Peds Exam 3 Flashcards
Endocrine, neurologic, and neuromuscular disorders
A patient suffered an injury to the cerebral cortex. They are lying in bed w/ rigid flexion of arms, plantar flexed feet, and extended legs. How would the nurse describe this position?
Decorticate posturing.
A patient suffered a possible brain stem injury. What type of posturing would the nurse expect and what would this look like?
Decerebrate posturing. Rigid extension, pronation of arms and legs, flexed wrists and fingers, clenched jaw, extended neck.
The nurse should know that opisthotonic posturing is associated with which age group? And what is this caused by?
Infants. Severe muscle spasms r/t immature nervous system.
The nurse is assessing a patient that falls asleep when not being stimulated. How would the nurse describe this patient’s LOC?
Obtunded.
During assessment, the nurse notes that the patient has sunset eyes. What is this a sign of and what is this often associated with?
Sign of Increased ICP. Associated w/ hydrocephalus.
Irregular breathing, bradycardia, and hypertension are the components of…
Cushing’s triad.
What is Cushing’s triad associated with?
Increased ICP
What are early signs of ICP?
Headache, N/V, blurred vision, tachycardia.
A patient has decreased LOC, bradycardia, irregular respirations, cheyne-stokes respirations, posturing, and fixed + dilated pupils. What are these signs?
Late signs of increased ICP.
What are the 3 main types of seizures?
- Tonic clonic
- Febrile
- Absence
A patient has spina bifida cystica w/ myelomeningocele, what does the nurse expect to see when assessing the patient’s back?
Sac filled w/ CSF, nerves, and meninges.
A nurse is caring for a patient w/ seizures. The nurse knows that this medication can only be mixed w/ saline, has more side/adverse effects, and must have CA, Mag, folate, and drug level monitored when taking the med..
Phenytoin.
The nurse is caring for a 1 year old patient that has seizures that last 15-20 sec once daily and experiences a short postictal period. What type of seizure is this?
Febrile seizure
A patient on the unit is actively having a seizure. Which actions should the nurse take?
- Do not restrain, loosen restrictive clothing
- Maintain position to provide patent airway (side-lying, oral suction, O2)
- Do not attempt to open mouth or insert artificial airway
- Remove glasses
- Stay w/ them
- Remain calm
The nurse is with a patient who just had a seizure. What should the nurse do?
- Maintain side-lying position
- Monitor VS, breathing, head position, and tongue
- Assess for injuries
- Neuro checks
- Promote rest. re-orient patient
Do not offer food and fluids immediately
The nurse is reviewing the results of a lumbar puncture. What findings indicate bacterial meningitis?
- Decreased glucose
- Increased WBCs
- Increased protein
A patient w/ hydrocephalus has a VP shunt placed. What complication should the nurse monitor for?
Blockage and infection.
The nurse is caring for a patient that has recently been using aspirin. What condition is related to aspirin usage?
Reye Syndrome
Which lab findings would confirm the nurse’s suspicion of Reye Syndrome?
Elevated LFTs, ammonia, bilirubin, and PT
A patient with Reye syndrome has elevated ammonia levels. What complication can arise if this is left untreated?
Encephalopathy.
The nurse knows that assessing for sensation, pulses, skin temp and color, spontaneous movement, and CRT are part of what focused assessment? And when would this assessment be used?
Neurovascular assessment. Used when pt has a fractures.
What are the main complications r/t fractures?
Compartment syndrome and osteomyelitis.
During assessment of a child, the nurse notes that the asymmetrical gluteal folds while in prone position, an unequal # of skin folds on posterior thighs, and one shorter limb. What condition does the nurse suspect?
DDH
When caring for a patient with DDH, what are the nurse’s priorities?
- Neuromuscular assessment
- skin care
- Education
What is a focal point of education regarding management of DDH with a Pavlik harness?
Do not adjust straps, do not remove the harness unless approved by provider (not at all for first few weeks), and do skin care.
A patient undergoes assessment and displays a + Gower’s sign. They are referred for a muscle biopsy where they are noted to have absence of dystrophin. What condition is suspected?
