UNIT 3 EXAM Intracranial Regulation + Infection Exemplars: Seizures and Meningitis

A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present? 1.Increased protein 2.Increased glucose 3.Decreased specific gravity 4.Decreased white blood cell count

1 Bacterial meningitis causes increased permeability of the blood-cerebrospinal fluid barrier, resulting in increased protein in cerebrospinal fluid. The glucose level will be within the expected range. The specific gravity will be increased, as will the white blood cell count.

A client is admitted to the emergency department in the midst of persistent tonic-clonic seizures (status epilepticus). Diazepam is to be administered immediately. In addition to decreasing central neuronal activity, what other effect does the nurse anticipate? 1.Relaxing peripheral muscles 2.Slowing cardiac contractions 3.Dilating tracheobronchial structures 4.Providing amnesia of the convulsive episode

1 Diazepam is a tranquilizer and anticonvulsant used to relax skeletal muscles during continuous seizures. Diazepam does not slow cardiac contractions. Diazepam does not dilate the tracheobronchial structures. Diazepam does not provide amnesia of the convulsive episode.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1.Meningitis 2.Spinal cord injury 3.Intracranial bleeding 4.Decreased cerebral blood flow

1 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? 1.Private room or cohort client 2.Personal respiratory protection device 3.Private room with negative airflow pressure 4.Mask worn by staff when the client needs to leave the room

1 Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

A nurse is caring for an infant with meningitis. When the nurse extends the baby's leg, the hamstring muscles go into spasm and the infant begins to cry. What sign or reflex is the infant exhibiting? 1.Kernig sign 2.Babinski reflex 3.Chvostek sign 4.Cremasteric reflex

1 The Kernig sign is indicative of meningitis; it is demonstrated by a spasm of the hamstring muscles when the legs are extended. The Babinski reflex is dorsiflexion and fanning of the toes when the sole is stroked; adults with neuromuscular impairment and healthy infants exhibit this sign. The Chvostek sign is elicited by tapping on the facial nerve in the region of the parotid gland; spasm indicates tetany. In a male, the cremasteric reflex is elicited by stroking the inner thigh; this should cause the testes to retract into the scrotal sac.

A 12-year-old girl is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. Three days after admission the child is afebrile and asymptomatic but appears sad and cries frequently. How should the nurse help the child verbalize her thoughts and feelings? 1.By telling the child that she seems sad and upset 2.By encouraging the parents to speak with their child 3.By showing the child some photos of hospitalized children and having the child tell stories about them 4.By having the child watch videotapes about sick children and answering any questions that the child might have

1 The child is old enough to respond when a direct question is asked or an open-ended statement of assessment is made. The parents may be too emotionally involved to effectively help their child communicate feelings. Younger children benefit from the projective technique of being shown photos of children in a similar situation and then constructing stories about them. Younger children benefit from the projective technique of watching videos of other sick children and asking questions about them.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? 1.Hypotension 2.Tachycardia 3.Slurred speech 4.No abnormal finding

3 The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur

The nurse enters a child's room and discovers that the child is having a seizure. Which actions should the nurse take? Select all that apply. 1.Call a code. 2.Run to get the crash cart. 3.Turn the child on her side. 4.Loosen any restrictive clothing. 5.Check the child's respiratory status. 6.Place an airway into the child's mouth.

3,4,5 During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse loosens clothing around the child's neck and ensures a patent airway by checking respiratory status. A code is called if the child is not breathing or the heart is not beating. There are no data in the question indicating that this is the case. The nurse stays with the child to reduce the risk of injury and to allow for observation and timing of the seizure. Nothing is placed into the child's mouth during a seizure because this could injure the child's mouth, gums, or teeth.

For how long should a nurse maintain isolation of a child with bacterial meningitis? 1.For 12 hours after admission 2.Until the cultures are negative 3.Until antibiotic therapy is completed 4.For 48 hours after antibiotic therapy begins

4 Most children are no longer contagious after 24 to 48 hours of intravenous antibiotics. Twelve hours after admission is inadequate, even if antibiotics are started immediately. Keeping the child isolated until cultures are negative or antibiotic therapy is complete is an excessively long period and is unnecessary.

