Chapter 38 PrepU question
During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed?
-Increase in head circumference -Only one pupil is dilated and reactive is a sign of intracranial mass
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:
Battle sx
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority? Risk for delayed development Risk for injury Risk for ineffective tissue perfusion: cerebral Risk for self-care deficit: bathing and dressing
Risk for injury
Sx of increased ICP
Bulging fontanels Decrease appetite Restless Trouble sleeping
Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): diuretic. antihistamine. anticonvulsant. steroid.
Steroid Rationale: a steriod: reduce inflammation and pressure on vital centers of brain. Diuretic: reduce edema Anticonvulsant: used with increase ICP to prevent seizure
Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? moderate closed-head injury early closure of the fontanels (fontanelles) congenital hydrocephalus intracranial hemorrhaging
intracranial hemorrhaging
The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? frequent temperature assessment use of anticonvulsant medications ketogenic diet vagus nerve stimulation
use of anticonvulsant medications Rationale: Compete control of seizure can be achieved for most ppl thru using of anticonvulsant drug therapy. Frequent temperature assessment would only be useful in febrile seizure. Ketone diets used to reduce seizure activity Stimulating the left vagus nerve intermittently with electrical pulse to reduce seizure frequency
A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents? "The surgery was successful. Do you have any questions?" "This only happens in 1 out of 2,000 births." "I told you yesterday there would be facial swelling." "I will be watching hemoglobin and hematocrit closely."
"The surgery was successful. Do you have any questions?"
A school-aged child with seizures is prescribed phenytoin sodium, 75 mg four times per day. What instruction would the nurse give the parents regarding this medication? Numbness of the fingers is common while taking this drug The child will have to adhere to good tooth brushing Watching television while taking the drug may cause seizures Even small doses may cause noticeable dizziness
The child will have to adhere to good tooth brushing Rationale: A S/E of phenytoin sodium is gingival hyperplasia. Good tooth brushing helps prevent inflammation under the hypertrophied tissue
During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? Dramatic increase in head circumference Pupil of one eye dilated and reactive Vertical nystagmus Posterior fontanel (fontanelle) is closed
Correct: Dramatic increase in head circumference Build up of fluid in the brain. Only one pupil that is dilated and reactive is a sx of an intracranial mass. Vertical nystagmus indicates brain stem dysfunction.
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?
Positive Kernig sign A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy
The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? She always cries when the person holding her has on glasses...I guess glasses scare her." "She typically breastfeeds, but lately we have had to supplement with some rice cereal." "She has been irritable for the last hour....seems like she is just upset for some reason." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper."
She has been irritable for the last hour....seems like she is just upset for some reason."
The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my children aspirin!" What could the nurse say to begin educating the parent? "Sometimes it is hard to tell what products may contain aspirin." "Do you think that maybe your child took aspirin on his or her own?" "Do not worry; you are in good hands. We have it under control now." "Aspirin in combination with the virus will make the brain swell and the liver fail."
"Sometimes it is hard to tell what products may contain aspirin." Two common medications containing salicylates are bismuth subsalicylate and effervescent heartburn relief antiacid.
The meningococcal vaccine should be offered to high-risk populations. If never vaccinated, who has an increased risk of becoming infected with meningococcal meningitis? Select all that apply. 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates 12-year-old child with asthma 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti 9-year-old child who was diagnosed with diabetes when he was 7 years old 8-year-old child who is in good health
18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates 12-year-old child with asthma 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti 9-year-old child who was diagnosed with diabetes when he was 7 years old
A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? Assess the level of consciousness (LOC). Notify the primary health care provider. Place the child on fall precaution. Place a patch over the client's affected eye.
Assess the level of consciousness (LOC).
