Chapter 28 Flashcards Preview

Peds > Chapter 28 > Flashcards

Flashcards in Chapter 28 Deck (18):
1

Which of the following phrases describes a characteristic of most neonatal seizures?
a. Generalized seizure
b. Tonic-clonic seizure
c. Well-organized seizure
d. Subtle and barely discernible seizure

Ans: D
Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to maintain a generalized seizure.
The newborn's central nervous system is not sufficiently developed to maintain a tonic-clonic (generalized) seizure.
The newborn's central nervous system is not sufficiently developed to maintain a well-organized seizure.

2

What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
a. Shrill, high-pitched cry
b. Photophobia
c. Pulsating anterior fontanel
d. Vomiting and diarrhea

Ans: A
A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants. The characteristic cry occurs secondary to the pressure being placed on the meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present with diarrhea, it is more indicative of a gastrointestinal disturbance.

3

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. What is the priority assessment for this child?
a. Reactivity of pupils
b. Doll's head maneuver
c. Oculovestibular response
d. Funduscopic examination to identify papilledema

Ans: A
Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine injury.
Assessing for an oculovestibular response is a painful test that should not be done for a child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.

4

The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest
a. neurologic health
b. severe brain damage
c. decorticate posturing
d. decerebrate posturing

Ans: A
The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4 months of age. Therefore, the presence of these reflexes indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes.

5

The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing intervention is to
a. continue to monitor temperature.
b. initiate a pain assessment.
c. apply a hypothermia blanket.
d. administer aspirin stat.

Ans: C
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely important to institute temperature-lowering interventions such as hypothermia blankets and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the priority.
Pain assessments should be ongoing, but this is not the priority at this time. Lowering the body temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not effective with temperatures as high as 105º F (40. 5ºC).

6

The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain
a. cannot occur if the child is comatose.
b. may occur if the child regains consciousness.
c. requires astute nursing assessment and management.
d. is best assessed by family members who are familiar with the child.

Ans: C
Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the nurse should be monitoring physiologic and behavioral manifestations

7

What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child?
a. Suction the child frequently.
b. Provide environmental stimulation.
c. Turn the head side to side every hour.
d. Avoid activities that cause pain or crying.

Ans: D
Nursing interventions should focus on assessment and interventions to minimize pain. These activities can cause the ICP to increase.
Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase ICP.
Environmental stimulation should be minimized because it can increase ICP.
The child's head should not be turned side to side. If the jugular vein is compressed, the ICP can rise.

8

The nurse is caring for a 2-year-old child who is unconscious but stable after a car accident. The child’s parents are staying at the bedside most of the time. What is an appropriate nursing intervention?
a. Suggest that the parents go home until the child is alert enough to know they are present.
b. Use ointment on the lips but do not attempt to cleanse the teeth until swallowing returns.
c. Encourage the parents to hold, talk to, and sing to the child as they usually would.
d. Position the child with proper body alignment and the head of the bed lowered 15 degrees.

Ans: C
The parents should be encouraged to interact with the child. Senses of hearing and tactile perception may be intact, and stimulation is important in the child's recovery.
Suggesting that the parents go home until the child is awake is not recommended. The child may be able to hear that they are present, and this stimulation may assist in recovery.
Oral care is essential in the unconscious child. Mouth care should be done at least twice daily to prevent oral infections.
The head of the bed should be elevated, not lowered, in a child with neurologic involvement.

9

The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration–deceleration head injuries because the
a. anterior fontanel is not yet closed.
b. nervous tissue is not well developed.
c. scalp of head has extensive vascularity.
d. musculoskeletal support of head is insufficient.

Ans: D
The relatively large head size coupled with insufficient musculoskeletal support increases the risk to infants of acceleration–deceleration head injuries.
The lack of closure of the anterior fontanel is not relevant to the development of acceleration–deceleration head injuries in infants.
The lack of well-developed nervous tissue is not relevant to the development of acceleration–deceleration head injuries in infants.
The vascularity of the scalp is not relevant to the development of acceleration–deceleration injuries in infants.

10

The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. The most appropriate nursing action is to
a. notify the practitioner immediately.
b. assess for level of consciousness (LOC).
c. observe closely for signs of increased intracranial pressure (ICP).
d. administer pain medication and assess for response.

Ans: A
The worsening of symptoms may indicate that the ICP is increasing. The practitioner should be notified immediately because this is considered a medical emergency.
Assessing for the LOC should be done as part of the assessment.
The nurse is noting signs of potentially increased ICP as described; therefore, this has already been completed.
Pain medication should not be given, because it can often mask the signs of increasing ICP. The priority nursing intervention is to consult with the practitioner immediately.

