Neurological Conditions Flashcards
Myelomeningocele
Which intervention would the nurse include in the plan of care after the closure of a newborn’s myelomeningocele?
Measuring head circumference daily
The surgical closure of the sac decreases the absorptive surface and eliminates a route by which spinal fluid drains. Because the cranial sutures have not closed, the skull will expand if fluid increases, causing hydrocephalus and an enlarged head circumference.
Seizure
Which action would the nurse take after finding a child having a tonic-clonic seizure?
Protecting the child from self-injury
Because the child is in a crib, the nurse would remain, observe, and protect the child from injury to the head or extremities during seiure activity.
Seizure
Which is the most important safety measure for the nurse to institute immediately when a 2-year-old child has a seizure?
Placing the child in the side-lying position
The side-lying position promotes a patent airway; the tongue can moce away from the back of th epharynx, and saliva can flow out of the mouth by gravity.
VPN
Which education would the nurse provide the parent of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus?
The shunt may need to be replaced as the child grows older
Shunts are updated, with the length of the tubing increased as the child grows.
VPN
Which position would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus?
Supine on the unaffected side
Placing the infant supine will prevent complications from too-rapid reduction of intracranial fluid; placing the infant on the unaffected side will prevent pressure on the shunt valve.
VPN
Which nursing care would the nurse provide for an infant the first 24 hours after surgical placement of a ventriculoperitoneal shunt for hydrocephalus?
Monitoring the infant for increasing intracranial pressure
The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid and increased intracranial pressure.
Meningitis
Which clinical finding would indicate possible meningitis in an infant with an infected ventriculoperitoneal shunt?
Fever
Lethargy
Stiff neck
Poor feeding
A low-grade fever progressing to a high fever occurs in meningitis. An infectious process that causes meningitis may result in rigidity and hyperextension of the neck (opisthotonos). Central nervous system irritation may result in irritability, lethargy, and anorexia.
VPN
Which care plan would the nurse implement for a 1-month-old infant with hydrocephalus scheduled to have surgery for the insertion of a ventriculoperitoneal shunt?
Maintaining a satisfactory comfort level to limit crying
Preventing crying will avoid sudden increases in intracranial pressure.
VPN
A child who has undergone surgery to revise a ventriculoperitoneal shunt is to be discharged. For which behavior would the nurse advise the parent to call the clinic or seek immediate care?
Appears drowsy after a nap and becomes irritable
Drowsiness and irritability are characteristic signs of increasing intracranial pressure; other signs and symptoms includes nausea, projective vomiting, headache, and diminished physical activity.
Meningitis
Which complication would the nurse recognize as the most serious in an infant with meningitis?
Peripheral circulatory collapse
Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock, petechiae, ecchymotic lesions, vomiting, prostration, and hypotension.
Myelomeningocele
A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. Which education would the nurse provide the parent?
The child will probably require a program of intermittent straight catheterization
Most children with spinal cord damage resulting from spina bifida can be managed successfully with a program of intermittent straight catheterization.
Spina Bifida
Which parent education about skin care would the nurse provide to the parents of an infant with spina bifida?
Frequent diaper changes with cleansing are needed
Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown.
