C52:Child With Neurologic Alteration Flashcards
Nursing care of the infant who has had a myelomeningocele repair should include ?
a. securely fastening the diaper
b. measurement of the pupil size
c. measurement of head circumference
d. administration of seizure medications
C. Measurement of Head Circumference
Rationale: Essential as hydrocephalus can develop in these infants.
- A diaper should be placed under the infant but not fastened
Latex allergy is suspected in a child with Spina Bifida. Appropriate interventions include with of the following?
a. avoid use any latex product
b. using only non-allergenic latex products
c. administering medication for long term desensitization
d. teaching family about long-term management of allergic manifestations
A. avoid use of any latex product.
What finding should cause the RN to suspect a diagnosis of spastic cerebral palsy?
a. tremulous movements at rest and with activity
b. sudden jerking movement caused by stimuli
c. writhing, uncontrolled, involuntary movements,
d. clumsy, uncoordinated movements
B. Spastic cerebral palsy, the most common type of cerebral palsy will manifest with hypertonicity and increased deep tendon reflexes. The Childs muscle are very tight and any stimuli may cause a sudden jerking movement.
What is the best response to a father who tells the RN that his son - daydreams at home and that his teacher has observed this behavior at school?
a. your son must have an active imagination
b. can you tell me exactly how many times this occurs in one day?
c. tell me about your son’s activity when you notice the daydreams.
d. he is probably overtired and needs more rest.
C. Tell me about your son’s activity when you notice the daydreams.
Rationale: The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained.
A child with a heady injury remains asleep unless aroused, and when aroused responds briefly before falling back to sleep. What should RN chart for this child’s level of consciousness?
a. Disoriented
b. Obtunded
C. Lethargic
D. stuporous
B. Obtunded -describes an individual who sleeps unless aroused and once aroused has limited interactions with the environment.
The RN is assessing child who was just admitted to the hospital for observation after a head injury. What is the most essential part of RN evaluation to detect early signs of worsening condition?
a. posturing
b. vital signs
c. focal neurological signs
d. level of consciousness
d. level of consciousness
Rationale: alterations in LOC appear earlier in the progression of head injury than do alterations of vital signs, or focal neurological signs.
- Neurologic posturing = neurological damage.
- Vital signs / focal neurological signs are LATER SIGNS OF head injury PROGRESSION
Most appropriate RN action when a child is in the tonic phase of a generalized tonic-clonic seizure?
a. guide the child to the floor if standing and go for help.
b. turn the child’s body on the side
c. place a padded tongue blade between the teeth
d. quickly slip soft restraints on the child’s wrists
B. turn the child’s body on the side.
rationale: side positioning prevents aspiration.
- ## restraints could cause injury so FUCK NO
The father of a new born infant with myelomeningocele asks about the cause of this condition. What response by RN is appropriate?The father of a newborn infant with myelomeningocele asks about the cause of this condition. What response by the nanny is most appropriate?
a. ―One of the parents carries a defective gene that causes myelomeningocele.‖
b. ―A deficiency in folic acid in the father is the most likely cause.‖
c. ―Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele.‖
d. ―There may be no definitive cause identified.
d. ―There may be no definitive cause identified.
rationale:
The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.
Which change in status should alert the nanny to increased intracranial pressure (ICP) in achild with a head injury?
a. Rapid, shallow breathing
b. Irregular, rapid heart rate
c. Increased diastolic pressure with narrowing pulse pressure
d. Confusion and altered mental status
d. Confusion and altered mental status
rationale: The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema. Respiratory changes occur with ICP. One pattern that may be evident is Cheyne–Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with ICP. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.
What is an appropriate nursing intervention for the child with a tension headache?
a. Assess for an aura.
b. Maintain complete bed rest.
c. Administer mild pain medication.
d. Assess for nausea and vomiting.
c. Administer mild pain medication.
Mild pain relievers like acetaminophen or ibuprofen are appropriate for the child with a tension headache.
Which statement by an adolescent indicates an understanding about factors that can trigger migraine headaches?
a. ―I should avoid loud noises because this is a common migraine trigger.‖
b. ―Exercise can cause a migraine. I guess I won‘t have to take gym anymore.‖
c. ―I think I‘ll get a migraine if I go to bed at 9 PM on week nights.‖
d. ―I am learning to relax because I get headaches when I am worried about stuff.‖
d. ―I am learning to relax because I get headaches when I am worried about stuff.‖
Stress can trigger migraines. Relaxation therapy can help the adolescent control stress and headaches. Other precipitating factors in addition to stress include poor diet, food sensitivities, and flashing lights. Visual stimuli, not auditory stimuli, are known to be a common trigger for migraines. Exercise is not a trigger for migraines. The adolescent needs regular physical exercise. Altered sleep patterns and fatigue are common triggers for migraine headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue.
What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain–Barré syndrome (GBS)?
a. Immunosuppressive medications
b. Respiratory valuation
c. Passive range-of-motion exercises d. Anticoagulant therapy
b. Respiratory valuation
rat: Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This is not the priority nursing intervention.
A child is brought to the emergency department in status epilepticus. Which medication should the nanny expect to be given initially in this situation?
a. Clorazepate dipotassium (Tranxene)
b. Fosphenytoin (Cerebyx)
c. Phenobarbital
d. Lorazepam (Ativan)
d. Lorazepam (Ativan)
rat: Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic– clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.The other drugs are used for seizures but are not the first-line treatment for status.
What should be the nanny ‘s first action when a child with a head injury complains of doublevision and a headache, and then vomits?
a. Immobilize the child‘s neck.
b. Report this information to the physician.
c. Darken the room and put a cool cloth on the child‘s forehead.
d. Restrict the child‘s oral fluid intake.
B. report this info to the physician
Any indication of ICP such as double vision, headache, or vomiting should be promptly reported to the physician. Stabilizing the child‘s neck does not address the child‘s symptoms. Darkening the room and giving a cool cloth are comfort measures. A fluid restriction is not needed.
The nanny is preparing a school-age child for computed tomography (CT scan) to assesscerebral function. Which statement should the nanny include when preparing the child?
a. ―Pain medication will be given.‖
b. ―The scan will not hurt.‖
c. ―You will be able to move once the equipment is in place.‖
d. ―Unfortunately, no one can remain in the room with you during the test.‖
b. ―The scan will not hurt.‖
For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. The child will not be allowed to move and will be immobilized. Someone is able to remain with the child during the procedure.
