Ricci 38 (2) Flashcards
The nurse is caring for a neonate who is suspected of having sepsis. Which assessment
findings would the nurse interpret as most indicative of sepsis?
A. Rash on face
B. Edematous neck
C. Hypothermia
D. Coughing
Answer: C
Rationale: Premature infants have more fragile capillaries in the periventricular area than term
infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial
deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all
newborns.
The nurse knows that children have larger heads in relation to the body and a higher center of
gravity. When developing a teaching plan for parents, the nurse includes information about an
increased risk for which problem?
A. Febrile seizures
B. Head trauma
C. Caput succedaneum
D. Posterior plagiocephaly
Answer: B
Rationale: The larger head size in relation to the body, coupled with a higher center of gravity,
causes children to hit their head more readily when involved in motor vehicle accidents, bicycle
accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput
succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during
head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture.
The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of
the illness. The nurse would assess the child most carefully for what finding?
A. Indications of increased intracranial pressure
B. An increase in the blood glucose level
C. A decrease in the liver enzymes
D. A presence of protein in the urine
Answer: A
Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if
treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme
levels typically increase. Blood glucose levels and protein in the urine are not characteristic of
this illness.
The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which
instruction is essential for the nurse to teach the parents?
A. Monitor their child’s level of sedation.
B. Watch for fever indicating infection.
C. Gradually reduce the dosage as seizures stop.
D. Monitor for an allergic reaction to the medication.
Answer: A
Rationale: Diazepam is useful for home management of prolonged seizures and requires that the
parents be educated on its proper administration. Monitoring the child’s level of sedation is key
when giving diazepam because it slows the central nervous system. Parents need to monitor the
overall health of the child, including temperature when needed, but that has nothing to do with
the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is
necessary to prevent seizures or status epilepticus. This is not done without a physician’s order.
Monitoring for allergic reactions is necessary when any medications have been prescribed, but is
not specific to diazepam.
- As a result of seizure activity, a computed tomography (CT) scan was performed and showed
that an 18-month-old child has intracranial arteriovenous malformation. When developing the
child’s plan of care, what would the nurse expect to implement actions to prevent?
A. Drug interactions
B. Developmental disabilities
C. Hemorrhagic stroke
D. Respiratory paralysis
Answer: C
Rationale: Intracranial hemorrhage or hemorrhagic stroke is a risk for children with intracranial
arteriovenous malformation. Drug interactions are a risk for children who are treated with
combinations of anticonvulsants for epilepsy. Children with hydrocephalus are at an increased
risk for developmental disabilities. Respiratory paralysis is a risk of botulism that typically
affects infants younger than 6 months of age.
A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or
symptom would alert the nurse that the child may have bacterial meningitis?
A. Fixed and dilated pupils
B. Frequent urination
C. Sunset eyes
D. Sunlight is “too bright”
Answer: D
Rationale: Photophobia, or intolerance of light, is another symptom of bacterial meningitis.
Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention.
Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate
increased intracranial pressure typical of hydrocephalus.
A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a
priority?
A. Hyperextending the child’s head while placing him on his side
B. Using a tongue blade to pry open the child’s jaw
C. Loosening the child’s clothing to ensure a patent airway
D. Protecting the child from harm during the seizure
Answer: D
Rationale: During a seizure, the child should not be held down in a specific position. Protecting
the child’s head and body during the seizure is the priority. Ensuring a patent airway is an
important intervention but is not accomplished by loosening the child’s clothing or
hyperextending his head. The child should be placed on his side and nothing should be inserted
into his mouth to forcibly open the jaw.
The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his
breath when he gets frustrated. What will be most important to include in this plan?
A. Provide cuddle time whenever the child begins to act out.
B. Explain the child’s behavior to the parents.
C. Encourage the parents to interact more with the child.
D. Stay close to prevent injury when he gets frustrated.
Answer: D
Rationale: Encourage the parents to maintain a safe environment when an episode is occurring,
but to avoid giving extra attention to the child after the event since this could encourage
repetition of the behavior. It is important for the parents to understand what is happening, but
rewarding the child with cuddle time when he is misbehaving provides incorrect reinforcement
of behaviors. Encouraging the parents to interact more with the child may be helpful, but the
priority is safety for the child.
The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most
important to address when teaching the child and parents about living with this condition?
A. Multiple corrective surgeries to slowly remove diseased parts of his brain
B. Physical, occupational, and speech therapy to maximize his potential
C. Support for maintaining self-esteem because of his altered lifestyle
D. Hyperventilation therapy to counteract the periods of decreased oxygenation
Answer: C
Rationale: The effects of living with a seizure disorder can be devastating, and it is essential for
the child to receive support to maintain self-esteem. While corrective surgery is possible, it
would only be performed once. Physical, occupational, speech, and hyperventilation therapy are not indicated for treatment of epilepsy.
A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which
food selection would be most appropriate for his lunch?
A. Fried eggs, bacon, and iced tea
B. A hamburger on a bun, French fries, and milk
C. Spaghetti with meatballs, garlic bread, and a cola drink
D. A grilled cheese sandwich, potato chips, and a milkshake
Answer: A
Rationale: The ketogenic diet involves a high intake of fats, adequate protein intake, and a very
low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of
dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates.
Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate,
and the French fries and the milk both contain fat and protein, but both contain a lot of
carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are
protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich
has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and
the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic
meal.
A child with increased intracranial pressure is being treated with hyperventilation. The nurse
understands that after this treatment:
A. PaCO2 levels decrease, causing vasoconstriction.
B. drainage of cerebrospinal fluid occurs.
C. activity is controlled via a stimulator.
D. hyperexcitability of the nerves is reduced.
Answer: A
Rationale: Hyperventilation decreases PaCO2, which results in vasoconstriction and therefore
decreases intracranial pressure. A shunt would allow for drainage of cerebrospinal fluid. A vagal
nerve stimulator is used to provide an appropriate dose of stimulation to manage seizure activity.
Anticonvulsants decrease the hyperexcitability of nerves.
The nurse assesses a child’s level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child’s level of consciousness?
A. Confusion
B. Obtunded
C. Stupor
D. Coma
Answer: B
Rationale: Obtunded is a state in which the child has limited responses to the environment and
falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to
vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful
stimuli.
During a well-child visit, the nurse assesses an infant’s ability to suck on a pacifier. The nurse
is assessing which cranial nerve?
A. Olfactory
B. Trigeminal
C. Facial
D. Accessory
Answer: B
Rationale: To test the trigeminal nerve, the nurse would note the strength of the infant’s suck on a
pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The
facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would
be assessed during spontaneous crying or smiling. The accessory nerve is assessed when the
infant is in the sitting position and symmetry of the head position is noted.
- The nurse inspects the eyes of a child and observes that the sclera is showing over the top of
the iris. The nurse documents this finding as:
A. Decorticate posturing
B. Nystagmus
C. Doll’s eye
D. Sunsetting
Answer: D
Rationale: Sunsetting is when the sclera of the eyes is showing over the top of the iris.
Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held
over the chest, and flexion of the wrists with both hands fisted and the lower extremities
adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements.
Doll’s eye is a maneuver that tests for symmetric eye movement to the opposite side when the
head is turned in the other direction.
What finding would lead the nurse to suspect that a child is beginning to develop increased
intracranial pressure?
A. Bradycardia
B. Cheyne-Stokes respirations
C. Fixed, dilated pupils
D. Projectile vomiting
Answer: D
Rationale: Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia,
Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial
pressure.
