Question 1

When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of which of the following?

Accepted Answer

Premature infants, especially those born before 30 weeks, are at higher risk for intracranial hemorrhage due to the fragility of their blood vessels and underdeveloped brain structures.

Question 2

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 of the following problems?

Accepted Answer

Children's larger heads in relation to their bodies and a higher center of gravity make them more prone to falls, which increases the risk of head trauma.

Question 3

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 which of the following?

Accepted Answer

Reye syndrome is associated with acute encephalopathy and fatty liver deposits, leading to increased intracranial pressure as a critical concern. The other options are not directly related to the primary complications of Reye syndrome.

Question 4

The physician has ordered rectal diazepam (Valium) for a 2-year-old boy with status epilepticus. Which of the following instructions is essential for the nurse to teach the parents?

Accepted Answer

Monitoring the child's level of sedation is crucial because diazepam can cause significant sedation, and parents need to be aware of this potential side effect to ensure the child's safety.

Question 5

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, the nurse would expect to implement actions to prevent which of the following?

Accepted Answer

Intracranial arteriovenous malformations (AVMs) are abnormal connections between arteries and veins in the brain that bypass the capillary system. They can lead to increased risk of bleeding within the brain, known as hemorrhagic stroke, due to the high pressure of arterial blood flow directly into veins, which are not designed to handle such pressure. The nurse's plan of care would include actions to prevent a hemorrhagic stroke.

Question 6

A 16-year-old boy complains to the school nurse of headaches and a stiff neck. Which of the following signs and symptoms would alert the nurse that the child may have bacterial meningitis?

Accepted Answer

Sunlight being "too bright" or photophobia is a common symptom of meningitis, indicating sensitivity to light, which along with headaches and a stiff neck, can suggest bacterial meningitis.

Question 7

A 4-year-old boy has a febrile seizure during a well-child visit. Which of the following would be a priority?

Accepted Answer

The priority during a seizure is to protect the child from harm, ensuring they do not injure themselves.

Question 8

The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his breath when he gets frustrated. Which of the following will be most important to include in this plan?

Accepted Answer

It is important to stay close to prevent injury when the child holds his breath, as this behavior can lead to fainting or falls.

Question 9

The nurse is caring for an 8-year-old boy who has chronic epilepsy. Which of the following would be most important to address when teaching the child and parents about living with this condition?

Accepted Answer

Support for maintaining self-esteem is crucial for a child living with chronic epilepsy. This condition can significantly alter a child's lifestyle, including limitations on activities that might trigger seizures, potential social stigma, and the psychological impact of living with a chronic illness. Addressing self-esteem helps the child cope with these changes and promotes a positive self-image.

Question 10

A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which of the following food selections would be most appropriate for his lunch?

Accepted Answer

The ketogenic diet is high in fats, moderate in proteins, and very low in carbohydrates. Fried eggs and bacon fit this description well, while the other options are high in carbohydrates, which are limited in a ketogenic diet.

Question 11

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands the need for this treatment is based on which of the following?

Accepted Answer

Hyperventilation leads to a decrease in PaCO2 levels, which causes cerebral vasoconstriction, thereby reducing intracranial blood volume and intracranial pressure.

Question 12

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. The nurse documents this finding as:

Accepted Answer

Obtunded describes a state where the child is less alert and falls asleep unless stimulated, which matches the scenario described.

Question 13

During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve?

Accepted Answer

The trigeminal nerve (cranial nerve V) is responsible for the sensation in the face and motor functions such as biting and chewing, which are involved in the action of sucking on a pacifier.

Question 14

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:

Accepted Answer

Sunsetting is a condition where the sclera is visible above the iris, often associated with increased intracranial pressure in children.

Question 15

Which of the following would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?

Accepted Answer

Projectile vomiting is an early sign of increased intracranial pressure in children.

Question 16

A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of which of the following into the discussion?

Accepted Answer

Febrile seizures are generally benign and do not typically lead to long-term health issues such as cognitive problems, structural brain damage, or an increased risk of epilepsy.

Question 17

A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates?

Accepted Answer

Myoclonic seizures are not common in neonates. Neonatal seizures are more commonly focal clonic, multifocal clonic, or tonic.

Question 18

Hydrocephalus is suspected in a 4-month-old infant. Which of the following would the nurse expect to assess?

Accepted Answer

Lower extremity spasticity is a common sign in infants with hydrocephalus due to the pressure the excess cerebrospinal fluid puts on the brain, potentially affecting the brain's ability to communicate effectively with the muscles, leading to spasticity or stiffness in the muscles, particularly in the lower extremities.

Question 19

A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they state which of the following?

Accepted Answer

Shunts often need to be replaced or revised as a child grows, so additional surgeries are typically necessary.

Question 20

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which of the following? Select all answers that apply.

Accepted Answer

A stiff neck, photophobia, and vomiting are common symptoms of bacterial meningitis.

Quiz 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder