finding does the nurse evaluate further? The child cannot recall yesterday's events. The child requests a drink of water and a popsicle. The mother is pacing in the triage room continuously. The mother states that the child did not eat after the game.

The child cannot recall yesterday's events. Memory loss can be associated with postconcussion syndrome, and therefore the patient may have difficulty remembering yesterday's events. This information helps the nurse direct further care.

A child is diagnosed with early stage hydrocephalus. What actions should the nurse perform? Select all that apply. Place padding on all four of bed rails. Teach parents to expect high-pitched crying. Administer ondansetron (Zofran) for vomiting. Provide orientation to the room, call light, and personnel. Consult dietician for dietary supplement recommendations.

Place padding on all four of bed rails. Although seizures are a late sign, any time intracranial pressure (ICP) is increased enough to be symptomatic, seizure precautions should be instituted to protect patient. Administer ondansetron (Zofran) for vomiting. Vomiting occurs due to pressure within the brain on structures that control vomiting, however the action of vomiting increases ICP. The nurse should make every attempt to reduce actions that increase ICP. Provide orientation to the room, call light, and personnel. The child may exhibit confusion, and providing orientation may reduce the severity of the confusion. Consult dietician for dietary supplement recommendations. An infant with early stage hydrocephalus will present with poor feeding, and therefore the nurse may notice the child is not gaining weight.

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? Reorientation of the patient Glasgow Coma Scale assessment Institution of seizure precautions Preparations for a neurologic emergency

Preparations for a neurologic emergency A neurologic emergency may be occurring in a child who exhibits suddenly fixed and dilated pupils. During a neurologic emergency the child may not be able to be reoriented; the priority is preparing for the possible consequences of a neurologic emergency. When the pupils suddenly become fixed and dilated,the priority nursing action is not a Glasgow Coma Scale assessment or institution of seizure precautions, but instead, preparations for dealing with a neurologic emergency.

A child is brought to the clinic with suspected fetal alcohol spectrum disorder (FASD). What action taken by the nurse will be a priority in caring for this patient and the family? Share with the family that FASD is caused by the mother's ingestion of alcohol during pregnancy. Tell the family that if a diagnosis of FASD is made, the first year of life will likely be tremulous and difficult. Prepare the family for the necessity of a workup to determine the symptoms and other conditions associated with the disorder. Have the parents discuss their expectations for the child's development to determine whether the parents' expectations are realistic.

Prepare the family for the necessity of a workup to determine the symptoms and other conditions associated with the disorder. An extensive workup is needed when a child is suspected of having FASD. The parents need to be prepared for the assessments and testing that will be required to confirm or rule out the diagnosis.

The nurse is caring for a 7-year-old patient who reports sustaining a leg injury while falling down the stairs three days ago. The nurse notes abrasions to the left elbow and a right tibia fracture. Which indicator may raise the suspicion of child maltreatment? Patient has abrasion on his elbow Delay in seeking treatment for the trauma Patient has never broken his tibia previously The patient was alone when the injury occurred

Delay in seeking treatment for the trauma Delay in seeking treatment for the trauma is an important indicator that might raise the suspicion of child maltreatment in the emergency setting.

What are the priorities when developing a nursing plan of care for a ten-year-old patient with Guillain-Barré syndrome (GBS)? Select all that apply. Assess daily for fever, stiff neck, or confusion. Determine bilateral lower extremity strength. Check vital signs and trends every four hours. Perform tests of lower and upper sensory function. Observe chewing and swallowing of solids and liquids. Evaluate respiratory rate and use of accessory muscles.

Determine bilateral lower extremity strength. Neuromuscular impairment can be a finding in patients affected by Guillain-Barré. Assessing the patient's lower extremity strength will therefore be a priority. Check vital signs and trends every four hours. Autonomic instability may cause dizziness or the inability to alter heart rate and is a priority when developing a nursing care plan for a patient with Guillain-Barré syndrome. Perform tests of lower and upper sensory function. Guillain-Barré syndrome often presents with limb paresthesia, which is defined as altered sensation from the patient's limbs. This will be a priority in developing a care plan for this patient. Observe chewing and swallowing of solids and liquids. The patient with Guillain-Barré syndrome may develop cranial nerve dysfunction that could inhibit the ability to swallow. This will therefore be a priority in developing a nursing care plan for the patient. Evaluate respiratory rate and use of accessory muscles. The phrenic nerve may be affected in a patient with Guillain-Barré syndrome resulting in respiratory failure of the patient. Evaluating respiratory status will be a priority in caring for this patient.

Which clinical manifestations are likely to develop in a 3-year-old child after initial stabilization for bleach ingestion? Select all that apply. Development of metabolic acidosis Development of esophageal strictures Development of liver necrosis and jaundice Development of hypokalemia and dehydration Development of organ perforation and vascular complications

Development of esophageal strictures As the damaged esophagus begins to heal, the child may have continued difficulty swallowing due to the development of strictures. Development of organ perforation and vascular complications When a child has a severe burn, the damage can lead to eventual perforation of an organ. This can lead to vascular collapse and shock.

A nurse has 25 years of experience working in the emergency department (ED) treating and managing pediatric patients. Treating which area of the pediatric patient should she have most experience? Arm Leg Head Wrist

Head The head makes up a large proportion of the child's body relative to the rest of the body. An experienced ED nurse should be used to treating head injuries because this area of the body is injured more than other areas.

The nurse cares for a child with Guillain-Barré syndrome. The nurse notes a frequent, weak cough and decreased bilateral hand grips. What actions should the nurse take? Select all that apply. Place a nasal cannula on the patient at 2 L/min. Obtain a pillow nurse call light for patient's use. Raise head of the bed to a semi-Fowler's position. Do not allow patient to have anything to eat or drink. Explain to patient what was assessed and the meaning.

Obtain a pillow nurse call light for patient's use. With inadequate grip strength, and Guillain-Barré, which is progressively decreasing strength from toes working toward neck, patient needs a way to call the nurse. A pillow call light allows patient to turn the head slightly to touch pad that calls the nurse. Raise head of the bed to a semi-Fowler's position. The patient is having difficulty with oral and respiratory muscles. This will affect swallowing of saliva and diaphragmatic excursion. Placing the head of bed (HOB) up will decrease the patient's work and help prevent aspiration and hypoventilation. Do not allow patient to have anything to eat or drink. Patient is at risk for aspiration and needs to be NPO until swallowing can be further evaluated. Explain to patient what was assessed and the meaning. The patient should usually be told what is going on and what health care provider is doing. Patient's Guillain-Barré is progressing as evidenced by decreased strength in hands and inability to forcefully cough. Patient may soon require intubation and should be aware of that.

The nurse is caring for a patient in hypovolemic shock. The patient has a patent airway, unlabored breathing, and capillary refill less than 4 seconds. Which prescription should the nurse anticipate receiving first from the health care practitioner? Obtain vascular access Administer oral antibiotics Prepare patient for surgery Begin hemodynamic monitoring

Obtain vascular access Once the airway, breathing, and circulation are established, the next priority for the nurse is adequate vascular access.

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? Stupor Lethargy Confusion Obtundation

Obtundation Obtundation is a level of consciousness described as arousable with stimulation. Stupor is marked by continued deep sleep, slow response to vigorous and repeated stimulation, and moaning responses to stimuli. Lethargy is marked by limited spontaneous movement, sluggish speech, drowsiness, and falling asleep quickly. Confusion is indicated by impaired decision-making.

An eight-year-old child is brought to the emergency department by his parents with signs of late hydrocephalus. The nurse manages what expected findings in this patient? Select all that apply. Setting-sun sign Ongoing seizure activity Restlessness and irritability Blood pressure 140/90 mm Hg Heart rate of 45 beats per minute

Ongoing seizure activity Seizures occur in a child with late hydrocephalus due to brain stress from excess fluid. The nurse administers benzodiazepines. Blood pressure 140/90 mm Hg An increased blood pressure will be exhibited in patient with late hydrocephalus. If parents desire more than comfort care, nurse may give medications to decrease blood pressure. Heart rate of 45 beats per minute A child with late hydrocephalus will exhibit decreased heart rate. If parents desire more than comfort care, nurse may give medications as ordered to increase heart rate.

A child is brought to the emergency department for altered mental status. Which would be the most concerning assessment finding? The child reacts angrily to being awakened. The child does not recall the trip to the hospital. The child believes the triage room is the bedroom. Parents state that the child does not recognize them.

Parents state that the child does not recognize them. A child who does not recognize the parents is classified a disoriented level of consciousness. More serious than confusion and delirium, disorientation indicates that the child is suffering from a more severe decrease in level of consciousness, and this would be the most concerning assessment.

The eleven-year-old patient is admitted with an incomplete spinal cord injury at C4. Which findings cause the nurse the most concern? Select all that apply. Patient reports difficulty taking a deep breath. Patient is unable to lift arms or grasp eating utensils. Patient's blood pressure increases to 150/92 mm Hg. Patient has "goose bumps," small raised bumps on the skin. Patient's whole blood glucose level increases to 190 mmol/L.

Patient reports difficulty taking a deep breath. A cervical injury affects the ability to control abdominal muscles and other muscles in the thorax, such as the diaphragm which helps to control depth of purposeful inspiration. This could be a sign that the spinal cord injury is actually complete, has progressed, or that there is additional damage to the spinal cord. The patient may require intubation as progression continues. Patient's blood pressure increases to 150/92 mm Hg. Autonomic dysreflexia is characterized by a sudden rise in blood pressure and will need to be a priority in caring for this patient to prevent intracranial hemorrhage, seizures, and heart attack. Patient has "goose bumps," small raised bumps on the skin. Typically associated with being cold, these raised papillae could indicate that the patient is experiencing hypothermia or autonomic dysreflexia and intervention is needed quickly.

The hospitalized child with spina bifida has broken out in a rash. What actions should the nurse take? Select all that apply. Place a precautions sign on the door and in the room. Change out the gloves in the room and outside the door. Request that the health care provider prescribe a steroid. Check the patient's vital signs for a temperature elevation. Ask the hospital's rapid response team to evaluate the child.

Place a precautions sign on the door and in the room. There is likely a latex allergy. A sign indicating the patient is allergic to latex is needed on the door and above the bed to alert other health care workers. Additionally, at a minimum, it should be listed on the patient's armband. The next exposure could induce anaphylaxis. Change out the gloves in the room and outside the door. Children with spina bifida are at high risk for developing latex allergies due to chronic illness resulting in increased exposure to latex-containing products over time. If latex-containing gloves are in the room, they must be removed until it can be determined definitely whether this rash is related to latex. Request that the health care provider prescribe a steroid. A steroid and/or antihistamine will calm the immune reaction to the latex. Check the patient's vital signs for a temperature elevation. This rash could be related to a virus instead of latex. The nurse should begin to rule that out by assessing the patient for a fever.

The nurse is caring for a child who is unresponsive after being struck by a vehicle. The child sustained multiple injuries and was diagnosed with cardiogenic shock. The child's parents are tearful and refuse to speak with the provider about the child's prognosis. Which action would the nurse take to enhance family coping? Select all that apply. Ask the parents to refrain from staying at the child's bedside Provide concise, accurate information to the parents at frequent intervals Give information in a calm, relaxed, and empathetic manner Encourage parents to participate in the child's care as appropriate Provide simple explanations to the child and parents of procedures before initiating them Provide detailed information, using correct medical terminology so parents will understand

Provide concise, accurate information to the parents at frequent intervals The nurse's action of providing concise, accurate information to parents at frequent intervals enhances family coping. Give information in a calm, relaxed, and empathetic manner The nurse's action of giving information in a calm, relaxed, and empathetic manner enhances family coping. Encourage parents to participate in the child's care as appropriate The nurse's action of encouraging parents to participate in the child's care as appropriate provides them with some degree of control. Provide simple explanations to the child and parents of procedures before initiating them The nurse's action of providing simple explanations to the child and parents before initiating them enhances family coping.

A school nurse is providing education to a group of teachers regarding working with intellectually disabled school-aged children. What information is most important for the nurse to emphasize? Be prepared to tell the children what you want them to do repeatedly. Discuss the need for hands-on activities and practice to help the children learn. Put a stop sign picture on any object or area that you do not want the children to touch or enter. Show the children what you want them to do so that they can watch what you do and imitate your actions.

Put a stop sign picture on any object or area that you do not want the children to touch or enter. Safety is the most important information. Frequent visual reminders should be provided for children with intellectual disability.

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 ago. What is the most appropriate assessment for this child? Reactivity of pupils Doll's head maneuver Oculovestibular response Funduscopic examination to identify papilledema

Reactivity of pupils Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. The doll's head maneuver should not be performed if there is a cervical spine injury. Assessment for an oculovestibular response is a painful test that should not be done in a child who is displaying a variable level of consciousness. Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.

A mother treated her 6-year-old child's fever with aspirin. The child was brought to the emergency department and diagnosed with a varicella infection. The nurse assesses that the patient has impaired consciousness. What are the next steps in nursing management? Select all that apply. Record intake and output every 1-2 hours. Administer a broad-spectrum antibiotic as prescribed. Continue to treat the fever with aspirin every 4-6 hours. Monitor ammonia levels, liver enzymes, and coagulation studies. Monitor the child's oxygen saturation and heart rate continuously.

Record intake and output every 1-2 hours. Maintenance of fluid and electrolyte balance is essential in this child with increased intracranial pressure (ICP) cause by Reye's syndrome. Monitor ammonia levels, liver enzymes, and coagulation studies. Reye syndrome can cause liver dysfunction, affecting ammonia levels, liver function, and coagulation abilities. The nurse monitors laboratory studies for intervention. Monitor the child's oxygen saturation and heart rate continuously. Because of the child's impaired consciousness, the cardiorespiratory status needs to be monitored due to the risk of rapid deterioration.

The nurse is caring for a child with autism spectrum disorder (ASD). What should the nurse do to best assist the child's tolerance of the hospitalization? Select all that apply. Regularly assess for any changes in the child's behavior, such as withdrawal or self-injury. Provide the child with her favorite stuffed animal each time that she needs to recognize that it is time to get ready for bed. Regularly rotate patient care with other nurses to keep from becoming stressed and impatient as a result of meeting the child's needs. Speak with the parents about the usual routines the child prefers for getting ready for the day ahead in the morning and going to bed at night. Help the child to maintain a routine that is consistent with the routines of other patients to keep the child from feeling different from the other children.

Regularly assess for any changes in the child's behavior, such as withdrawal or self-injury. The nurse should monitor for symptoms that can indicate anxiety and a lack of comfort to determine how the child is adapting to the hospitalization. Provide the child with her favorite stuffed animal each time that she needs to recognize that it is time to get ready for bed. Many children with ASD will require specific cues to remain oriented. Providing a familiar object will keep the child from being overly stressed by the changes related to hospitalization. Speak with the parents about the usual routines the child prefers for getting ready for the day ahead in the morning and going to bed at night. If the nurse knows the routines that the child usually follows, the nurse can follow the same routines, which will minimize the stress that the child experiences during hospitalization.

