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.
