Peds Neurologic Alterations 3 from Mom
B Activity of the brain An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Percent of functional brain tissue would be determined by a series of tests.
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? A Percent of functional brain tissue B Activity of the brain C Sites of brain injury D Extent of intracranial bleeding
D C, A, D, B, E Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.
A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number A being the first priority and letter E being the last priority). A Check for bladder distention B Raise the head of the bed C Contact the physician D Loosen tight clothing on the client E Administer an antihypertensive medication A C, D, A, B, E B C, A, D, E, B C C, E, D, B, A D C, A, D, B, E
D Cl. difficile has not been linked to meningitis.
A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans? A. S. pneumonia B. H. influenza C. N. meningitis D. Cl. difficile
D Rigid extension and pronation of the arms and legs Decebrate posturing is characterized by the rigid extension and pronation of the arms and legs.
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A Abnormal flexion of the upper extremities and extension of the lower extremities B Flaccid paralysis of all extremities C Rigid pronation of all extremities D Rigid extension and pronation of the arms and legs
B. Ischemic embolism If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.
A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?* A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis
D. The temporal lobe is responsible for hearing, learning, and feelings/emotions
A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected?* A. Frontal lobe B. Occipital lobe C. Parietal lobe D. Temporal
B Placing the client on a Stryker frame Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A Logrolling the client on a firm mattress B Placing the client on a Stryker frame C Keeping the client on a stretcher D Logrolling the client on a soft mattress
2. This type of eye injury is considered blunt force trauma to the eyes, and the child should be evaluated medically for assessment and prevention of eye damage. Slight blurring could indicate eye injuries, such as detached retina and hyphema, which need immediate medical intervention.
What would be the most appropriate advice to give to the parent of a child with slight visual blurring after being hit in the face with a basketball? 1. "Apply ice, observe for any further eye complaints, and bring him back if he has increased pain." 2. "Take him to the emergency department to ensure that he does not have any internal eye damage." 3. "Call your pediatrician if he starts vomiting, is hard to wake up, or has worsening of eye blurring." 4. "Observe for any further eye complaints, headaches, dizziness, or vomiting, and if worsening occurs, take him to your pediatrician."
C An interval when the client is oriented but then becomes somnolent A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.
When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? A An interval when the client's speech is garbled B An interval when the client has a "warning" symptom, such as an odor or visual disturbance. C An interval when the client is oriented but then becomes somnolent D An interval when the client is alert but can't recall recent events
C Ventricular tap, suctioning, use of analgesics, ketogenic diet - A ketogenic diet was not listed as a way to manage ICP
Which of the following are not ways to manage ICP? A Surgery, temperature regulation, suctioning, ventricular tap B Airway management, monitoring ICP, positioning, pain management C Ventricular tap, suctioning, use of analgesics, ketogenic diet D Environmental restrictions, surgery, ventilation, monitor ICP
D Encephalitis
Which of the following is inflammation of the brain? A Meningoencephalitis B Meningitis C Cerebalitis D Encephalitis
A MRI All others are lab and diagnostic tests used to test for meningitis
Which of the following is not a test for meningitis? A MRI B nasopharyngeal culture C CBC D Lumbar puncture
C Lasix is used as a diuretic to reduce ICP
Which of the following medication may be administered for management of ICP? A Abraxane B Cialis C Lasix D Albuterol
D The USA has a high rate of penicillin resistant pneumococi and first line treatment should include vancomycin until sensitivities are known.
A 4 year old girl is admitted with pneumococcal meningitis. She has just returned from a holiday to Disneyland, Florida, 2 days before. What are you going to treat her with: A. Ceftriaxone B. Amoxicillin and gentamicin C. Benzylpenicillin and rifampicin D. Cefotaxime and vancomycin
F ICP is caused by increased pressure from brain masses, blood volume, CSF volume or any combination
Common causes of intracranial pressure (ICP) are: A Viral infections B Brain mass (tumors, edema) C Increased CSF volume D Increased blood volume E All of the above F B, C & D
A Inability to elicit a Babinski's reflex Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A Inability to elicit a Babinski's reflex B Reflex emptying of the bladder C Hyperreflexia D Positive reflexes
A Lack of acquired resistance to the various etiologic organisms Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.
Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A Lack of acquired resistance to the various etiologic organisms B Occlusion or narrowing of the CSF pathway C Congenital anatomic abnormality of the meninges D Natural affinity of the CNS to certain pathogens
C Cloudy CSF, elevated protein, and decreased glucose A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? A Clear CSF, elevated protein, and decreased glucose B Clear CSF, decreased pressure, and elevated protein C Cloudy CSF, elevated protein, and decreased glucose D Cloudy CSF, decreased protein, and decreased glucose
A Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn't a cause of dysreflexia.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A Noxious stimuli B Headache C Lumbar spinal cord injury D Neurogenic shock
C. Liver enzymes. ALT was formerly called SGPT (serum glutamic pyruvic transaminase). It is an enzyme found mainly in liver cells. Smaller amounts are also in other organs of the body. When the liver becomes damaged, this enzyme leaks into the blood. A blood test can measure the level of ALT in the blood. Almost all cases of Reye syndrome have increased levels of certain liver enzymes, including ALT. Other liver enzyme tests are also generally done to check for liver damage. Persistent vomiting after a viral infection, along with high levels of liver enzymes, may mean a case of Reye syndrome. Other possible causes of liver problems, including rare inherited disorders that can mimic Reye syndrome, would also need to be eliminated.
ALT (alanine aminotransaminase) is high in cases of Reye syndrome. What does this test measure? A. Oxygen in the blood B. Glucose levels C. Liver enzymes D. White blood cells E. None of the above
3. Initial and serial neurological assessments would be a priority nursing intervention in a child with a neurological problem. It is to monitor for changes in neurological status.
After airway, breathing, and circulation have been assessed and stabilized, which intervention should the nurse implement for a child diagnosed with encephalitis? 1. Assist with a lumbar puncture, and give reassurance. 2. Obtain a throat culture, then begin antibiotics. 3. Perform initial and serial neurological assessments. 4. Administer antibiotics and antipyretics.
A Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children.
Among children aged 2 months to 3 years, the most prevalent form of meningitis is caused by which microorganism? A. Hemophilus influenzae B. Morbillivirus C. Streptococcus pneumoniae D. Neisseria meningitidis
D. All of the above. Vomiting that begins 3 to 7 days after the chickenpox or flu is one of the main symptoms of Reye syndrome. The vomiting usually becomes more and more severe over the next 12 hours. Other symptoms include listlessness, disorientation, delirium, convulsions, and loss of consciousness. If a child has these symptoms, you should seek medical help right away. In infants, the symptoms of Reye syndrome may not include vomiting.
What are symptoms of Reye syndrome? A. Vomiting that doesn't stop B. Irritability C. Confusion D. All of the above
D. All of the above. It may also be confused with encephalitis or a mental illness, according to the NINDS.
What is Reye syndrome often confused with? A. Meningitis B. Drug overdose C. Poisoning D. All of the above
B Headaches
What is the most common reason kids miss school? A Doctor's appointment B Headaches C Lazy parents D Influenza, pneumonia or common cold
D Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved.
The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test: A. Blood culture. B. Throat and ear culture. C. CAT scan. D. Lumbar puncture.
A False
Dexamethasone improves mortality in meningococcal meningitis A False B True
D Put the client in the high-Fowler's position Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Elevating the client's legs, putting the client flat in bed, or putting the bed in the Trendelenburg's position places the client in positions that improve cerebral blood flow, worsening hypertension.
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A Put the client in the Trendelenburg's position B Elevate the client's legs C Put the client flat in bed D Put the client in the high-Fowler's position
D Total protein of 85mg/dl Total protein should be 15-45mg/dl
Heather is admitted to the hospital with suspected meningitis. Which of the following indicates she is positive for this infection? A Spinal fluid glucose of 65mg/dl B CBC White blood cell of 7,500 mm3 C Intracranial pressure of 110mm/H20 D Total protein of 85mg/dl
A Call DHS to report child abuse All other options are listed as proper management of head trauma
In the case of non-accidental head trauma in infants, which of the below is not a course of management? A Call DHS to report child abuse B Educate the parent about placing the baby in a safe place, checking on them every 15 min and calling for help if they feel desperate C Monitor the child for infection and increased ICP D Order or request CT, MRI, opthamologic exam or x-rays
B Respiratory distress, wide pulse pressure, fixed dilated pupils - in addition, significant change in LOC, bradycardia, & increased systolic BP are signs of late ICP. Option D are early signs of ICP, while the other two options are combinations of early and late signs
Late signs of ICP include A Headache, asymmetrical pupils, fever B Respiratory distress, wide pulse pressure, fixed dilated pupils C Projectile vomiting, bradycardia, change in LOC D Generalized seizures, slight change in vital signs, headache
D All of the above CBC White blood cells should be 5000-10,000 mm3, Neutrophilis should be 65%, appearance of spinal fluid should be clear, glucose should be 50-80 mg/dl, total protein should be 15-45 mg/dl, spinal fluid white blood cells should be 0-3 mm3, cell differential should be 0-1 neutrophils, gram stain should show no bacteria and intracranial pressure should be <140 mm/H20
Little Julie is admitted to the hospital with suspected meningitis. Which of the following indicates she is positive for this infection? A White blood cell 26,000 mm3 B Hazy spinal fluid analysis C Intracranial pressure 185mm/H20 D All of the above
D. None of the above. There is no cure for Reye syndrome. A child who develops the condition and early on is monitored carefully for correct fluid and electrolyte balance has a good chance for recovery. Those who are not diagnosed early enough may develop brain damage or a coma.