In order to terminate ocular exposure, which interventions should the nurse provide to a patient who has experienced exposure to a powdered poison? Select all that apply. Administer a chelating agent Remove contaminated clothing Irrigate the eyes with warm water or saline Induce vomiting to reduce absorbed poison levels Eliminate powder from skin and clothing; wash skin

Remove contaminated clothing Remove any contaminated clothes; residual powder could endanger the child and health care workers. Irrigate the eyes with warm water or saline Irrigation of the eyes with water or normal saline is crucial for terminating ocular exposure of any poison. Eliminate powder from skin and clothing; wash skin Brush off chemical powders from the skin, and wash the skin. Residual powdered poison is dangerous for both the child and health care workers.

The nurse monitors the pediatric patient for seizures. While the patient is intubated and sedated, what findings might indicate seizure activity? Select all that apply. Low urinary output Rhythmic muscle contraction Decreased oxygen saturation A temperature of 103 degrees Fahrenheit A decrease in heart rate to 50 beats per minute

Rhythmic muscle contraction The patient who is intubated also receives neuromuscular sedatives to allow the ventilator to work for the lungs. Muscular contraction could be much more subtle but can be an indicator of seizure activity. Decreased oxygen saturation A decreased oxygen saturation can be associated with seizure activity, and therefore this should be noted and appropriate seizure precautions taken. A temperature of 103 degrees Fahrenheit A sedated patient should be monitored for hyperthermia which may indicate the patient is having a seizure. Seizures cause increased muscle movement, even if the typical jerking motions are not visible. This increased activity causes a rise in temperature, just like the act of shivering does. A decrease in heart rate to 50 beats per minute A sedated patient should be monitored for cardiac dysrhythmias. A change in heart rate to bradycardia or to tachycardia may indicate the patient is having a seizure because heart dysrhythmias often accompany seizure activity.

What is a clinical manifestation of increased intracranial pressure in infants? Photophobia Vomiting and diarrhea Shrill, high-pitched cry Pulsating anterior fontanel

Shrill, high-pitched cry A shrill, high-pitched cry is a common clinical manifestation of increased intracranial pressure (ICP) in infants. The characteristic cry occurs as a result of the pressure being placed on the meningeal nerves, which causes pain. Photophobia is not indicative of increased ICP in infants. A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a bulging anterior fontanel. Vomiting is one of the signs of increased ICP in children, but when present with diarrhea it is more indicative of a gastrointestinal disturbance.

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. Which information is most important for the nurse to teach the parents? Most usual childhood activities must be restricted Cognitive impairment is to be expected with hydrocephalus Shunt malfunction or infection requires immediate treatment Parental protection is essential until the child reaches adulthood

Shunt malfunction or infection requires immediate treatment Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions. The development of cognitive impairment depends on the extent of damage before the shunt was placed. Limits should be appropriate to the child's developmental age.

The nurse is caring for an infant brought in with a high fever, cough, labored breathing, and tachypnea. Which general appearance finding would be most concerning for the nurse? Diarrhea Poor feeding Weak, continuous cry Skin is cool and mottled

Skin is cool and mottled Cool, mottled skin is a sign of poor tissue perfusion and can indicate shock in an infant with labored breathing and tachypnea.

The twelve-year-old patient with spina bifida exhibits learning delays. What other assessment findings does the nurse anticipate? Select all that apply. Slow to follow directions Difficulty swallowing foods Upper limb discoordination Frequent respiratory infections Bowel and bladder incontinence

Slow to follow directions If the child's spine is affected high enough to result in learning delays, additional processing delays, such as following directions, might be expected. Difficulty swallowing foods The child's cognitive delays are related to the height of the neural tube defect, however difficulty swallowing may occur and can also indicate the child also has Chiari II malformation. Upper limb discoordination The child with learning delays secondary to spina bifida will also have difficulty with gross and fine motor skills using the arms and hands. Bowel and bladder incontinence Even fairly low neural tube defects can result in incontinence. A defect as high as this one definitely leads the nurse to anticipate incontinence.