Cushing's triad

HTN (widening pulse pressure: elevated SBP and low DBP) bradycardia irregular respirations (cheyne-stokes)

A prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

2 capsules You must convert 0.2 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose. Desired/available X capsule = capsules/dose 200mg/100mg X 1 capsule = 2 capsules

A 6-year-old child is experiencing tonic-clonic seizures, and carbamazepine 15 mg/kg/day divided equally into two doses is prescribed. The child weighs 44 lb (20 kg). The medication available is carbamazepine suspension 100 mg/5 mL. How many milliliters should the nurse administer in one dose? Record your answer using one decimal place. ___ mL

7.5 Convert the child's weight of 44 lb to kilograms (44 ÷ 2.2 = 20); 20 kg × 15 mg/kg = 300 mg for the entire day. Divide 300 mg into two doses (300 mg ÷ 2 = 150 mg/dose). Use ratio and proportion to calculate the dose.

A nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. What is the purpose of these precautions? 1.They keep the child away from uninfected people. 2.The infectious process is interrupted as quickly as possible. 3.The child is protected from contracting a secondary infection. 4.They prevent the development of a hospital-acquired infection.

1 Droplet precautions reduce the transmission of infection from the child to other individuals (cross-infection). The microorganisms are transmitted to others in respiratory droplets. Droplet precautions do not interrupt the infectious process; they protect those in contact with the child from contracting the infection. Droplet precautions do not protect the child from contracting secondary infections; they protect others from being exposed to the child's pathogens. Thorough hand washing and aseptic techniques, not droplet precautions, limit the spread of hospital-acquired infections.

A 13-month-old child is admitted with a tentative diagnosis of bacterial meningitis, and the practitioner schedules a lumbar puncture. What is the most important action the nurse should take in preparation for the lumbar puncture? 1.Asking the parents what they were told about the test 2.Using a doll to demonstrate the procedure to the child 3.Obtaining a pacifier for the child to suck on during the procedure 4.Telling the parents that they may stay with their child during the test

1 Informed consent is required. The procedure should be explained to the parents by the practitioner, and the nurse should confirm the parents' comprehension and have them sign the consent form. The child is too young to comprehend a demonstration of the procedure. Although staying with the child may be important to the parents, it is not the priority. Although a pacifier may keep the child calm, this is not the priority, either.

A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the primary health care provider's prescriptions, which would the nurse question as appropriate for a child with this diagnosis? 1.Administer an oral antibiotic. 2.Maintain strict intake and output. 3.Draw blood for a culture and sensitivity. 4.Place the child on droplet precautions in a private room.

1 Medication to treat acute bacterial meningitis is administered intravenously, not orally. A culture and sensitivity is done to determine if the diagnosis is bacterial or viral. Until meningitis is ruled out, the child is placed in isolation on droplet precautions because the disease is spread by airborne means. Strict intake and output should be maintained.

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion? 1. Positive Kernig sign 2.Glasgow coma score: 10 3.Absence of nuchal rigidity 4.Negative Brudzinski sign

1 Meningitis may occur secondary to surgical procedures on the brain. It is highly probable when Kernig sign is positive. The Glasgow coma scale is used as a reliable way of recording the conscious state of the client, but it is not used to diagnose meningitis. A meningitis diagnosis is highly probable with a positive Brudzinski sign and the presence of nuchal rigidity (e.g., stiff neck).

The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to caring for their child who has a chronic illness. Which statement, if made by the parents, would indicate a need for further teaching? 1."Our child sleeps in our bedroom at night." 2."We worry about injuries when our child has a seizure." 3."Our child is involved in a swim program with neighbors and friends." 4."Our babysitter just completed cardiopulmonary resuscitation training."

1 Parents are especially concerned about seizures that might go undetected during the night. The nurse needs to decrease parental overprotection and should suggest the use of a baby monitor at night. Involvement in a swim program and knowing CPR identify parental understanding of the disorder. Worrying about injuries when a child has a seizure is a common concern. The parents need to be reminded that as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care is appropriate to minimize complications.

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? Select all that apply. 1.Irritability 2.Bradycardia 3.Hyperalertness 4.Decreased pulse pressure 5.Decreased systolic blood pressure

1,2 Irritability is a classic sign of increased intracranial pressure, because it signals disruption of the central nervous system. Bradycardia is a classic late sign of increased intracranial pressure. With increased intracranial pressure there is decreased alertness or loss of consciousness. The pulse pressure increases with increased intracranial pressure. The systolic blood pressure increases with increased intracranial pressure.

