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34 Cards in this Set
- Front
- Back
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Which of the following is characteristic of most neonatal seizures?
Generalized Tonic-Clonic Well organized Subtle and barely discernible |
Subtle and barely discernible. Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting, eye rolling, and arching of the back.
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Which of the following is a clnical manifestation of Increased ICP in infants?
Shrill, high pitched cry photophobia pulsating anterior fontanel Vomiting and diarrhea |
Shrill, high pitched cry. A shrill, high-pitched cry is common clin manifestation of IICP in infants. The characteristic cry occurs secondary to the pressure being placed on the miningeal nerves, causing pain. Photophobia is not indicative of IICP in infants. A pulsating anterior fonanel is normal in infants. Would see a bulging anterior fontanel in IICP. Vomiting is in children.
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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. Which of the following is the priority assessment for this child?
Reactivity of pupils Doll's head maneuver Oculovestibular response Funduscopic exam to identify papilledema |
Reactivity of pupils - indication of neurologic health. Pupils shuld be assessed for no reaction, unilateral reaction, and rate of reactivity.
Dolls head maneuver should not be performed if there is a cervical spine injury. Assessing for oculosvestibular response is a painful test that should not be done on a child ho is having variable levels of consciousness. Papilledema does not develop for 24 - 48 hours in the course of unconsciousness. |
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The nurse is performing a neurologic assessment on a 2-month old infant after a car accident. Moro, tonic neck, wand withdrawal reflexes are present. The nurse should recognize that these reflexes suggest which of the following?
Neurologic health Severe brain damage Decorticate posturing Decerebrate posturing |
Neurologic Health
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The temperature of an adolescent who is unconscious is 105 degrees F. The priority nursing action is to:
Continue to monitor temperature Initiate a pain asessment NON Apply a hypothermia blanket Adminster aspirin stat |
Apply a hypothermia blanket - Brain damage can occur at temperatures as high as 105. It is extremely important to institute temperateure-lowering interventions such as hypothermia blankets and tepid baths immediately.
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The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain:
cannot occur if child is comatose may occur if child regains consciousness requires astute nursing assessmetn and managemetn Is best assessed by family members who are familiar with child. |
Requires astute nursing assessment and management - Since 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.
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Which of the following is a nurinsg intervention used to prevent increased intracranial pressure (ICP) in an unconsious child?
Suction child frequently Provide enviornmental stimulation Turn head side to side every hour Avoid activities that cause pain or crying |
Avoid activities that cause pain or crying.
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The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerale to acceleration-decelearation head injuries because:
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Musculskeletal support of head is insufficient - The relatively large head size coupled with insufficient musculoskeltal support increases the risk to infants of accel-decel head injuries.
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The nusre is admitting a young child to the hospital b/c bacterial meningitis is suspected. Which of the following is the major priority of nursing care?
Initiate isolation precautions as soon as diagnosis confirmed. Initiate isolation precautions as soon as the causative agent is identified. Administered antibiotic therapy as soon as it is orderd Admin sedatives and analgesics on a preventive scheduled to manage pain. |
Admin Antibiotic therapy as soon as the causative agent is identified - Are begun as soon as possible to prevent death and to avoid resultant disabilities.
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The nurse is planning care for a school aged child with bacterial meningitis. Which of the following nursing interventions should be included?
Keep enviornment stimuli to a minimum. Avoid giving pain medications that could dull sensorium. Measure head circumference to assess developing complications Have child move head side to side at least every 2 hours. |
Children with meningitis are sensitive to noise, bright lights, and other extenral stimuli because of the irritation on the meningeal nerves. The nurse should keep the room as quite as possible with a minimum of external stimuli, including lighting. A school aged child will have closed sutures; thus head circum cannot change. Child should be placed on side-lying position with HOB slightly elevated. Should avoid measures such as lifting head that increases discomfort and puts tension on the neck.
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A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is:
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Status epilepticus
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The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. Which of the following should the nurse include:
Parenteral protection is essential until child reaches adulthood. Mental retardation is to be expected with hydrocephalus Shunt malfunction or infection requires immediate treatment. Most usual childhood activities must be restricted |
Shunt malfunction or infection requires immediate treatment
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Cerebral Palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is which of the following?
Birth asphyxia Neonatal diseases Cerebral trauma Prenatal brain abnormalities |
Prenatal brain abnormalities: Most common currently identifiable cause of CP is exhisting brain abnormalities during the prenatal period.