A young child is having a seizure that has lasted 35 minutes. The nurse also recognizes a loss of consciousness and identifies which type of seizure? Status epilepticus An absence seizure A generalized seizure A simple partial seizure

Status epilepticus Status epilepticus is a generalized seizure that lasts more than 30 minutes. This is considered a medical emergency and requires immediate treatment. Absence seizures are generalized seizures that are characterized by brief loss of consciousness, blank staring, and fluttering of the eyelids. Generalized seizures are the most common form of seizures. They include tonic-clonic (grand mal) seizures and absence (petit mal) seizures. Tonic-clonic seizures involve tonic-clonic activity and loss of consciousness and affect both hemispheres of the brain. Simple partial seizures are characterized by varying sensations and motor behaviors.

The nurse is caring for a 3 year old diagnosed with pneumonia one week previously. The parents report the child has become lethargic and appears to have more difficulty breathing. The nurse notes delayed capillary refill, tachycardia, and tachypnea. Which prescription should the nurse implement first? Supplemental oxygen Hemodynamic monitoring IV fluid bolus of normal saline Parenteral antibiotic therapy

Supplemental oxygen Supplemental oxygen should be initiated first for a patient with signs of shock, hypoxia, and poor tissue perfusion.

The health care provider examines a 7-year-old child, revealing increased deep tendon reflexes, hypertonia, flexion, and a scissors gait. Which intervention does the nurse include in this patient's plan of care? Give the parents teaching pamphlets about antiseizure medication. Ensure the child has a hospital bed and bedside commode for use at home. Provide the child with a diet plan that includes reduced-fat milk and cheeses. Teach the child and parents how to monitor for and address learning difficulties.

Teach the child and parents how to monitor for and address learning difficulties. Children with cerebral palsy tend to have learning disabilities and poor attention spans. Educating parents on how to seek help for these problems as they arise is an essential part of this child's care plan.

The term "lethargic" is used to describe a postoperative child's level of consciousness (LOC). What findings does this term imply? SATA The child has sluggish speech. The child is confused about place. The eyes follow objects only by reflex. There is limited spontaneous movement. The child is drowsy and falls asleep quickly.

The child has sluggish speech. There is limited spontaneous movement. The child is drowsy and falls asleep quickly. Level of consciousness is determined by observations of the child's responses to the environment. The "lethargic" child has sluggish speech and limited spontaneous movement. The child is drowsy and falls asleep quickly. The child is not fully conscious. A "disoriented" child has decreased LOC and is confused about the time and place. In the "persistent vegetative state" the child has permanently lost function of the cerebral cortex. The eyes of this child follow objects only by reflex.

The school nurse is evaluating a 6-year-old child for behavior problems noticed in the classroom. Which findings cause the nurse to be concerned that the child is having seizures? Select all that apply. The child does not answer, even when spoken to directly. The child is noted to periodically bob his head while sitting. The child is sleepy in class and often lays head down to sleep. The child looks away for a few seconds then returns to activity. The child exhibits a blank facial expression in the middle of a conversation.

The child is noted to periodically bob his head while sitting. Head bobbing indicates muscle tone changes and can be indicative of an absence seizure. The child looks away for a few seconds then returns to activity. If the child's eyes look blankly in space momentarily or upward briefly and the child returns to the activity that was paused, this is a sign of an absence seizure. The child exhibits a blank facial expression in the middle of a conversation. This is not typical behavior and indicates a possible absence seizure.

The parents of a child with a neurologic disorder and severe intellectual disability are concerned about the child's frequent emotional changes and anger. How might the nurse interpret these changes in emotion? The child may be frustrated and unable to appropriately express needs. The child requires behavioral interventions to prevent hurting self and others. The child may be having temper tantrums which will likely turn into self-injurious behaviors if the parents do not intervene. The child is not functioning at the expected level for a child with a severe intellectual disability and needs further assessment.