An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? Select all that apply. 1.Fever 2.Lethargy 3.Stiff neck 4.Poor feeding 5.Depressed fontanels

1,2,3,4 A low-grade fever progressing to a high fever occurs in meningitis. An infectious process that causes meningitis may result in rigidity and hyperextension of the neck (opisthotonos). Central nervous system irritation results in irritability, lethargy, and anorexia. The fontanels will be tense or bulging as intracranial pressure increases.

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. 1.Remain calm. 2.Time the seizure. 3.Ease the child to the floor. 4.Loosen restrictive clothing. 5.Keep the child on her back

1,2,3,4 When a child is having a seizure, the nurse should remain calm, time the seizure, ease the child to the floor if the child is standing or seated, keep the child on the side (to prevent aspiration), and loosen restrictive clothing.

A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply. 1.Seizures 2.Vomiting 3.Bulging fontanels 4.Subnormal temperature 5.Decreased respiratory rate

1,2,5 Irritation of cerebral tissue can cause seizures. Pressure on vital centers can cause vomiting. Pressure on the respiratory center results in a decreased respiratory rate. A 2-year-old child's fontanels are closed, so bulging fontanels are not a sign of increased intracranial pressure in this case. The inflammatory process of meningitis causes an increase in temperature.

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? 1.Offering clear fluids whenever the child is awake 2.Checking the child's level of consciousness hourly 3.Assessing the child's blood pressure every four hours 4.Administering the prescribed oral antibiotic medicatio

2 Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation. The child is too ill to ingest anything by mouth; also, vomiting is likely. Hydration is maintained intravenously. Taking the blood pressure and other vital signs every four hours is insufficient monitoring; many changes can occur in this time span. Intravenous antibiotics have a rapid systemic effect and are preferable to those administered by way of the oral route.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed. 2.Placing an airway at the bedside. 3.Placing the bed in the high position. 4.Putting a padded tongue blade at the head of the bed. 5.Placing oxygen and suction equipment at the bedside. 6.Flushing the intravenous catheter to ensure that the site is patent.

1,2,5,6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is creating 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. 1.Time the seizure. 2.Restrain the child. 3.Stay with the child. 4.Place the child in a prone position. 5.Move furniture away from the child. 6.Insert a padded tongue blade in the child's mouth.

1,3,5 A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on her or his side in a lateral position. Positioning on the side prevents aspiration, because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

Which nursing actions apply to the care of a child who is having a seizure? Select all that apply. 1.Time the seizure. 2.Restrain the child. 3.Stay with the child. 4.Insert an oral airway. 5.Loosen clothing around the child's neck. 6.Place the child in a lateral side-lying position.

1,3,5,6 During a seizure, the nurse should stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. The child is not restrained, because this could cause injury to the child. The child is placed on his or her side in a lateral position. Nothing is placed in the child's mouth during a seizure because this could injure the child's mouth, gums, or teeth. Positioning on the side prevents aspiration, because saliva drains out of the corner of the child's mouth. The nurse should loosen clothing around the child's neck and ensure a patent airway.

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

What is the priority nursing intervention for an infant with a myelomeningocele before surgical correction? 1.Minimizing infection 2.Preventing trauma to the sac 3.Monitoring for increasing paralysis 4.Assessing the degree of bowel and bladder control

2 A meningomyelocele is thinly covered and fragile. Trauma to the sac can damage functioning neural tissue; an intact sac eliminates a potential portal of entry for microorganisms. Although minimizing infection is extremely important, it is not the priority; care of the sac is even more important, because an intact sac bars entry by microorganisms. Although observation for paralysis is an important nursing measure, it is not the priority. The extent of a meningomyelocele will influence the child's ability to control bowel and bladder function, but control is not developed until the toddler and preschool years.

A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which action should the nurse take? 1.Hold the medication and notify the healthcare provider. 2.Administer the next dose of the medication as prescribed. 3.Hold the next dose and then resume administration as prescribed. 4.Call the healthcare provider to obtain a prescription with an increased dose.

2 Administering the next dose of the medication as prescribed is within the therapeutic range of 10 to 20 mg/L (40 to 80 mcmol/L); the nurse should administer the drug as prescribed. The phenytoin level is within the therapeutic range of 10 to 20 mg/L (40-80 mcmol/L); there is no need to hold the dose and notify the healthcare provider. Holding the next dose and then resuming administration as prescribed is unsafe and will reduce the therapeutic blood level of the drug. Calling the healthcare provider to obtain a prescription with an increased dose is unnecessary; the blood level is within the therapeutic range.