What is the treatment for Reye syndrome? A. Antibiotics B. Surgery C. Antiviral medicine D. None of the above
A, D, E Medications to treat ICP include Antibiotics, Anticonvulsants (Dilantin, phenobarbital), benzodiazepines, Analgesics, Osmotic diuretics (Lasix), Corticosteroids
Medicinal treatment for ICP includes which of the following classes of drugs? (select all that apply) A Antibiotics B Phosphodiesterase inhibitors C Bronchodilators D Analgesics E Benzodiazepines F Antihistimines
D Altered level of consciousness, asymmetrical pupils, generalized seizures - in addition, other signs may be headache, SLIGHT change in vital signs & projectile vomiting
Nurse Holly is assessing a child and suspects ICP. Which of the following have lead her to this conclusion? A Inability to remain focused on a toy, constant chewing on fingers, constant desire to nurse B A recent febrile seizure, fever, thick nasal secretions, swelling in the eyes C Projectile vomiting, presence of a rash on face and neck, change in vital signs D Altered level of consciousness, asymmetrical pupils, generalized seizures
E. A and B. It occurs mainly in children, although some cases have been reported in adults. Although Reye syndrome is serious and often fatal, it is rare. The number of cases of Reye syndrome in the U.S. has fallen sharply since parents have been warned not to give children aspirin or products containing aspirin. Children who take aspirin seem to be at higher risk for developing the condition.
Reye syndrome primarily affects which age group? A. Infants B. Children and teens C. Adults D. Older adults (older than 65) E. A and B
C, E, F Tension headaches (associated with stress due to school, anxiety, demanding schedules, fasting, and inadequate sleep)
Tension headaches are most commonly associated with (select all that apply) A menses B viral infection C anxiety D brain tumor E fasting F inadequate sleep
B Nonaccidental head trauma
The leading cause of traumatic death in infancy is A SIDS B Nonaccidental head trauma C Aspiration D Genetic disorders
C Kernig's sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.
The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig's sign. Which finding would indicate the presence of this sign? A. Flexion of the hips when the neck is flexed from a lying position B. Calf pain when the foot is dorsiflexed C. Inability of the child to extend the legs fully when lying supine D. Pain when the chin is pulled down to the chest
D A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, 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 fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. 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 Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A Negative Kernig's sign B Absence of nuchal rigidity C A Glascow Coma Scale score of 15 D A positive Brudzinski's sign
2(. Outbreaks of infectious meningitis are most likely to occur in dense community groups such as college campuses, jails, and military installations.)
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak? 1. Clients recently discharged from the hospital. 2. Residents of a college dormitory. 3. Individuals who visit a third world country. 4. Employees in a high-rise office building.
C Middle ear infection Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumonococcus. A chronically draining ear is frequently also found.
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A Bladder infection B Fractured clavicle C Middle ear infection D Septic arthritis
3(. A positive Kernig's sign (client unable to extend leg when lying flat) and nuchal rigidity (stiff neck) are signs of bacterial meningitis, occurring because the meninges surrounding the brain and spinal column are irritated.)
he nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.
1. Priority nursing intervention with pediatric trauma patients is airway assessment while maintaining cervical spine precautions. If the airway is compromised, immediate corrective action should be taken prior to assessment of breathing
A 10-month-old is carried into the emergency department by her parents after she fell down 15 stairs in her walker. Which would be your highest priority nursing intervention? 1. Assess airway while simultaneously maintaining cervical spine precautions. 2. Assess airway, breathing, and circulation simultaneously. 3. Prepare for diagnostic radiological testing to check for any injuries. 4. Obtain venous access and draw blood for testing.
A Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? A. Instituting droplet precautions B. Administering acetaminophen (Tylenol) C. Obtaining history information from the parents D. Orienting the parents to the pediatric unit
B Tenseness of the anterior fontanel Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Periorbital edema is incorrect because periorbital edema is not associated with meningitis. Positive Babinski reflex is incorrect because a positive Babinski reflex is normal in the infant. Negative scarf sign is incorrect because it relates to the preterm infant, not the infant with meningitis.
A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for: A Positive Babinski reflex B Tenseness of the anterior fontanel C Negative scarf sign D Periorbital edema
A Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? A Reposition the client to avoid neck flexion B Administer 100mg of pentobarbital IV as ordered. C Administer 1 g Mannitol IV as ordered D Increase the ventilator's respiratory rate to 20 breaths/minut
B Untreated bacterial meningitis has a mortality are approaching 100%, so rapid antibiotic treatment is essential. The other interventions will help reduce CNS stimulation and irritation, and should be implemented as soon as possible. Focus: Prioritization
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? Discuss A. Administer codeine 15 mg orally for the patient's headache. B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
B. The cerebellum is important for coordination and balance.
A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?* A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory
C Epidural hematoma An epidural hematoma occurs when blood collects between the skull and the dura mater. In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain's surface.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? A Subarachnoid hemorrhage B Subdural hematoma C Epidural hematoma D Contusion
D Laceration of the middle meningeal artery Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A Thromboembolism from a carotid artery B Venous bleeding from the arachnoid space C Rupture of the carotid artery D Laceration of the middle meningeal artery
C Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A Maintain neutropenic precautions B Maintain enteric precautions C Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics D No precautions are required as long as antibiotics have been started
A "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A "Wake him every hour and assess his orientation to person, time, and place." B "Notify the physician immediately if he has a headache." C "Watch him for keyhole pupil the next 24 hours." D "Expect profuse vomiting for 24 hours after the injury."
C Positive Kernig's sign A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition.
Which of the following assessment data indicated nuchal rigidity? A Positive homan's sign B Negative Kernig's sign C Positive Kernig's sign D Negative Brudzinski's sign
3. Blood cultures should be performed immediately before administration of any antibiotics. Weight will have been taken upon admission to the medical floor, so would not be necessary or of the utmost priority.
The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Weigh the client in hospital attire. 3. Blood cultures 4. Provide a quiet, calm, and dark room.
D. All of the above. Reye syndrome usually occurs when a child is recovering from a viral illness. But it can develop as early as a few days after the viral illness begins. Although healthcare providers don't know what causes the syndrome to develop, research has found that children who take aspirin products during the viral illness are at higher risk for Reye syndrome. That's why you should not give children or teens aspirin (acetylsalicylic acid) or products that contain sodium or bismuth salicylates. Check the labels on over-the-counter (OTC) medicines carefully. The FDA requires that products containing these substances carry a warning label.
Which illness often comes before the development of Reye syndrome? A. Chickenpox B. Influenza (flu) C. Pneumonia D. All of the above
A, C, E Migraine headaches (triggered by stress, foods, menses, fatigue, hunger)
Which of the following are causes for migraine headaches in adolescents ? (Select all that apply) A food B blood pressure C fatigue D viral infection E hunger F thirst
A Fever with severe headache, URI, malaise - in addition, signs include disorientation and confusion, nausea and vomiting
Which of the following are common symptoms of encephalitis? A Fever with severe headache, URI, malaise B Nausea, vomiting, diarrhea, upset stomache C Fever, confusion, enlarged lymph nodes, increased thirst D URI, neurologic signs, neck pain, rash
C Childhood diseases of viral causation such as mumps Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.
Which of the following pathologic processes is often associated with aseptic meningitis? A Ischemic infarction of cerebral tissue B Cerebral ventricular irritation from a traumatic brain injury C Childhood diseases of viral causation such as mumps D Brain abscesses caused by a variety of pyogenic organisms
D Hemorrhagic skin rash DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A Cyanosis B Dyspnea on exertion C Edema D Hemorrhagic skin rash
E. A and D. Although Reye syndrome affects all the organs in the body, it does the greatest damage to the brain and liver. It causes a severe increase in pressure in the brain and massive accumulations of fat in the liver.
Which part of the body is affected the most by Reye syndrome? A. Brain B. Lungs C. Stomach D. Liver E. A and D