The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing in the figure (Decebrate). The nurse is aware that this type of posturing is the result of injury to what area? brain stem cerebral cortex frontal lobe mid-cervical
Brain stem Decerebrate: injury of brain stem Decorticate: damage of cerebral cortex
When assessing a neonate for seizures, what would the nurse expect to find? Select all that apply tachycardia elevated blood pressure jitteriness ocular deviation tonic-clonic contractions
Correct answer: Tachycardia Elevated blood pressure Jitteriness Ocular deviation Tonic-clonic contraction: common in older children
The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? Decorticate posturing and fixed and dilated pupils Decreased pupil reaction and decreased respiration. Headache and sunset eyes Dizziness and irritability
Decorticate posturing and fixed and dilated pupils Rationales: Late sx of increase ICP: Decerebrate or decorticate posturing and fixed and dilated pupils Early sx of increase ICP: Pupil rxn, decrease respiration, HA, sunset eyes, dizziness and irritability
A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate for administration? Select all that apply. Diazepam Lorazepam Fosphenytoin Gabapentin Carbamazepine
Diazepam Lorazepam Fosphenytoin Rationale: Gabapentin and carbamazepine are anticonvulsant used to treat and prevent general seizure
A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? Institute droplet precautions in addition to standard precautions. Encourage the mother to hold and comfort the infant. Educate the family about preventing bacterial meningitis. Palpate the child's fontanels (fontanelles).
Institute droplet precautions in addition to standard precautions.
Absence seizures are marked by what clinical manifestation? A. Brief, sudden onset of increased tone of the extensor muscle B. Loss of motor activity accompanied by a blank stare C. Sudden, brief jerks of a muscle group D. Loss of muscle tone and loss of consciousness
Loss of motor activity accompanied by a blank stare Absence seizure consists of a sudden, a brief arrest of the child's motor activity accompanied by a blank state and loss of awareness. A-Tonic seizure C. myoclonic seizure D-Atonic seizure
Any individual taking phenobarbital for a seizure disorder should be taught: to brush his or her teeth four times a day. never to discontinue the drug abruptly. never to go swimming. to avoid foods containing caffeine.
Never to discontinue the drug abruptly
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? Administer lorazepam rectally to the client. Refer the client to a neurologist. Discuss dietary therapy with the client's caregivers. Protect the child from hitting the arms against the bed.
Protect the child from hitting the arms against the bed.
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? Report the findings to the pediatric health care provider. Reassess the head circumference in 24 hours. Document that the infant has microcephaly. Tell the parent the infant's brain is underdeveloped.
Report the findings to the pediatric health care provider. These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain
The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session? Tell me your concerns about your child's shunt. Call the doctor if she gets a persistent headache. Her autoregulation mechanism to absorb spinal fluid has failed. Always keep her head raised 30º.
Tell me your concerns about your child's shunt. Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.
The nurse helps position a child for a lumbar puncture. correct positioning for this procedure?
The child will placed in a side lying position with knee bent and neck flexed to assist with arching the back. Newborns maybe seated upright with their head bent forward.
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "If he is out of bed, the helmet's on the head." "Bike riding and swimming are just too dangerous." "Use this information to teach family and friends." "You'll always need a monitor in his room."
Use this information to teach family and friends." Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions.
The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? While turning the child's head to the left, the eyes turn to the right. While stimulating the child's foot, the big toe points upward and other toes fan outward. While calling the child's name, the child stares straight ahead and does not turn to the sound. While assessing the child's pupils, there is no change in diameter in response to a light.
While assessing the child's pupils, there is no change in diameter in response to a light. Rationale: To perform the child's eye reflex examination, the nurse shine a penlight into eyes and observe if pupil constrict. Constrict is normal. Lack of pupillary light reflex indicate increase ICP
After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect? hydrocephalus anencephaly encephalocele spina bifida occulta
hydrocephalus Rationale: Hydrocephalus results from an imbalance in the production and absorption of cerebrospinal fluid. In hydrocephalus, cerebrospinal fluid accumulates within the ventricular system and causes the ventricles to enlarge and increases in intracranial pressure. Anencephaly, encephalocele and spina bifida occulta are all neural tube defects.
A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply. oxygen gauge and tubing suction at bedside tongue blade padding for side rails smelling salts
oxygen gauge and tubing suction at bedside padding for side rails
The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain? cerebral angiography lumbar puncture video electroencephalogram computed tomography
video electroencephalogram Rationale: EEG: determine the precise localization of seizure area in the brain. Cerebral angiography: dx vessel defects or space-occupying lesions. Lumbar puncture: dx hemorrhage, infection, obstruction in the spinal canal CT: dx congenital abnormalities such as NTD
A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? Teach the child and his parents to keep a headache diary. Review the signs of increased intracranial pressure with parents. Have the child sleep without a pillow under his head. Have the parents call the doctor if the child vomits more than twice.