Muscular dystrophy (Duchenne)
What are the priorities of care regarding muscular dystrophy?
Prevent aspiration, encourage mobility, maximize cardiopulmonary function, and address psychosocial aspects r/t the disease.
A nurse recognizes the following complications are r/t which non-progressive condition?
- Seizures, aspiration, delayed growth and development, and hydrocephalus
Cerebral Palsy
A nurse is caring for a patient that just underwent surgery to correct scoliosis. What are the priority nursing actions?
PCA pump for pain management, use log-rolling method, monitor for bleeding (H&H), frequent neurovascular assessments, assess drainage, turn/cough/deep breathe.
A nurse is caring for a patient with type 1 DM. The patient is hypoglycemic and incoherent. which action should the nurse take?
Administer glucagon.
A patient on the unit is hypoglycemic and is fully conscious, what should the nurse do to correct the hypoglycemia?
Give the patient simple carbs PO/ PB cracker.
A patient on the unit is suspected to have growth hormone deficiency. Which diagnostic is used to confirm this diagnoses and what finding indicates a positive diagnosis?
Skeletal survey. Result of bone age +2 standard deviation less than actual age indicates positive diagnosis.
A patient that was diagnosed with GH deficiency is being discharged. What education should be given regarding medication administration?
The patient will be taking synthetic growth hormone (somatotropin) via subcutaneous injection at night, daily, in equal doses.
A patient on the unit is being assessed and is found to have all primary teeth remaining, a prominent forehead, and a high pitched voice. What diagnostic test does the nurse suspect will be ordered? and what condition is suspected?
The nurse should expect a skeletal survey to be ordered. The nurse should suspect growth hormone deficiency.
If a patient has congenital hypothyroidism, what labs would the nurse expect to see in the chart?
Decreased T4, Increased TSH.
What is the 2nd most common injury in physical child abuse?
Fractures
A 16 year old patient presents to the unit w/ severe, persistent vomiting, lethargy, a + Babinski sign, sluggish pupils, and elevated LFTs. What condition do you suspect?
Reye Syndrome
You are caring for a 1 month old infant admitted for FTT r/t poor sucking reflex, hypotonia, and macroglossia. HR- 88, T- 36.6 C, tachypneic w/ moderate intercostal retractions. Based on the findings, what diagnosis does the nurse suspect?
Congenital hypothyroidism
Aspart, lispro, and glulisine are what type of insulin?
Rapid acting
A nurse needs to give short acting insulin. What should she administer?
Regular insulin.
What is intermediate acting insulin?
NPH
Glargine, detemir, and degludec are what type of insulin?
Long acting
A patient exhibits signs of atlantoaxial instability. The nurse should know that this complication if associated w/ what condition?
Trisomy 21
What are the 3 priorities of care regarding a patient w/ Trisomy 21?
- Prevent complications
- Promote nutrition
- G&D support and education.
Why is hourly glucose monitoring done for patients being treated for DKA?
If BG falls more than 100mg/dL/hr cerebral edema may occur.
What daily medication would you expect to be ordered for a child with congenital hypothyroidism?
L Thyroxine
What additional test is used to confirm growth hormone deficiency?
Pituitary function test.
A nurse notices that a patient suddenly has unilateral dilation of a pupil. What do they suspect?
Intracranial mass
A nurse sees a new order for phenytoin via IM injection. What should the nurse do next?
Call the doctor to clarify. IM administration is contraindicated.
The nurse should know that gingival hyperplasia is a common adverse effect of what medicine?
Phenytoin
The nurse knows a positive kernig and brudzinski sign are indicative of what?
Bacterial meningitis
What is considered normal range for ICP?
About 5 to 15 mmHg
A nurse is assessing a patient that has a sac-like protrusion of meninges on the vertebrae. No deficits are noted. What diagnosis does the nurse suspect?
Spina bifida cystica w/ meningocele.
What are the known risk factors for trisomy 21?
Maternal age > 35 and paternal age > 55.