The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective? 1."We're glad we only have to give our child the medication for 30 days." 2."We will make appointments for follow-up blood work and care as directed." 3."We're glad there are no side effects from taking the antiseizure medications." 4."After our child has been seizure free for 1 month, we can discontinue the medication."

2 Antiseizure medications are continued for a prolonged time even if seizures are controlled. Periodic reevaluation of the child is important to assess the continued effectiveness of the medication, to check serum medication levels, and to determine the need to alter the dosage if indicated. Antiseizure medications have potential side effects, and parents should be informed of such effects specific to the medication the child will be taking. Withdrawal of medication follows a predesigned protocol, usually begun when the child has been seizure free for at least 2 years. When a medication is discontinued, the dosage should be reduced gradually over 1 to 2 weeks.

A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. What does the nurse explain to the parents is the primary reason this procedure is performed? 1.To identify the presence of blood 2.To determine the causative agent 3.To reduce the intracranial pressure 4.To measure the spinal fluid glucose level

2 Organisms that cause meningitis are often harbored in the spinal fluid. The lumbar puncture helps determine whether meningitis is present and whether the causative agent is bacterial or viral. Although some blood may be found in the spinal fluid, its presence is not a confirmation of the diagnosis of meningitis. More conservative measures, such as medications or positioning, are used to reduce intracranial pressure. Although testing for spinal fluid glucose level may be done, it will not reveal the causative agent.

A nurse is caring for an infant born with a myelomeningocele who is scheduled for surgery. What is the priority preoperative goal for this infant? 1.Keeping the infant sedated 2.Keeping the infant infection free 3.Ensuring maintenance of leg movement 4.Ensuring development of a strong sucking reflex

2 Prevention of infection is the priority both before and after the repair of the sac. Sedatives are not indicated; analgesics are administered as needed. Leg movement may be a postoperative goal, although it may be unrealistic because these infants' lower bodies are usually paralyzed. The sucking reflex is not associated with myelomeningocele.

A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report on the cerebrospinal fluid (CSF) supports this diagnosis? 1.Decreased cell count 2.Increased protein level 3.Increased glucose level 4.Low spinal fluid pressure

2 The blood-brain barrier is affected in bacterial meningitis, permitting the passage of protein into the CSF. The cell count will be increased. The glucose level is decreased in proportion to the duration of the disease. Spinal fluid pressure will be increased.

An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? 1.Using disposable diapers 2.Placing the infant in the prone position 3.Performing neurologic checks above the site of the lesion 4.Washing the area below the defect with a nontoxic antiseptic

2 The prone position is the best position for preventing pressure on the sac. Diapers should not be applied because they may irritate or contaminate the sac. Assessment of the area below the defect is essential in determining motor and sensory function. There is no indication for the use of an antiseptic.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1."Alcohol is not contraindicated while taking this medication." 2."Good oral hygiene is needed, including brushing and flossing." 3."The medication dose may be self-adjusted, depending on side effects." 4."The morning dose of the medication should be taken before a serum medication level is drawn."

2 Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a primary health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a MedicAlert bracelet.

A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate? 1.Healthy spinal fluid 2.Increased glucose level 3.Increased white blood cell (WBC) count 4.Rising number of red blood cells (RBCs)

3 A high WBC count causes spinal fluid to appear cloudy and possibly milky white; it is a sign of infection. Healthy spinal fluid is clear. An increased glucose level does not affect the color or clarity of the spinal fluid. RBCs give the spinal fluid a sanguineous, not cloudy, appearance.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1.Enteric 2.Contact 3.Droplet 4.Neutropenic

3 A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

A newborn with a myelomeningocele is being transferred immediately from the birthing room to the neonatal intensive care unit (NICU). What is the initial nursing intervention? 1.Start antibiotic prophylaxis 2.Provide routine newborn care 3.Apply a sterile saline dressing 4.Assess the infant for paralysis

3 Applying a sterile saline dressing helps prevent infection while keeping the membranes moist. Although the infant should be assessed for paralysis, it is not the priority. Antibiotics are not given prophylactically. This newborn needs more than just routine care because of the outpouching of the meninges.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3 Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

A lactating woman takes fluoxetine to treat depression. Her newborn developed tremors, seizures, and fever. Which drug-induced physiologic alterations may be responsible for the central nervous system effects of the drug on the neonate? 1.Increase in fat content 2.Increase in protein binding 3.Immature blood-brain barrier 4.Delayed first stooling

3 Many drugs are able to enter the neonate's brain due to the immature blood-brain barrier causing central nervous system effects. Neonates have a low fat content. Protein binding is decreased in neonates because the liver is immature and produces fewer proteins. First pass elimination is decreased in neonates due to the liver's immaturity.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1.Clear CSF, decreased pressure, and elevated protein level 2.Clear CSF, elevated protein, and decreased glucose levels 3.Cloudy CSF, elevated protein, and decreased glucose levels 4.Cloudy CSF, decreased protein, and decreased glucose levels

3 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

A nurse is caring for a child with meningococcal meningitis. What clinical finding does the nurse expect to encounter during a physical assessment? 1.Severe glossitis 2.Low-grade fever 3.Purpuric skin rash 4.Tremors of the extremities

3 Meningococcal meningitis is identified by its epidemic nature and purpuric skin rash. Glossitis and tremors are not characteristic of meningococcal meningitis, and the fever of meningitis is usually high.

What does a nurse recognize as the most serious complication of meningitis in young children? 1.Epilepsy 2.Blindness 3.Peripheral circulatory collapse 4.Communicating hydrocephalus

3 Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock, petechiae, ecchymotic lesions, vomiting, prostration, and hypotension. Although epilepsy or blindness may occur, neither condition is as serious a complication as peripheral circulatory collapse. Similarly, although hydrocephalus may occur, it is rare and not as serious as peripheral circulatory collapse.

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? 1.Pregnancy must be avoided while taking phenytoin. 2.The client may stop the medication if it is causing severe gastrointestinal effects. 3.There is the potential of decreased effectiveness of birth control pills while taking phenytoin. 4.There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

3 Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions. Pregnancy does not need to be "avoided" while taking phenytoin; however, because phenytoin may cause some risk to the fetus (Pregnancy Category D medication), consultation with the primary health care provider should be done if pregnancy is considered. Telling a client that there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A client should not be instructed to stop antiseizure medication.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign 4.A Glasgow Coma Scale score of 15

3 Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. What is the priority nursing care? 1.Monitoring intracranial pressure 2.Adding pads to the side of the bed 3.Administering prescribed antibiotics 4.Hydrating the client with hypotonic saline

3 The Brudzinski sign (when the neck is flexed while in the supine position, flexion of the hips occurs) indicates bacterial meningitis, a complication of sinusitis; the client's greatest need is a regimen of antibiotics to which the causative agent is sensitive. Bacterial meningitis causes increased intracranial pressure and it is important for the nurse to monitor for manifestations of increased intracranial pressure; however, in this circumstance, it is not the priority because monitoring alone does not affect outcomes . Because of the risk for seizures in bacterial meningitis, padded side rails are an important nursing intervention; however, this intervention does not have priority over instituting the appropriate antibiotic therapy to eradicate the cause of the meningitis. The data do not indicate a need for a hypotonic solution for hydrating the client.

The nursing student is writing a plan of care for a child who presents with an acute head injury. The nursing instructor reviews the plan of care and praises the student for identifying which assessment as a priority? 1.Inspecting the scalp 2.Pupillary assessment 3.Airway and breathing 4.Palpating the child's head

3 The first step in the emergency treatment of child with head injury includes the ABCs - airway, breathing, and circulation - assessments. The other assessments are included when evaluating a head injury, but the priority is ABC.

A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure? 1.Monitoring the child's vital signs 2.Padding the side rails of the toddler's crib 3.Placing the child in the side-lying position 4.Bringing suction equipment to the bedside

3 The side-lying position promotes a patent airway; the tongue can move away from the back of the pharynx, and saliva can flow out of the mouth by gravity. Although monitoring of vital signs is important, a patent airway is the priority. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met. Suctioning may be unnecessary; the child should not be left alone while equipment is obtained.

Which antiepileptic drug is used as the first-line treatment for absence seizures? 1.Phenytoin 2.Diazepam 3.Valproic acid 4.Acetazolamide

3 Valproic acid is used as the first-line treatment for absence seizures. Phenytoin is used to treat partial, secondary, and generalized tonic-clonic seizures. Diazepam is used to treat status epilepticus. Acetazolamide is used as an adjunct drug for the treatment of absence seizures.