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The major goals of therapy for children with CP include:
Reversing degenerative process that have occurred Curing the underlying defect causing the disorder Preventing spread to individuals in close contract with the chidlren NON Recognizing the disorder early and promoting optimal development |
Recognizing the disorder early and promoting optimal development.
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A 3 year old has CP, and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. Which of the following is the most appropriate nursing action related to feeding the boy?
Bottle- or tube-feed him a sepcialized formula until he gains sufficient weight. Stabilize his jaw with one hand (either from a front or side position) to facilitate swallowing Place him in well-supported , semireclining position to make use of gravity flow. Plae him in a sitting position with his neck hyperextended to make use of gravity flow. |
Stailize his jaw with one hand
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An 8 year old has been diagnosed with moderate cerebral palsy (CP). She recently began participation in a regular classroom for part of the day. Her mother asks the school nurse about joing the after-school Girl Scout troop. The nurse's response should be based on knowledge that:
Most activities such as girl scouts cannot be adapted for children with CP After school activities usually result in extreme fatigue for children with CP trying to participate in activities such as Girl socuts leads to lowering self esteem in children with CP after-school activities often provide children with CP with opportunities for socialization and recreation |
Opportunities for scoializtion and recreation.
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A neural tube defect that is not visible externally in the lumbosacral area would be called:
Meningocele Myelomeningocele Spina bifida Cystica Spina Bifida occulta |
Spina Bifida Occulta: often will not be noticed. A clue to the presence of this internal disorder will be a dimple or tuft of hair on the lumbosacral area.
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A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. The nurses repsonse should be based on which of the following?
There is no genetic basis for the defect Prenatla detection is not possible yet Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. The concentration of a fetoprotein in amniotic fluid can potentially indicate the presence of defect prenatally. |
Fetal ultrasound and elevated concentrations of a - fetoprotein in amniotic fluid many indicate the presence of anecephaly, myelominogecele or other neural tube defects. No chromosoma lstudies that currently diagnose SB
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A 6 year old girl born with a myelomeningocele has a neurogenic bladder. Her parents have been performing clean intermittent catheterization. The nurse should recommend which of the following?
Teach the child to do self cath Teach the child appropriate bladder control Continue having the parents do the cath Encourage the family to consider urinary diversion |
Teach the child to do self- cath _ At 6 years of age this child should have deterity to perform the intermittent cath herself. This will give her more control and master over her disability.
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Which of the following most accurately describes bowel function in children born with myelomeningocele?
Incontinence cannot be prevented Enemas and laxatives are contraindicated Some degree of fecal incontinence can usually be achieved A colostomy is usually required by the time the child reaches adolescence. |
Some degree of fecal continence can usually be achieved - With diet modification and regular toliet habits to prevent constipation and impaction, some degree of fecal continence can be achieved.
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Which of the following is an important nursing intervention when caring for a child with myelomeningocele in preop stage?
Place child on side to decrease pressure on the spinal cord Apply aheat lamp to facilitate drying and toughening of the sac Keep skin clean and dry to prevent irritation from diarrheal stools Measure head circum and examine fontanels for signs that might indicating developing hydrocephalus |
Measure head circum…Obstructive hydrocephalus is freqently associated with myelomeninogcele.
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A child with spina bifida has developed a latex allergy from numerous bladder cathertizations and surgeirs. A priority nursing intervention is to:
Recommend allergy testing. Provide a latex-free enviornement Use only powder-free latex gloves Limit the use of latex products as much as possible |
Provide a latex-free environment. From birht on, limitation of exposure to latex is essnetial in an attempt to minmize sensitization.
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A 3 year old child is scheduled for surgery to remove Wilms Tumor from one kidney. The parents ask the nurse about what treamtents, if any will be necessary after recovery from surgery. The nurse's explanation should be based on knowledge that:
No additonal treatments are usually necessary. Chemo is usually not necessary Chemotherapy with or without radioatherapy is indicated Kidney transplant will be indicated within the year. |
Chemotherapy with or without radioterapy is indicated: Detemrination of chemo and / or radio therapy as tx modatlities will be made based on histologic pattern of the tumor.
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The nurse is caring for a child with Wilms tumor. Which of the following is the most important nursing intervetnion preoperatively?
