Buscar
Estás en modo de exploración. debe iniciar sesión para usar MEMORY

   Inicia sesión para empezar

level: Ch 49

Questions and Answers List

level questions: Ch 49

QuestionAnswer
The nurse caring for a child with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema.False
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent what information in regard to seizures?Convulsive activity occurs
A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)?Cloudy appearance
When caring for an infant who is hospitalized with Haemophilus influenzae meningitis, an important nursing intervention for the child would be for the nurse to:check the child's neurological status every 2 hours.
What information is most correct regarding the nervous system of the child?As the child grows, the gross and fine motor skills increase.
Haemophilus influenzae meningitis is usually spread by which of the following methods of transmission?Droplet
The health care provider orders phenytoin 4 mg/kg/day in three divided doses for a child who has a seizure disorder. The child weighs 35 lb and the medication is available at 30mg/5mL. What is the amount in mL for one dose of this child's medication? Round to the nearest tenth.3.5 mL
The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents?Monitor their child's level of sedation.
The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as:Sunsetting
A nurse is preparing a school-aged child for a lumbar puncture. The nurse would expect to position the child in which manner?On her side with the head flexed forward and knees flexed to the abdomen
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room?A private room near the nurses’ station
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?Positive Kernig sign
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?Signs of increased intracranial pressure (ICP)
To detect complications as early as possible in a child with meningitis who’s receiving I.V. fluids, monitoring for which condition should be the nurse’s priority?Cerebral edema
The nurse is assisting to position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure?“For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back.
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse?Gather appropriate equipment and signage for respiratory isolation precautions.
The mother of a 6-month-old states that she does not understand how her child has contracted botulism. What is the best response by the nurse?"Botulism is caused by contaminated food. Honey is a common source."
The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching?"I need to watch for any new bruises or bleeding and let my health care provider know about it."
The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse?Administer lorazepam IV as prescribed.
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 has been irritable for the last hour....seems like she is just upset for some reason."
A doctor orders the placement of an ICP monitor in a patient with cerebral edema. The nurse is aware that this surgery will take place in the infratentorial region of the brain.False
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?“Use this information to teach family and friends.”
What is a true statement regarding status epilepticus?It is a common neurologic emergency in children.
The nurse is caring for a 12-month-old infant diagnosed with Haemophilus influenzae meningitis. Which clinical manifestation would likely have been noted in this child?High-pitched cry and nuchal rigidity
Isabelle, age 7, 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 Isabelle 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 best for the nurse to say to this mother?“This might or might not be a problem. Watch Isabelle 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 mother of a child newly diagnosed with an intellectual disability tells the nurse that her partner disagrees with the diagnosis and believes that the child is perfectly normal. The mother shares with the nurse that she finds this reaction frustrating and confusing. Which action by the nurse would be appropriate in supporting this mother?Reassure the mother that her partner's reaction is a normal stage in the grieving process.
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?Risk for injury related to seizure activity
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.
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.
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?"
The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures?Understanding the side effects of medications
The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding?Indications of increased intracranial pressure
A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority?Protecting the child from harm during the seizure
The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition?Support for maintaining self-esteem because of his altered lifestyle
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?Decrease environmental stimulation
An otherwise healthy 18-month-old child with a history of febrile seizures is in the wellchild clinic. Which statement by the father would indicate to the nurse that additional teaching should be done?“I always keep phenobarbital with me in case of a fever.”
A 9-year-old girl who is suspected of having an infection of the central nervous system is undergoing a lumbar puncture to withdraw cerebrospinal fluid for analysis. The nurse knows that the needle will be introduced into the subarachnoid space at the level of which of the following vertebrae?L4 or L5
Put the following events of a generalized epileptic seizure in correct order:Prodromal period Tonic stage Clonic stage Postictal period
A nursing instructor has completed a class session on Guillain-Barré syndrome. Which statement by a student indicates a need for further education?"Paralysis peaks at about 3 weeks before recovery, but most do not completely recover from the paralysis."
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?"I hate to think that I will need to be worried about his having seizures for the rest of his life."
The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform?Assess the child's level of consciousness.
The premise behind using plasmapheresis in patient diagnosed with Guillain-Barré syndrome includes which of the following?Prevention of demyelination
During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve?Trigeminal
A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, “I had a sinus infection and sore throat a couple of days ago.” The nurse suspects bacterial meningitis based on which findings? Select all that apply.Complaints of stiff neck Photophobia Vomiting
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?Minimal or no alteration in muscle tone, with a brief loss of consciousness
Antibiotic therapy to treat meningitis should be instituted immediately after which event?Collection of cerebrospinal fluid (CSF) and blood for culture
A nurse is caring for a 6-year-old boy with Guillain-Barré syndrome who has been in the hospital with this condition for 3 weeks. Which intervention should the nurse be implementing to prevent deep vein thrombosis in this child?Applying support stockings
