Hockenberry Chapter 30 - Evolve

What is a clinical manifestation of increased intracranial pressure (ICP) in infants?

a. Irritability

b. Photophobia

c. Vomiting and diarrhea

d. Pulsating anterior fontanel

A

What is included in the assessment for the Glasgow Coma Scale?

a. Pupil reactivity and motor response

b. Level of consciousness and verbal response

c. Eye opening and verbal and motor response

d. Intracranial pressure and level of consciousness

C

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hr ago. What is the most essential in this assessment?

a. Reactivity of pupils

b. Doll's head maneuver

c. Oculovestibular response

d. Funduscopic examination to identify papilledema

A

The nurse is caring for a child with multiple injuries who is comatose. What information is accurate related to pain in this child?

a. Cannot occur if the child is comatose.

b. May occur if the child regains consciousness.

c. Requires astute nursing assessment and management.

d. Is best assessed by family members who are familiar with the child.

C

The nurse is caring for a 2-year-old girl who is unconscious but stable after a car accident. Her parents are staying at the bedside most of the time. What is an appropriate nursing intervention?

a. Suggest that the parents go home until she is alert enough to know they are present.

b. Encourage the parents to hold, talk, and sing to her as they usually would.

c. Use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns.

d. Position her with proper body alignment and the head of the bed lowered 15 degrees.

B

Why are infants particularly vulnerable to acceleration-deceleration head injuries?

a. The anterior fontanel is not yet closed.

b. The nervous tissue is not well developed.

c. The scalp of the head has extensive vascularity.

d. Musculoskeletal support of the head is insufficient.

D

What findings would indicate to the nurse further assessment and treatment is needed for a child with mild head injury?

a. Vomiting

b. Sleepiness

c. Headache, even if slight

d. Confusion or abnormal behavior

D

A 3-year-old child is hospitalized after submersion injury. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." What is the appropriate response by the nurse?

a. "He still needs a little extra oxygen."

b. "I'm sure he is fine, but the doctor wants to make sure."

c. "It is important to observe for possible physical reasons for the accident."

d. "The reason for hospitalization is that complications could still occur."

D

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is a priority of nursing care?

a. Initiate isolation precautions as soon as diagnosis is confirmed.

b. Provide environmental stimulation to keep the child awake.

c. Administer antibiotic therapy as soon as it is available.

d. Administer sedatives and analgesics on a preventive schedule to manage pain.

C

A child is brought to the emergency department after experiencing a seizure at school. He has no history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. What is the best response by the nurse?

a. "Epilepsy is easily treated."

b. "Very few children have actual epilepsy."

c. "The seizure may or may not mean that your child has epilepsy."

d. "Your child has had only one convulsion; it probably won't happen again."

C