Teach the child and his parents to keep a headache diary. A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress.
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Onset and character of fever Degree and extent of nuchal rigidity Signs of increased intracranial pressure (ICP) Occurrence of urine and fecal contamination
Signs of increased intracranial pressure (ICP)
The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. eye opening verbal response motor response fontanels (fontanelles) posture
Eye opening Verbal response Motor response
A 6-year-old child with hydrocephalus had a ventriculoperitoneal (VP) shunt placed 6 weeks ago and now has experienced a seizure, vomiting, and loss of appetite. Which intervention will target the child's priority need? Administer intravenous antibiotics as prescribed. Pad and raise the rails on the child's bed. Educate the parents about seizure precautions. Prepare a menu with the child's favorite foods.
Administer intravenous antibiotics as prescribed. Rationale: The major complications associated with shunts are infection and malfunction. When a shunt malfunctions the child experiences vomiting, drowsiness, and headache. When infection has occurred the child experiences increased vital signs, poor feeding, vomiting, decreased responsiveness, seizure activity and signs of local inflammation along the shunt tract. When an infection occurs the priority of care is to treat the infection with IV antibiotics.
A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." "Since the EEG was negative there must be some other cause for the seizures. The lumbar puncture is necessary to determine what the cause is." "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose." "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder."
"The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Rationale: Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures. 24h EEG can help in diagnosing a seizure disorder
A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? Take vital signs every 4 hours Monitor temperature every 4 hours Decrease environmental stimulation Encourage the parents to hold the child
Decrease environmental stimulation Rationale A child with diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, cause child to cry, in turn increasing ICP. Vitals should initially every hr. Temperature should monitor every 2 hr Children with bacterial meningitis are usually more comfortable if allow to flat bc the position does not increase ICP
A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? "Did you use any medications, like aspirin, for the fever?" "Did you give your child any acetaminophen, such as Tylenol?" "What type of fluids did your child take when he had a fever?" "How high did his temperature rise when he was ill?"
"Did you use any medications, like aspirin, for the fever?" -Reye syndrome S/S of Reye syndrome Severe and continual vomiting, changes in mental status, lethargy, irritability
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever."
"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Febrile seizure occur when the child has a rapid in temp and are not associated with development of seizure later in life. Administer correct acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.
The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine."
"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."
While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? "I will cradle her in my arms after the procedure for at least 30 minutes." "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things." "My child may have a headache after the procedure. If she does, she can have something for the pain." "I need to encourage my child to drink at least 1 glass of water after the procedure."
"I will cradle her in my arms after the procedure for at least 30 minutes." After the procedure , the child is encouraged to lay flat for at least 30 min.
A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."
"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."
The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? "Watch for changes in his behavior or eating patterns." "Call the doctor if he gets a headache." "Always keep his head raised 30 degrees." "Limit the amount of television he watches."
"Watch for changes in his behavior or eating patterns." Rationale: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increase crying, inability to settle down may indicate increase ICP
The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction? "I will watch my baby for irritability and difficulty feeding." "My baby's cerebrospinal fluid is increasing intracranial pressure." "The VP shunt will help drain fluid from my baby's brain." "This shunt is the only surgery my baby will need."
Correct: "This shunt is the only surgery my baby will need." Rationale: VP shunt can be used to drain excess CSF, it will need to be replaced as child grows, require shunt revision surgery at various time during the client's life.
The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? Educate the family on the shunt. Monitor the client for signs of infection. Assess the client's respiratory status. Measure the client's head circumference.
Assess the client's respiratory status.
The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the fully conscious stupor obtunded decreased level of consciousness
Correct: Obtunded Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Fully conscious describes a child who has no neurologic changes. Stupor exists when the child only responds to vigorous stimulation Decrease level of consciousness is vague term that does not describe assessment findings
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Place multiple pillows in the room to assist with propping the child's head up. Provide information regarding policies of the unit's playroom for the parents to review. Gather appropriate equipment and signage for respiratory isolation precautions. Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized.
Gather appropriate equipment and signage for respiratory isolation precautions.
In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? Delayed growth and development related to physical restrictions Risk for injury related to seizure activity Risk for acute pain related to surgical procedure Ineffective airway clearance related to history of seizures
Risk for injury related to seizure activity