A panicked mother calls the health care provider's office and reports that her 5-year-old has a high fever and just had a seizure. The mother asks the nurse what she should do. Which is the nurse's best response?Report to the emergency room for medical evaluation
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.”
The nurse is caring for a child diagnosed with Sturge-Weber syndrome. Which assessment finding supports this diagnosis?port-wine birthmark on the upper part of the face
The nurse is in the room when a child with a seizure disorder is having a seizure. The child is exhibiting generalized jerking muscle movement, and the nurse notes the bed appears to be wet with urine. The child is in which stage of the generalized seizure?Clonic
The nurse is discussing discipline issues with a group of caregivers of preschool-aged children who have a cognitive impairment. One father tells the group that after he tells his child to stop doing something, the child just continues. Parents in the group make the following statements. Which statement indicates an understanding of disciplining the cognitively impaired child?“We wait until a behavior happens a second time and immediately put our child in time out.”
In caring for a child with a seizure disorder, the primary goal of treatment is:the child will be free from injury during a seizure
The nurse is observing a group of children diagnosed with various types of cerebral palsy. One of the children has an awkward and wide-based gait. The nurse recognizes this characteristic as common in which type of cerebral palsy?Ataxic cerebral palsy
A 16-year-old boy reports to the school nurse of headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis?Sunlight is “too bright”
A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion?Febrile seizures are benign in nature.
A nurse is performing a complete neurological examination of a 7-year-old boy. She will now test his cerebellar function. Which of the following tests would be appropriate for this purpose?Ask the boy to touch each finger on one hand with the thumb that hand in rapid succession
When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that applyThe nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions.
In completing a neurologic assessment on a preschool-aged client, the student nurse plans to assess for stereognosis. Which technique demonstrates the proper way to assess for stereognosis?Ask the child to close the eyes and hold out a hand; place a key in the hand. Then ask the child to identify the object
The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question?Initiate an IV of 0.9% NS to run at 250 mL/hr.
The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a “fit" at home. Which inquiry would be best to start with?“What happened just before the seizures?”
The nurse is caring for a child who had a seizure, fell to the ground, and hit and injured his face, head, and shoulders. When notifying the healthcare provider, which type of seizure is the nurse most likely to report?Atonic
The nurse is doing an in-service with a group of peers. The topic of the four stages seen in tonic-clonic seizures is being discussed. Place the following stages seen in the tonicclonic seizure in the order they would occur.Clonic phase Aura Postictal period Tonic phase Prodromal period
A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes: Streptococcus group B Haemophilus influenzae type B Streptococcus pneumoniae Neisseria meningitidis What would the nurse highlight as the most common cause of meningitis in newborns?Streptococcus group B
To detect complications as early as possible in a child with meningitis who’s receiving I.V. fluids, monitoring for which condition should be the nurse’s priority?Cerebral edema
A nurse is performing a neurologic examination of a 5-year-old child. She asks the boy to close his eyes, and then she places a crayon in his hand and asks him to identify it. Which type of ability is the nurse testing for in this boy?Stereognosis
The student nurse is preparing to perform a neurologic exam on a 4-year-old child. Which statement by the student would require an intervention by the nursing instructor?“I will test the child’s remote memory by showing the child my car keys and asking him to remember it and recall it in about 5 minutes.
The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching?"I need to watch for any new bruises or bleeding and let my health care provider know about it."
The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse?Administer lorazepam IV as prescribed.
The mother of a child newly diagnosed with an intellectual disability tells the nurse that her partner disagrees with the diagnosis and believes that the child is perfectly normal. The mother shares with the nurse that she finds this reaction frustrating and confusing. Which action by the nurse would be appropriate in supporting this mother?Reassure the mother that her partner's reaction is a normal stage in the grieving process
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.
The nurse is caring for a child who was injured in a bike accident. The nurse determines that a child is experiencing late signs of increased intracranial pressure based on which assessment findings? Select all that apply.Bradycardia Fixed dilated pupils Irregular respirations
A nurse is examining a boy with cerebral palsy. He has hypertonic muscles and abnormal clonus in his legs and walks on his toes. Which of the following is the type of cerebral palsy that this boy is demonstrating?Spastic
Put the following events of a generalized epileptic seizure in correct order:Prodromal period Tonic stage Clonic stage Postictal period
What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?Projectile vomiting
A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, “I had a sinus infection and sore throat a couple of days ago.” The nurse suspects bacterial meningitis based on which findings? Select all that apply.Complaints of stiff neck Photophobia Vomiting
Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position?Placing the child on your hip
A nurse is providing information to the parents of a child diagnosed with absence seizures. What information would the nurse expect to include when describing this type of seizure? Select all that applyThis type of seizure is more common in girls than it is in boys. You might see a blank facial expression after a sudden stoppage of speech. This type of seizure is usually short, lasting for no more than 30 seconds. You might have mistaken this type of seizure for lack of attention.
A nurse is performing a complete neurological examination of a 7-year-old boy. She will now test his cerebellar function. Which of the following tests would be appropriate for this purpose?Ask the boy to touch each finger on one hand with the thumb that hand in rapid succession
In completing a neurologic assessment on a preschool-aged client, the student nurse plans to assess for stereognosis. Which technique demonstrates the proper way to assess for stereognosis?Ask the child to close the eyes and hold out a hand; place a key in the hand. Then ask the child to identify the object.
A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure?semi-Fowler's position with a parent at the bedside
A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion?Febrile seizures are benign in nature.
The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding?Indications of increased intracranial pressure