Saunders Child Health- Neurological

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

"When picking up your infant, support the infant's neck and head with the open palm of your hand."

The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?

"I need to give frequent, small, nutritious meals if my child starts to vomit."

A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?

"It involves only the anterior portions of the client's brain."

Which represents a primary characteristic of an autism spectrum disorder?

Lack of social interaction and awareness

The nurse assists in developing a plan of care for the child with meningitis. Which should be the priority client problem for a child with a meningitis diagnosis?

Neurological dysfunction

The nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. Which is the best nursing action?

Notify the registered nurse (RN).

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?

Notify the registered nurse.

The nurse is developing a plan of care for a child with autism. The nurse should identify which priority problem for this child?

Risk for injury

The nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that which are the primary signs/symptoms of meningitis?

Severe headache and neck stiffness

The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?

Sulfisoxazole

The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome?

The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).

The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which should the nurse perform to monitor for a major symptom of this condition?

Check for responses to painful stimuli from the torso downward.

A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of which finding?

Confirmation of the diagnosis

A child with a brain tumor returns from the recovery room following "debulking" of the tumor. The nurse assigned to care for the child monitors the child for brainstem involvement. Which sign would indicate that brainstem involvement occurred during the surgical procedure?

Elevated temperature

The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?

Maintain moisture of the normal saline dressing on the gibbus area.

A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?

Notify the registered nurse of the finding.

A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately?

Temperature 100.9° F

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.

Turn the client to the side during a seizure. Keep side rails and other hard objects padded

The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?

Changes in level of consciousness

The nurse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

Time the seizure. Stay with the child. Move furniture away from the child.

The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?

Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding?

Dysfunction in the cerebral hemisphere

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?

Maximize the child's assets and minimize the limitations.

The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation should the nurse expect to make during data collection of the child?

The child sleeps unless aroused and, once aroused, interacts poorly with the environment.

The nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?

"If my baby has a high-pitched cry, I should call the health care provider

The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which?

Decorticate posturing

The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action should the nurse take?

document the findings

The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction?

"Call the health care provider if the infant has a high-pitched cry."

The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside?

A bottle of sterile normal saline

The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside?

A suction apparatus and oxygen

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

Initiating seizure precautions

The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, which is a priority intervention?

Palpating the anterior fontanel

The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms should the nurse expect to find during the initial data collection? Select all that apply.

fever irritability Nuchal rigidity

A client has been prescribed valproic acid (Depakene) for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching?

"I am so glad that I won't lose any of my hair. I was worried what my friends would think."

The nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching?

"Our child sleeps in our bedroom at night."

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?

A chronic disability characterized by impaired muscle movement and posture

Which finding would indicate that a child had a tonic-clonic seizure during the night?

Blood on the pillow

A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record?

Elevated vanillylmandelic acid (VMA) levels in the urine

The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign?

Extend the leg and knee and check for pain.

A child is diagnosed with Reye's syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention?

Providing a quiet atmosphere with dimmed lights

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for which complication?

Signs of increased intracranial pressure

A child has a basilar skull fracture. Which health care provider's prescription should the nurse question?

Suction via the nasotracheal route as needed.

When checking a child's glossopharyngeal nerve function, the nurse should perform which data collection technique?

Test sense of sour or bitter taste on the posterior segment of the tongue.

A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?

The child's cervical spine

The nurse should implement which in the care of a child who is having a seizure? Select all that apply.

time the seizure stay with the child loosen clothing around the childs neck

When checking a child's trochlear nerve function, the nurse should perform which data collection technique?

Have the child look down and in.

The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components should be included in the plan of care? Select all that apply.

Maintain the bed in a low position. Pad the side rails of the bed with blankets. Place the child in a side-lying lateral position if a seizure occurs. Protect the child's head, body, and extremities if a seizure occurs

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?

Nausea

The nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. Which action would best assist in determining the causes of the seizure?

Obtaining a history regarding factors that may occur before the seizure activity

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?

Safety with activities