NEURO CLASS MATERIALS Flashcards
A nurse is caring for the child in with a tonic clonic seizure. The nurse needs to [A] at the start of the seizure as the priority concern is [B].
A) Clear the area around client
B) Safety
The nurse notes that the seizure has been ongoing for more than five minutes. The nurse knows that [A] is the most effective treatment at this time. After the seizure resolves, the priority for the nurse to monitor is [B].
A) diazepam PR (diastat * dial w/amount of med you want to give) - rectal med - most available
B) Bradypnea
note: *tachycardia can be a sign of seizure DURING a seizure
What is concerning?
Seizure resolved ten minutes post medication administration. Client is lethargic and responsive to painful stimuli. Audible sonorous respirations at a rate of 6 bpm with small amount of oral secretions. - Nancy Nurse, RN
- lethargy
- responsive to painful stimuli bc ONLY when painful
- sonorous respirations
- 6 bpm
- oral secretions
*snoring potential sign of obstruction
**lowest level of arousal — concerning
test for non-epileptic seizure —> lift arm and drop it
Choose the actions that should be done within the next 5 minutes, 30 minutes, or 60 minutes (post-ictal)
Perform nasopharyngeal suction *ONLY if concern for aspiration
Perform Bag-Valve-Mask ventilation
Complete documentation
Call for help
Stimulate client
Insert artificial airway
Start an IV
Obtain vital signs
Elevate HOB ** can’t bag a pt with HOB elevated
Perform focused neuro assessment
Right away:
suction - right away if secretions are noted
bag\
call for help
stimulate
IV (maybe)
vitals
neuro assess (throughout)
Within 30
- artificial airway
- IV
WIthin 60
-document
What information should the nurse include in discharge teaching? (SELECT ALL THAT APPLY.)
A. Loosen clothing and ensure safety at the start of a seizure.
B. Place a tongue blade in the client’s mouth during a seizure.
C. The client cannot go swimming, even with a friend.
D. The client should avoid being in a car at night.
E. The client may return to school upon discharge.
F. Illness can be a trigger for clients with seizure disorders.
A, D, E, F
Remove everything that’s a strangulation risk
A newborn with myelomeningocele is transferred to the pediatric hospital for a scheduled repair of the defect. There are no abnormal findings upon admission assessment with the exception of the lumbosacral defect.
See the Provider Prescriptions. Circle or underline the orders which are appropriate for this child; write the rationale for the appropriate orders and the rationale for why the other orders are inappropriate for this child.
Admit to Intensive Care Unit.
Place in an infant warmer.
Position PRONE
Vitals Q1HR
Notify MD if temp >38.5.
Cover sac W/GAUZE SATURATED WITH STERILE SALINE
NPO for surgery. IV fluids to run at maintenance rate.
Obtain baseline head circumference.
The nurse is caring for an infant 3 days after repair of myelomeningocele defect and VP shunt placement.
Infant is irritable and inconsolable with a high pitched cry. Full fontanelle (anterior and posterior). Infant has a large emesis with feeds. - Nancy Nurse, RN
Based upon the assessment findings, the nurse knows that the client is most likely experiencing [A] due to [B]. The nurse knows that the client’s [C] requires further assessment.
A) ICP
B) VP SHUNT MALFUNCTION
C) FOC
The nurse is creating a discharge checklist for clients and families following VP shunt insertion. Which of the following signs and symptoms of shunt malfunction and infection should the nurse include in the teaching plan? (SELECT ALL THAT APPLY.)
A. Emesis
B. Neurological changes
C. Fever
D. Diarrhea or constipation
E. Redness along shunt system
F. Poor feeding
G. Headache
H. Seizures
I. Vision changes
ALL EXCEPT FOR D.
A child with myelomeningocele is started on a bowel management plan. The child’s mother questions why this is being done. Which information should the nurse use as a basis for a response?
A. Lack of innervation to the colon predisposes the child to diarrhea.
B. Lack of innervation to the anal sphincter predisposes the child to being incontinent.
C. Chronic immobility increases the gastric–colic reflex.
D. Chronic immobility decreases the need for regular bowel movements.
B
The parents of a 12-month-old with a neurogenic bladder ask the nurse if their child will always have to be catheterized. Select the nurse’s best response.
A. “Your child will never feel when her bladder is full, so she will always have to be catheterized. Because she is female, she will always need assistance.”
B. “As your child ages, she will likely be able to sense when her bladder is full and will be able to empty it on her own.”
C. “Although your child will not be able to feel when her bladder is full, she can learn to urinate every 4 to 6 hours and therefore not require catheterizations.”
D. “Your child will never be able to completely empty her bladder spontaneously, but there are other options to traditional catheterization. An opening can be made surgically through the abdomen, allowing a catheter to be placed into the opening.” Vesicostomy
D.
All children with myelomeningocele are at risk for latex allergy and should be identified appropriately as applicable: Latex Risk or Latex Allergy. The hospital environment should be checked for latex safety hazards. Circle everything in the room that is concerning.
BANANA, AVOCADO, POINSETTIA, BALLOONS, GLOVES,
DT SO MANY PROCEDURES W/LATEX
The nurse is assessing a group of children for attainment of developmental milestones. Which child requires further evaluation?
A. 2-year-old who is toe walking
B. 6-month-old with head lag
C. 4-month-old who can roll over
D. 7-month-old who recently started crawling
B
A toddler-age client has just been diagnosed with spastic cerebral palsy. What information should the nurse include when teaching parents about the child’s dietary needs and feeding challenges? (SELECT ALL THAT APPLY.)
A. The paralysis of their muscles decreases their caloric need.
B. The spasticity of their muscles increases their caloric need.
C. The hypotonic muscles make eating difficult.
D. The child’s inactivity increases the risk of obesity.
E. Difficulty in swallowing or chewing increases potential for aspiration
B, E.
The nurse is obtaining a health history during the admission of a 4-year-old male. The mother states that child “used to run faster than his older sister but is now slower and is tripping all the time.” Based upon this history, what assessment findings would the nurse expect? (SELECT ALL THAT APPLY.)
A. Large calf muscles
B. Kernig’s sign
C. Ataxic gait
D. Gower’s sign
E. Hypertonia
A, D
A 5-year-old has been diagnosed with Duchenne Muscular Dystrophy. Which nursing intervention(s) would be appropriate? (SELECT ALL THAT APPLY.)
A. Discuss with the parents the potential need for respiratory support.
B. Explain that this disease is easily treated with medication.
C. Suggest exercises that will limit the use of muscles and prevent fatigue.
D. Assist the parents in finding a nursing facility for future care.
E. Encourage the parents to contact the school to develop an IEP.
A - * inspiratory pressure* nip score — assess ventilation
E.
** balance — don’t want to fatigue the kids too much
Match the history, current presentation, priority interventions and medications to the disorder.
CP
DMD
MYELOMENINGOCELE
MENINGITIS
ENCEPHALITIS