Avoid abdominal palpation Closely monitor arterial blood gases Prepare child and family for long-term dialysis Prepare child and family for renal transplantation |
Avoid abdominal palpation: Wilms tumors are encapsulated. It is extremely important to avoid any palpation of the mass to minimize the risk of disemination of cancer cells to adjacent and other sites. A sign should be placed over the bed indicating that no abdominal palpation should be conducted.
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The newborn diagnosed with phenylketonuria (PKU) will require long-term follow-up to assess for the development of:
Obesity Diabetes Insipidus Resp distress Mental retardation |
Mental Retardation: PKU an inborn error of meatabolism, may lead to mental retardation if early intervetnion is not performed.
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When planning care for an infant diagnosed with a myelominocele, it is MOST important the nurse identifieds which of the following principles of nursince care is MOSt important to paply when caring for an infant with myelomingocele?
Asepsis Exercise Hygiene Rest |
Asepsis : infection may cause meningitis and damage the brain; the CNS is very delicate; asepsis is extremly important.
Infant placed in prone position; head turned to one side for feeding; gentle ROB may be restricted to foot, ankle, and knee joints, Diapering may be contraindicated until after surgical repair of defect; change paddening benath infant as needed Frequent stroking and caressing wil meet need for tactile stimulation |
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Home care monitors pediatric client diagnosed with chrnoic seizure disorder. The nurse should intervene if which of the following is observed?
The parent takes the child's temp using an oral electronic thermometer Parent encourages child to play with boats during bath time Child wears a helmet when riding a bicycle The child eats p nut buta and jelly sand. |
The parent takes the child's temp with oral electronic thermometer: Seizures can occur without warning ; its dangerous to have a thermometer in the mouth b/c the child may start seizing.
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A four-week-old infant is brought to a health care provider by the parent b/c of vomiting and abdomianl distention. The infant is diagnosed as having pyloric stenosis and is admitted to the hospital. The nurse should expect the infan'ts emesis to have which of these qualities?
Black in apperance Diminished after feeindgs Be projectile Be accompanied by diarrhea |
Be projectile: other symptoms include weight loss, constipaiotion, dehydration, visible peristalic waves.
Coffe ground enemsis indicates bleeding; pyloric stenosis is obstruction of the passage way from the stomach to the duodenum due to enlargement of the sphincter muscle vomiting ocurs after feeindg; give small freq meals and psotion infant upright. May cause constipation not diarrhea. |
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The nurse performs a home care visit for a child diagnosed with cystic fibrosis. The nurse should intervene if which of the following is observed?
The child eats a high-protein, high cal diet The child has two to three stools per day The child swallows the pancreatic enzyme capsules whole. The child takes the pancreatic enzymes on hour after eating |
The child takes enzyme capusles one hour after eating: Should be taken at beginning of meal or with snacks or withing 30 min of eating; chewing or crushing beads destroys enteric coating.
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The nurse performs assessments in the well-baby clinic. The nurse identifies which of the following is a warning sign of CP?
The infant has poor head control after 3 months The infant sits with support by 8 months The infant uses arms and legs to crawl across the room The infant smiles at the mother by 3 months |
The infant has poor head control after 3 months
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A 3 day old infant is born with a myelomeningocele. The nurse caring for the neonate should place the infant in which of the following positions?
Prone Fowler's Trendelenburg's Sidelying |
Prone: Neural tube fails to close and fuse during development: prone position helps prevent pressure on the fatlike protrusion on the back; pressure on the area may rsult in IICP and may also cause a rupture of the sac leading to infection
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The nurse supervises a family caring for a child diagnosed with CP. The nurse should intervene if which of the folowing is observed?
The parent allows the child to rest prior to a physical therapy session The child wears a helmet when ambulationg in the house The older sister places a toy in the child's hands The parents offere high-calorie snacks to the child |
Apply a moist, sterile dressing
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Prior to surgery for myelomeningocele, which of the following actions should the nurse perform to care for the area of the defect?
Cleans the defect and leave the defect open to air Apply a dry steril dressing Apply a moist sterile dresing Apply antibiotic ointment and leave the area open to air |
Moist sterile dressing
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The nurse cares for an infant immediately after insertion of a shunt due to hydrocephalus. Which of the folowing observations by the nurse should be reported to the physician immediately?
The infant is lying flat in bed The infan'ts pupils are dilated The suture is pink Bowel sounds are heard in all quadrants |
Pupils dilated = IICP
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