Chapter 30: Select all Flashcards
- The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What
clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.)
a. High-pitched cry
b. Poor feeding
c. Setting-sun sign
d. Sunken fontanel
e. Distended scalp veins
f. Decreased head circumference
ANS: A, B, C, E
Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and an increased head
circumference.
- The nurse is caring for a child with increased intracranial pressure (ICP). What interventions should the
nurse plan for this child? (Select all that apply.)
a. Avoid jarring the bed.
b. Keep the room brightly lit.
c. Keep the bed in a flat position.
d. Administer prescribed stool softeners.
e. Administer a prescribed antiemetic for nausea.
ANS: A, D, E
Other measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit environment;
limiting visitors; preventing any sudden, jarring movement, such as banging into the bed; and preventing an
increase in ICP. The latter is most effectively achieved by proper positioning and prevention of straining, such
as during coughing, vomiting, or defecating. An antiemetic should be administered to prevent vomiting, and
stool softeners should be prescribed to prevent straining with bowel movements. The head of the bed should be
elevated 15 to 30 degrees.
- The nurse is preparing to admit a 5-year-old with an epidural hemorrhage. What clinical manifestations
should the nurse expect to observe? (Select all that apply.)
a. Headache
b. Vomiting
c. Irritability
d. Cephalhematoma
e. Pallor with anemia
ANS: A, B, C
The classic clinical picture of an epidural hemorrhage is a lucid interval (momentary unconsciousness)
followed by a normal period for several hours, and then lethargy or coma due to blood accumulation in the
epidural space and compression of the brain. The child may be seen with varying degrees of impaired
consciousness depending on the severity of the traumatic injury. Common symptoms in a child with no
neurologic deficit are irritability, headache, and vomiting. In infants younger than 1 year of age, the most
common symptoms are irritability, pallor with anemia, and cephalhematoma.
- The nurse is caring for a child with a subdural hematoma. The nurse should assess for what signs that can
indicate brainstem compression? (Select all that apply.)
a. Coma
b. Lethargy
c. Hemiplegia
d. Hemiparesis
e. Unequal pupils
ANS: C, D, E
Hemiparesis, hemiplegia, and anisocoria (unequal pupils) are signs of brainstem compression and require
emergency treatment targeted at decreasing increased intracranial pressure. Coma and lethargy are seen with a
subdural hematoma but do not indicate a brainstem compression.
- The nurse is preparing to admit a neonate with bacterial meningitis. What clinical manifestations should the
nurse expect to observe? (Select all that apply.)
a. Jaundice
b. Cyanosis
c. Poor tone
d. Nuchal rigidity
e. Poor sucking ability
ANS: A, B, C, E
Clinical manifestations of bacterial meningitis in a neonate include jaundice, cyanosis, poor tone, and poor
sucking ability. The neck is usually supple in neonates with meningitis, and there is no nuchal rigidity
- The nurse is preparing to admit an adolescent with bacterial meningitis. What clinical manifestations should
the nurse expect to observe? (Select all that apply.)
a. Fever
b. Chills
c. Headache
d. Poor tone
e. Drowsiness
ANS: A, B, C, E
Clinical manifestations of bacterial meningitis in an adolescent include, fever, chills, headache, and
drowsiness. Hyperactivity is present, not poor tone.
- The nurse is caring for a child with meningitis. What acute complications of meningitis should the nurse
continuously assess the child for? (Select all that apply.)
a. Seizures
b. Cerebral palsy
c. Cerebral edema
d. Hydrocephalus
e. Cognitive impairments
ANS: A, C, E
Acute complications of meningitis include syndrome of inappropriate antidiuretic hormone (SIADH), subdural
effusions, seizures, cerebral edema and herniation, and hydrocephalus. Long-term complications include
cerebral palsy, cognitive impairments, learning disorder, attention deficit hyperactivity disorder, and seizures.
- What cerebrospinal fluid (CSF) analysis should the nurse expect with viral meningitis? (Select all that
apply. )
a. Color is turbid.
b. Protein count is normal.
c. Glucose is decreased.
d. Gram stain findings are negative.
e. White blood cell (WBC) count is slightly elevated.
ANS: B, D, E
The CSF analysis in viral meningitis shows a normal or slightly elevated protein count, negative Gram stain, and a slightly elevated WBC. The color is clear or slightly cloudy, and the glucose level is normal
- The nurse is preparing to admit an adolescent with encephalitis. What clinical manifestations should the
nurse expect to observe? (Select all that apply.)
a. Malaise
b. Apathy
c. Lethargy
d. Hypoactivity
e. Hypothermia
ANS: A, B, D
The clinical manifestations of encephalitis include malaise, apathy, and lethargy. There is hyperactivity, not
hypoactivity, and hyperthermia, not hypothermia.
- The nurse is preparing to admit a 7-year-old child with complex partial seizures. What clinical features of
complex partial seizures should the nurse recognize? (Select all that apply.)
a. They last less than 10 seconds.
b. There is usually no aura.
c. Mental disorientation is common.
d. There is frequently a postictal state.
e. There is usually an impaired consciousness.
ANS: C, D, E
Clinical features of complex partial seizures include the following: it is common to have mental disorientation,
there is frequently a postictal state, and there is usually an impaired consciousness. These seizures last longer
than 10 seconds (usually longer than 60 seconds), and there is usually an aura.
11. What effects of an altered pituitary secretion in a child with meningitis indicates syndrome of inappropriate antidiuretic hormone (SIADH)? (Select all that apply.)
a. Hypotension
b. Serum sodium is decreased
c. Urinary output is decreased
d. Evidence of overhydration
e. Urine specific gravity is increased
ANS: B, C, D, E
The serum sodium is decreased, urinary output is decreased, evidence of overhydration is present, and urine
specific gravity is increased in SIADH. Hypertension, not hypotension, occurs.
- The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can
indicate Cushing triad? (Select all that apply.)
a. Fever
b. Flushing
c. Bradycardia
d. Systemic hypertension
e. Respiratory depression
ANS: C, D, E
Cushing triad (systemic hypertension, bradycardia, and respiratory depression) is a late sign of impending brainstem herniation. Fever or flushing does not occur with Cushing triad.
- The nurse is preparing to admit a 10-year-old child with absence seizures. What clinical features of absence
seizures should the nurse recognize? (Select all that apply.)
a. There is no aura.
b. There is a postictal state.
c. They usually last longer than 30 seconds.
d. There is a brief loss of consciousness.
e. There is an occasional clonic movement.
ANS: A, D, E
Clinical features of absence seizures include no auras, a brief loss of consciousness, and an occasional clonic
movement. There is no postictal state, and the seizures rarely last longer than 30 seconds
- The nurse is teaching the parents of a child with a seizure disorder about the triggers that can cause a
seizure. What should the nurse include in the teaching session? (Select all that apply.)
a. Cold
b. Sugared drinks
c. Emotional stress
d. Flickering lights
e. Hyperventilation
ANS: C, D, E
The most common factors that may trigger seizures in children include emotional stress, sleep deprivation,
fatigue, fever, and physical exercise. Other precipitating factors include sleep, flickering lights, menstrual
cycle, alcohol, heat, hyperventilation, and fasting. Cold and sugared drinks are not triggers for seizures
