nclex 16

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." Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. The child's shunt will not be affected by the amount of television viewed. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees.

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the following in the order that reflects this progression.

1. Oriented to person, place, and time. 2.Disorientation 3.Obtunded 4.Stupor 5.Coma Levels of consciousness in order from most alert to least alert are orientated to person, place, and time (full consciousness); confusion (disorientation); obtundation; stupor; and finally coma.

A nurse is providing information to the parents of a child diagnosed with absence seizures. Which of the following would the nurse expect to include when describing this type of seizure? Select all that apply.

You might see a blank facial expression after a sudden stoppage of speech. You might have mistaken this type of seizure for lack of attention. This type of seizure is usually short, lasting usually for no more than 30 seconds. This type of seizure is more common in girls than it is in boys. Absence seizures are more common in girls than boys and are characterized by a sudden cessation of motor activity or speech with a blank facial expression or rhythmic twitching of the mouth or blinking of the eyelids. This type of seizure lasts less than 30 seconds and may have been mistaken for inattentiveness because of the subtle changes. Absence seizures are not associated with a postictal state.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate?

"During delivery, your vaginal wall put pressure on the baby's head." Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery The use of forceps is associated with a cephalohematoma. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina.

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which of the following as a risk factor for hemorrhagic stroke?

Arteriovenous malformations (AVMs). Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke. Sickle cell disease is a risk factor for ischemic stroke. Congenital heart defects are risk factors for ischemic stroke. Meningitis or other infection is a risk factor for ischemic stroke

A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate to give in this situation? Select all that apply.

Fosphenytoin. Diazepam. Lorazepam. Commonly used medications for treating status epilepticus include lorazepam, diazepam, and fosphenytoin. Gabapentin and carbamazepine are anticonvulsants used to treat and prevent seizures in general.

While observing a child, the nurse notes that the child's arms and legs are extended and pronated. The nurse interprets this as indicating damage to which of the following?

Midbrain. The observations indicate decerebrate posturing, which occurs with damage to the midbrain. Decorticate posturing as evidenced by arm adduction, elbow flexion with arms over the chest, and wrist flexion with fisted hands indicates damage to the cerebral cortex. Meningeal irritation as with bacterial meningitis is manifested by opisthotonus in an infant. With this position, the head and neck are hyperextended to relieve discomfort. Damage to the cranial nerves would be manifested by defects in motor and/or sensory function depending on the cranial nerves affected.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. Which of the following would the nurse assess? Select all that apply.

Verbal response. Eye opening. Motor response. The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

A 6-year-old has had a viral infection for the past 5 days and is now having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which of the following questions?

"Did you use any medications like aspirin for the fever?" Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol is allowed for viral infections in the school-age child. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome.

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which of the following as a neural tube defect?

Arnold-Chiari malformation. Arnold-Chiari malformation is a deformity of the cerebellar tonsils being displaced into the upper cervical canal. Anencephaly is a neural tube defect. Encephalocele is a neural tube defect Spina bifida occulta is a neural tube defect.

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. Which of the following would the nurse identify as a possible trigger?

Drinking three cans of diet cola Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

When assessing a neonate for seizures, which of the following would the nurse expect to find? Select all that apply.

Elevated blood pressure. Tachycardia. Jitteriness. Ocular deviation. Neonatal seizures may be difficult to recognize but may be manifested by tremors, jitteriness, tachycardia and elevated blood pressure, and ocular deviation. Tonic-clonic contractions typically are more common in older children.

A child is diagnosed with aseptic meningitis. The child's mother states, "I don't know where she would have picked this up." The nurse prepares to respond to the mother, based on the understanding that this disorder is most likely caused by which of the following?

Enterovirus. Aseptic meningitis is the most common type of meningitis, and if a causative organism can be identified, it is usually a virus such as enterovirus. Streptococcus group B is a cause of bacterial meningitis. H. influenza type B is a cause of bacterial meningitis. E. coli is a cause of bacterial meningitis.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which of the following interventions would be most appropriate?

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. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis.

The nurse is caring for an 8-year-old girl who was in a car accident. Which of the following would lead the nurse to suspect a concussion?

The child is easily distracted and can't concentrate. A child with a concussion will be distracted and unable to concentrate. Vomiting and bruising behind the ear are signs of a subdural hematoma. Signs and symptoms of contusions include disturbances to vision, strength, and sensation. Bleeding from the ear and otorrhea are signs of a basilar skull fracture.

A mother has brought her 5-month-old son to the clinic because he has been drowsy and unresponsive. The child has hydrocephalus and had a shunt placed about a month previously. Which of the following symptoms indicate that the shunt is infected?

The child is not responding or eating well. Poor feeding and decreased responsiveness are signs of an infection. The nurse might also observe localized inflammation along the shunt tract. A high-pitched cry suggests increased intracranial pressure due to a shunt malfunction. Decreased and uneven pupil reaction times are symptoms of a shunt malfunction that is causing increased intracranial pressure. Bulging or tense fontanels suggest a shunt malfunction that is causing increased intracranial pressure.

After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on which of the following?

The swelling crosses the midline of the infant's scalp. The fact that the swelling crosses the midline of the infant's scalp indicates caput succedaneum. Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele. If the swelling is limited and does not cross the midline or suture lines, it would suggest cephalohematoma. Low birthweight does not suggest caput succedaneum

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which of the following interventions is most effective for eliminating breakthrough seizures? a.Instructing her teacher how to respond to a seizure b.Placing the child on her side on the floor d.Understanding the side effects of medications e.Treating the child as though she did not have epilepsyc

c, Understanding the side effects of medications. The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem.

The nurse determines that a child is experiencing late signs of increased intracranial pressure based on assessment of which of the following? Select all that apply.

Bradycardia, Irregular respirations, Fixed dilated pupils. Late signs of increased intracranial pressure include bradycardia, fixed and dilated pupils, and irregular respirations. Increased blood pressure and sunset eyes are early signs of increased intracranial pressure.

The nurse assesses a child and finds that the child's pupils are pinpoint. The nurse interprets this finding as indicating which of the following?

Brain stem dysfunction. Pinpoint pupils are commonly observed in poisonings, brain stem dysfunction, and opiate use. Fixed and dilated pupils are associated with brain stem herniation. Dilated but reactive pupils are seen after seizures. A single dilated but reactive pupil is associated with an intracranial mass.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for which of the following?

Closed head injury. A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for closed head injury. Positional plagiocephaly is caused by an infant's head remaining in the same position for too long. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which of the following interventions should the nurse take initially?

Institute droplet precautions in addition to standard precautions. Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Palpating the fontanels is used to assess for hydrocephalus. Educating the family about preventing bacterial meningitis would be appropriate later on once the initial infection has been controlled. Encouraging the mother to hold and comfort the child is an intervention but not the priority one: the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread.

During the physical assessment of a 2r-month-old infant, the nurse suspects the child may have hydrocephalus. Which of the following signs or symptoms was observed?

Dramatic increase in head circumference. A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain. Only one pupil that is dilated and reactive is a sign of an intracranial mass. A closed posterior fontanel would be frequently seen by this age. Vertical nystagmus indicates brain stem dysfunction.