The child may be frustrated and unable to appropriately express needs. Children with severe intellectual disability have limited expressive speech and limited self-help skills.

A 10-year-old patient with a history of fetal alcohol spectrum disorder (FASD) without any identifiable intellectual or physical impairments comes into the clinic with the parents. The parents want to know what impairments might be expected as their child continues to grow. What information should the nurse share with this family? The child may start to experience joint pain or stiffness. As your child begins to reach adolescence, seizures may begin to develop. Although your child does not seem to have any intellectual disability now, this may become more apparent in early adulthood. Your child is very lucky and will likely not have any more issues or problems become apparent because, with FASD, all the manifestations are present in infancy.

The child may start to experience joint pain or stiffness. Joint abnormalities are common manifestations in a child with FASD.

A twelve-year-old child's spina bifida lesion affects the upper lumbar vertebrae. The nurse evaluates that the child is meeting therapeutic goals when the child demonstrates which behaviors? Select all that apply. The child participates in exercise activities daily. The child walks without using leg braces prescribed. The child has successful attempts at bladder emptying. The child chooses to play alone at school during recess. The child bathes, dresses, and puts on shoes without help.

The child participates in exercise activities daily. Increasing the child's mobility is a goal in the care of a child with spina bifida, and therefore the child's continued ability to participate in daily exercise indicates the goals of care are being met. The child has successful attempts at bladder emptying. A child with spina bifida must be placed in a bladder-emptying program, and therefore successful attempts at emptying the bladder is an indicator that goals are being achieved. The child bathes, dresses, and puts on shoes without help. This is an appropriate act of independence and demonstrates the child is maintaining mobility and is actively working toward therapeutic goals.

The nurse received report about a child experiencing early signs of difficulties associated with mild intellectual disability. What behaviors should the nurse anticipate from the child? The child smears feces across the walls of the room. The child constantly rocks back and forth while sitting. The child spends time alone and rarely makes eye contact. The child disrobes in the halls and cannot be redirected to another activity when walking with the nurse.

The child spends time alone and rarely makes eye contact. Isolation and signs of low self-esteem are behaviors associated with mild intellectual disability.

The nurse evaluates a three-year-old child for developmental delays. When the nurse notes that the child has difficulty maintaining balance while walking, what other assessments does the nurse perform? Select all that apply. The nurse assesses overall muscle tone and strength. The nurse assesses for speech impairments and delays. The nurse assesses deep tendon and primitive reflexes. The nurse assesses level of consciousness and orientation. The nurse assesses for developmental milestone variances.

The nurse assesses overall muscle tone and strength. Cerebral palsy (CP) is characterized by abnormal muscle tone and therefore the nurse will assess the overall tone and strength at this time. Correct The nurse assesses for speech impairments and delays. Impaired speech is a characteristic developmental impairment found in CP and therefore this would be assessed at this time. Correct The nurse assesses deep tendon and primitive reflexes. A child with CP may have persistent primitive reflexes, which should have disappeared in infancy. In assessing a suspected neurologic disorder, the nurse should assess deep tendon reflexes as well. The nurse assesses for developmental milestone variances. The child with cerebral palsy may not have reached other milestones at appropriate ages, and therefore should be assessed for these at this time.

A nurse is working for the first time with a 17-year-old diagnosed with autism spectrum disorder (ASD). The adolescent seems very attached to a sibling. The parents encourage the 15-year-old sibling to spend the night in the hospital. Allowing a sibling to spend the night is against the policy of the hospital unit. Which is the nurse's best response? The nurse should uphold the policy in the unit to ensure that all children are treated equally and avoid conflict among the other patients. The nurse should recognize that the child should have either the parent or a staff member spend the night to ensure the safety of the child. The nurse should discuss the policy with the parents of the patient and develop a plan that meets the requirements of the facility and the needs of the adolescent. The nurse needs to put the child in a room close to the nurse's station so that the child can frequently be monitored by the staff and the policy of the unit can be upheld.