11

The postoperative care of a preschool child who has had a brain tumor removed should include
a. recording of colorless drainage as normal on the nurse's notes.
b. close supervision of the child while he or she is regaining consciousness.
c. positioning the child on the right side in the Trendelenburg position.
d. no administration of analgesics.

Ans: B
The child needs to be observed closely, with careful and frequent assessment of the vital signs and monitoring for signs of increasing intracranial pressure. Any changes should be reported immediately to the practitioner.
Colorless drainage may be leakage of cerebrospinal fluid from the incision site. This needs to be reported to the practitioner immediately.
The child should not be positioned in the Trendelenburg position postoperatively.
Analgesics can be used for postoperative pain as needed.

12

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is the major priority of nursing care?
a. Initiate isolation precautions as soon as the diagnosis is confirmed.
b. Initiate isolation precautions as soon as the causative agent is identified.
c. Administer antibiotic therapy as soon as it is ordered.
d. Administer sedatives and analgesics on a preventive schedule to manage pain.

Ans: C
Initiation of antibiotic therapy is the priority action. Antibiotics are begun as soon as possible to prevent death and to avoid resultant disabilities.
Isolation should be instituted as soon as a diagnosis is anticipated and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, then isolation precautions can be discontinued.
Isolation should be instituted as soon as a diagnosis is anticipated and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, then isolation precautions can be discontinued.
Initiation of antibiotics is the priority nursing intervention. Pain should be managed on an as-needed basis.

13

The nurse is planning care for a school-age child with bacterial meningitis. Which nursing intervention should be included?
a. Keep environmental stimuli to a minimum.
b. Avoid giving pain medications that could dull the sensorium.
c. Measure the head circumference to assess developing complications.
d. Have the child move the head side to side at least every 2 hours.

Ans: A
Children with meningitis are sensitive to noise, bright lights, and other external stimuli because of the irritation on the meningeal nerves. The nurse should keep the room as quiet as possible with a minimum of external stimuli, including lighting.
After consultation with the practitioner, pain medications can be used on an as-needed basis.
A school-age child will have closed sutures; therefore, the head circumference cannot change. The head circumference is not relevant to a child of this age.
The child is placed in a side-lying position, with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that increase discomfort and put tension on the neck.

14

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. Based on the nurse’s knowledge of seizures, the nurse recognizes this as
a. absence seizure.
b. generalized seizure.
c. status epilepticus.
d. simple partial seizure.

Ans: C
Status epilepticus is a generalized seizure that lasts more than 30 minutes. This is considered a medical emergency and requires immediate treatment.
Absence seizures are generalized seizures that are characterized by brief losses of consciousness, blank staring, and fluttering of the eyelids.
Generalized seizures are the most common form of seizures. They include tonic-clonic (grand mal) seizures and absence (petit mal) seizures. Tonic-clonic seizures have tonic-clonic activity and loss of consciousness and involve both hemispheres of the brain.
Simple partial seizures are characterized by varying sensations and motor behaviors.

15

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. An important part of the discussion with the parents is that
a. parental protection is essential until the child reaches adulthood.
b. mental retardation is to be expected with hydrocephalus.
c. shunt malfunction or infection requires immediate treatment.
d. most usual childhood activities must be restricted.

Ans: C
Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present.
Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions.
The development of mental retardation depends on the extent of damage before the shunt was placed.
Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions.

16

A child is admitted to the pediatric intensive care unit for a submersion injury. The child’s parents express guilt over the submersion injury to the nurse. The most appropriate response by the nurse is
a. “You will need to watch your child more closely in the future.”
b. “Why did you let your child almost drown?”
c. “Your child will be fine, so don’t worry.”
d. “Tell me more about your feelings.”

Ans: D
The nurse needs to be nonjudgmental and provide the parents an opportunity to express their feelings.
You will need to watch your child more closely in the future is a judgmental statement.
Why did you let your child almost drown? is a judgmental question.
Saying the child will be fine may not be true.

17

The most appropriate nursing intervention when caring for a child experiencing a seizure is to
a. restrain the child when a seizure occurs to prevent bodily harm.
b. place a padded tongue between the teeth if they become clenched.
c. suction the child during the seizure to prevent aspiration.
d. described and document the seizure activity observed.

Ans: D
The priority nursing intervention is to observe the child and seizure and document the activity observed.
The child should not be restrained, because this may cause an injury.
Nothing should be placed in the child’s mouth, because this may cause an injury not only to the child but to the nurse.
To prevent aspiration, the child should be placed on the side if possible to facilitate drainage.

18

A 3-year-old child is status post shunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.)
a. Personality change
b. Bulging anterior fontanel
c. Vomiting
d. Dizziness
e. Fever

Ans: A, C, E