A client who is at risk for seizures as a result of severe preeclampsia is receiving an intravenous infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. 1.Proteinuria 2.Epigastric pain 3.Respirations of 10 breaths/min 4.Loss of patellar reflexes 5.Urine output of 40 mL/hr

3,4 A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia. Magnesium sulfate toxicity is not accompanied by proteinuria; proteinuria is a sign of preeclampsia. Epigastric pain is associated with severe eclampsia, not magnesium sulfate toxicity. Urine output of 40 mL/hr is an acceptable output; an output of less than 30 mL/hr may contribute to the development of a toxic level of magnesium.

According to the Healthcare Personnel Vaccination Recommendations, what meningococcal conjugate vaccine dose should a nurse administer to a 12-year-old with an HIV infection? 1.Single initial dose and a booster dose 3 years later 2.Single initial dose and a booster dose 5 years later 3.Single initial dose and a booster dose 7 years later 4.Two initial doses and a booster dose at 16 years old

4 A 12-year-old with HIV would require two primary meningococcal conjugate vaccine delivered two months apart initially and a booster dose at the age of 16 years old. The client would require two initial doses, not a single initial dose, and a booster at 16 years old, not 3, 5, or 7 years later.

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1.Emergency cart 2.Tracheotomy set 3.Padded tongue blade 4.Suctioning equipment and oxygen

4 A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside but would be available in the treatment room or nearby on the nursing unit.

The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure? 1."Does twitching occur in the face and neck?" 2."Does the muscle twitching occur on one side of the body?" 3."Does the muscle twitching occur on both sides of the body?" 4."Does the child have a blank expression during these episodes?"

4 Absence seizures are brief episodes of altered awareness or momentary loss of consciousness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or the face or neck. Myoclonic seizures are brief, random contractions of a muscle group that can occur on one or both sides of the body.

The nurse caring for a child with suspected absence seizures is collecting data from the parents on how to manage the disorder. Which statement, if made by the parents, indicates the presence of signs congruent with this disorder? 1."My child does well with group activities." 2."My child leads the other children during group play." 3."My child is doing really well in school and has high grades." 4."My child's teacher mentioned that he seems to daydream a lot."

4 Absence seizures are very brief episodes of altered awareness. There is no muscle activity except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds but may occur one after another several times a day. The child experiencing absence seizures may appear to be daydreaming. If the child is participating in group activities, they sometimes need help catching up with the group, especially if a seizure occurs. Decreasing grades is a sign of absence seizures, as well as lowered intellectual processes.

A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1.Increasing fluids 2.Administering oxygen 3.Giving a tepid sponge bath 4.Instituting droplet precautions

4 Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort.

A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system? 1.Genitourinary tract 2.Gastrointestinal tract 3.Skin or mucous membranes 4.Cranial apertures or sinuses

4 Infections of cranial structures can cause meningitis because bacteria travel by way of direct anatomic route to the meninges and cerebrospinal fluid (CSF). The other parts of the body do not come into contact with CSF.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2.Maintain neutropenic precautions. 3.No precautions are required as long as antibiotics have been started. 4.Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

4 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the prescribed antibiotic as soon as a culture is obtained. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings? 1.Nausea, delirium, and fever 2.Severe headache and back pain 3.Photophobia, fever, and confusion 4.Severe headache, fever, and a change in the level of consciousness

4 The classic signs/symptoms of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early manifestation and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs/symptoms.

A child is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. What does the nurse conclude about isolation? 1.It is unnecessary during the incubation period. 2.It is required for 7 to 10 days until the fever subsides. 3.It will be unnecessary after the diagnosis is confirmed. 4.It will be necessary for 24 to 72 hours after the initiation of antibiotic therapy.

4 The meningococcal organism is rendered inactive after 24 to 72 hours of antibiotic therapy; isolation is not required after this time. Meningitis is not evident during the incubation period. The presence of a fever is not the influencing factor indicating the need for isolation. After the diagnosis of meningitis is confirmed, isolation is required for 24 to 72 hours after the institution of antibiotic therapy.

The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. Which action should the nurse perform for this test? 1.Tap the child's facial nerve and assess for spasm. 2.Compress the child's upper arm and assess for tetany. 3.Bend the child's head toward the knees and hips and assess for pain. 4.Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain.

4 To test for Kernig's sign, the client's leg is raised with the knee flexed and then extended at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig's sign. This is a common finding in meningitis. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees.

is a crash cart needed for a seizure patient

no unless seizure is not epilepsy/disorder related seizure disorder pts do not need a crash cart present