neurosensory & neuromuscular

Question 1

What are the general manifestations of meningitis?

Answer 1

photophobia
nausea
headache

Question 2

What are the manifestations of meningitis in a newborn?

Answer 2

No illness present at birth; progresses w/in a few days
poor muscle tone
weak cry
supple neck

Question 3

What are the manifestations of meningitis from 3 months to 2 years?

Answer 3

seizures w/ a high pitched cry
fever
bulging fontanels
poor feeding

Question 4

What are the manifestations of meningitis from 2 years through adolescence?

Answer 4

seizures (initial sign)
nuchal rigidity
positive brudzinski’s sign & Kernig’s sign (not reliable until 2 years old)

Question 5

What should be monitored with meningitis in newborns & infants?

Answer 5

head circumference & fontanels

Question 6

What requires immediate medical attention with meningitis?

Answer 6

presence of petechiae or a purpuric-type rash

Question 7

What are the priority nursing interventions for meningitis?

Answer 7

ISOLATE!
Correct fluid volume deficits, then restrict fluids until no inc. ICP
keep room cool
slightly elevate HOB or side-lying
NPO if decreased LOC
seizure precautions
decrease stimuli

Question 8

What medications are indicated for meningitis?

Answer 8

Antibiotics
Corticosteroids (dexamethasone)
-not indicated for viral
-most effective for decreasing neuro complications
Analgesics

Question 9

What will the CSF test look like if the infection is bacterial?

Answer 9

cloudy
inc WBC
inc protein
dec glucose
+ gram stain

Question 10

What will the CSF test look like if the infection is viral?

Answer 10

clear
slightly inc WBC
normal or slightly inc protein
normal glucose
- gram stain

Question 11

What are the precautions for meningitis?

Answer 11

droplet
wear a mask
isolation for 24 hrs after antibiotics

Question 12

What position is the patient in during a lumbar puncture for meningitis?

Answer 12

side-lying
head flexed
knees drawn up
assist in holding the child still
4-8 hrs after remain flat in bed

Question 13

What are the manifestations of inc ICP in newborns & infants?

Answer 13

bulging fontanels
separation of cranial sutures
inc head circumference
high-pitched cry
distended scalp veins
bradycardia
resp changes

Question 14

What are the manifestations of inc ICP in children?

Answer 14

headache
N/V
diplopia (double vision)
blurred vision
seizures
Bradycardia
resp changes

Question 15

What are the late manifestations of inc ICP?

Answer 15

alt. pupil response
posturing
dec motor response
Cheyenne-stokes
dec LOC
coma
flexion/extension

Question 16

What is flexion caused by?

Answer 16

dysfunction of cerebral cortex

Question 17

What is extension caused by?

Answer 17

dysfunction at the level of the midbrain

Question 18

What are the priority assessments for inc ICP?

Answer 18

LOC/GCS
pupils
motor activity
sensory perception
verbal response

Question 19

What are the priority interventions for inc ICP?

Answer 19

stabilize spine
airway
o2 sat >95%
insert foley
seizure precautions
calm restful environment

Question 20

What are the interventions to decrease ICP?

Answer 20

keep head midline
HOB >30
avoid hip flexion/extension
minimize oral suction (NO nasal suction)
avoid coughing, blowing nose, straining (stool softener)

Question 21

What findings should you report if inc ICP?

Answer 21

clear fluid (CSF) from ears & nose
bleeding from ears & nose (indicates skull fx)
epidural hematoma
subdural hematoma
cerebral edema
brain herniation

Question 22

Signs of epidural hematoma?

Answer 22

a short period of unconsciousness, then normal for a few hours & then lethargy, and coma

Question 23

Signs of a subdural hematoma?

Answer 23

vomiting
inc head circumference
lethargy
seizures
coma

Question 24

signs of brain herniation?

Answer 24

loss of blinking
loss of gag reflex
pupils don’t react to light
systemic HTN
bradycardia
coma
resp arrest

Question 25

What is a VP shunt used for?

Answer 25

provides primary drainage of CSF to the peritoneum

Question 26

What are the complications of a VP shunt?

Answer 26

shunt malfunction/failure - signs of inc ICP shunt infection (serious) - change in LOC, low-grade fever, dec appetite, sleep disturbances, signs of inc ICP

Question 27

What happens in the tonic phase of a tonic-clonic seizure?

Answer 27

10-30 sec eyes roll upward loss of consciousness contraction of the entire body (flexed arms, extended legs, head & neck) mouth snaps & tongue can be bitten increased salivation BP & HR increase

Question 28

What happens in the clonic phase of a tonic-clonic seizure?

Answer 28

30-50 sec violent jerking movements trunk & extremities have rhythmic contraction & relaxation foaming at the mouth incontinent movements slow down gradually then stop

Question 29

What is the postictal phase in a tonic-clonic seizure?

Answer 29

30 min arouses w/ difficulty confused impaired fine motor movements possible vomiting HA vision/speech difficulties excessive sleeping sore muscles no recollection

Question 30

What are the priority interventions during a seizure?

Answer 30

prevent injury side position loosen tight clothing DO NOT restrain, open their jaw or put anything in their mouth note onset, time, & characteristics of seizure allow seizure to end naturally reorient after, check for injuries

Question 31

What are the priority interventions after a seizure?

Answer 31

side position check VS neuro checks NPO until completely awake reorient and calm the child maintain seizure precautions check if tongue or lips were bitten

Question 32

When should you call EMS during a seizure?

Answer 32

child stops breathing seizures last more than 5 min status epilepticus occurs (seizure >30 min) pupils unequal post-seizure vomiting for 30 min following the seizure the child is unresponsive to pain or cannot be awakened Seizure occurs in water child's first seizure

Question 33

What visual impairments are expected with cognitive & sensory impairments?

Answer 33

myopia hyperopia Astigmatism anisometropia amblyopia strabismus -esotropia -exotropia cataracts glaucoma

Question 34

What hearing impairments are expected with cognitive & sensory impairments in infants?

Answer 34

lack of startle reflex failure to respond to noise absence of vocalization by 7 months lack of response to a spoken word

Question 35

What hearing impairments are expected with cognitive & sensory impairments in older children?

Answer 35

using gestures rather than talking after 15 months failure to develop understood speech by 24 months yelling irritability due to inability to gain attention shy or withdrawn inattentive speaking in monotone

Question 36

What are the nursing interventions for visual impairments?

Answer 36

provide normal to bright light for activities that require close vision assist w/ independence (braille, audiotapes, special computers) corrective lenses or laser surgery

Question 37

What are the nursing interventions for hearing impairments?

Answer 37

promote speech development, lip-reading & use of cued speech (hand gestures w/ verbal Communication) encourage socialization & use aids to promote independence -flashing light when the doorbell or phone rings, telecommunication devices, closed captioning sign language or interpreter help w/ the use of hearing aids

Question 38

How is preschool visual acuity tested?

Answer 38

Snellen chart, tumbling E or picture chart stand 10 feet away with heels on 10 foot mark

Question 39

How is preschool visual acuity tested?

Answer 39

Snellen chart, tumbling E or picture chart stand 10 feet away with heels on 10 foot mark wear glasses keep both eyes open cover 1 eye and read bottom line first must identify 4 out of 6 in the line to pass then start at top and move down

Question 40

What is partial visual impairment?

Answer 40

visual acuity of 20/70 to 20/200

Question 41

What is legal blindness?

Answer 41

visual acuity of 20/200 or worse OR a visual field of 20 degrees or less in the child's better eye