The nurse should discuss the policy with the parents of the patient and develop a plan that meets the requirements of the facility and the needs of the adolescent. The nurse needs to create a plan to help ensure the safety and comfort of the adolescent patient with ASD. Children and adolescents with ASD often need someone, in this case, the sibling, to help ensure their safety. The nurse can work with the parents to safely and correctly accomplish this.

The nurse is caring for patients on a pediatric neurology unit. Which patient should the nurse assess first? The patient diagnosed with a brain mass reporting a sudden loss of vision. The patient with a head injury after falling off a bicycle, reporting nausea and abdominal cramping. The patient admitted with meningitis, with a recently recorded temperature of 101.2 Fahrenheit. The patient diagnosed with a seizure disorder with the parent reporting the child has significant loss of appetite.

The patient diagnosed with a brain mass reporting a sudden loss of vision. A sudden loss of vision indicates rapidly increasing ICP, probable bleeding, and needs immediate evaluation.

What is the purpose of a lumbar puncture (LP)? To analyze cerebrospinal fluid To rule out subdural effusions To detect electrical activity To relieve intracranial pressure

To analyze cerebrospinal fluid An LP is done to obtain cerebrospinal fluid (CSF) for laboratory analysis. A subdural tap is performed to rule out subdural effusions. It is also done to remove CSF to relieve pressure. Electrical activity or spikes are detected by an electroencephalography (EEG). This test indicates the potential for seizures. LP is contraindicated in patients with increased intracranial pressure. A subdural tap or ventricular puncture may be done to remove CSF to relieve pressure.

Why does the nurse immediately place a child having a seizure episode into a side-lying position on a flat bed? To prevent hypoxia To prevent aspiration and choking To determine the need for oxygen To prevent continued seizure activity

To prevent aspiration and choking The nurse places the child in a side-lying position on a flat bed because this position prevents aspiration and choking. The nurse administers rescue breaths or oxygen as necessary to prevent hypoxia. The nurse monitors the oxygenation status in postictal state to determine the need for oxygen. The nurse administers antiepileptic medications as prescribed to prevent continued seizure activity.

During a seizure episode, the child's arms are flexed, eyes are rolled upwards, and legs, head, and neck are extended with increased salivation and loss of swallowing reflex. This is followed by violent jerking movements as the trunk and extremities undergo rhythmic contraction and relaxation. What type of seizure has the child experienced? Status epilepticus Myoclonic seizure Tonic-clonic seizure Psychomotor seizure

Tonic-clonic seizure The child has experienced a tonic-clonic seizure. During the tonic phase of the seizure, the child's arms are flexed, eyes are rolled upwards, and legs, head, and neck are extended with increased salivation and loss of swallowing reflex. This is followed by the clonic phase with violent jerking movements as the trunk and extremities undergo rhythmic contraction and relaxation. Status epilepticus is a series of seizures with very brief intervals to allow the child to regain consciousness and can lead to exhaustion, respiratory failure, and death. Myoclonic seizures are characterized by sudden, brief contractures of muscles and can occur either once or repetitively. Psychomotor seizures are manifested by a period of altered behavior, amnesia for the duration of the event, inability to respond to environment, impaired consciousness during the event, drowsiness or sleep following seizure, prolonged confusion, and complex sensory phenomenon.

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? Fluid restriction Diuretics Vasopressin Corticosteroids

Vasopressin Patients with diabetes insipidus lack vasopressin, resulting in increased urine output and decreased intravascular volume. Therefore the condition can be managed by administering vasopressin. The increased urine output results in dehydration, which can be aggravated by fluid restriction. Diuretics add to the patient's dehydration. Corticosteroids are not usually administered for managing diabetes insipidus.