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Head Injury
Tommy is a 6-year-old boy who fell off the swing yesterday and hit the back of his head on the pavement. He is now in the hospital in the intensive care unit, unresponsive. He has symptoms of increased intracranial pressure (ICP) from the fall.
- What are the clinical symptoms of increased ICP in a child Tommy's age? The correct answers are: Headache, nausea, forced vomiting, diplopia, blurred vision, and seizures
- When cerebral blood flow is decreased, what symptoms frequently occur? Correct Answer The correct answers are: Nausea, fainting, and dizziness 3. Identify the vital sign changes listed below that are associated with brainstem injury following acute head trauma. (Select all that apply.) A. Rapid or intermittent respirations B. Wide fluctuations in pulse C. Widening pulse pressure D. Extreme fluctuations in blood pressure E. Elevated temperature Correct Answer The correct answers are A, B, C, D, and E.
- One of Tommy's nursing diagnoses is Risk for Injury related to physical immobility, depressed sensorium, and intracranial pathologic condition. List four nursing interventions for this nursing diagnosis that focus on maintaining a stable ICP. Correct Answer The correct answer is: A. Elevate the head of the bed 15 to 30 degrees.
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B. Maintain the head in a midline position. C. Avoid pressure on neck veins. D. Avoid flexion or hyperextension of the neck. E. Avoid respiratory procedures such as suctioning. F. Prevent constipation. G. Minimize emotional stress and crying. H. Prevent or relieve pain. I. Monitor ICP. o What is the expected outcome related to the nursing diagnosis presented in question 4? Correct Answer The correct answer is: ICP will remain within safe limits. The child will show no evidence of increased ICP. o Complete the following table describing the diagnostic tests used to assess the extent of Tommy's head injury. Diagnostic Test Rationale for Test How Test Is Performed Brain computed tomographic (CT) scan without contrast Skull radiography Cervical spine radiograph Brain perfusion test o Correct Answer
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Meningitis Marshall is a 9-month-old child admitted to the pediatric nursing unit for Haemophilus influenzae meningitis. He has had no childhood immunizations.
- What clinical behaviors are expected in an infant with meningitis? The correct answers are: o Fever o Poor feeding o Vomiting o Irritability o Seizures o High-pitched cry o Bulging fontanel o Nuchal rigidity Rationale: The classic presentation of meningitis is rarely seen in infants and children between 3 months and 2 years; thus, the symptoms seen in an infant include fever, poor feeding, vomiting, marked irritability, toxic appearance, and frequent seizures accompanied by a high-pitched cry. The most significant findings include a bulging fontanel and nuchal rigidity.
- Definitive diagnosis of meningitis is made on the basis of what test? Correct Answer The correct answer is: Examination of cerebrospinal fluid by means of lumbar puncture. Rationale: Spinal fluid is analyzed for culture, Gram stain, blood cell count, and determination of glucose and protein count. These findings are usually diagnostic: the culture and Gram stain identify the causative organism, the white blood cell count is usually elevated and the glucose level is reduced, and the protein concentration is usually increased.
- Marshall may be kept on low-maintenance levels of fluids to prevent what two conditions? The correct answer is: Cerebral edema and increased intracranial pressure (ICP) Rationale: Increased ICP is avoided because it results in the reduction of cerebral perfusion pressure, which causes harmful neurologic consequences of the illness.
- Could this case of meningitis have been prevented? The correct answer is: Yes, by immunization with Hib vaccine. Rationale: Routine vaccinations for H. influenzae type b are recommended for all children
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beginning at 2 months of age. A significant decline in the incidence of H. influenzae type b disease has occurred since the introduction of the Hib vaccine.
Chapter 31: The Child with Cancer
Acute Lymphoblastic Leukemia
Todd is a 3-year-old child who has acute lymphoblastic leukemia. He is being seen in the oncology clinic for chemotherapy.
- Todd asks the nurse, "What is wrong with my blood?" The nurse's response should be based on knowledge that leukemia results in increased A. platelets. B. red blood cells. C. mature white blood cells. D. immature white blood cells. Correct Answer The correct answer is D. Rationale: A-D. Bone-marrow dysfunction causes a proliferation of immature cells, which depress bone marrow production of the formed elements of the blood by competing for and depriving the normal cells of the essential nutrients for metabolism; thus, platelet, red blood cell, and mature white blood cell production is decreased.
- Todd has some oral ulcers (stomatitis). His parents ask about oral hygiene. The nurse should suggest which of the following? A. Avoid brushing teeth until ulcers heal. B. Use frequent mouthwashes with normal saline. C. Use frequent mouthwashes with hydrogen peroxide. D. Cleanse teeth with lemon glycerin swabs. Correct Answer
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- The chemotherapeutic agents that Todd is receiving usually cause nausea and vomiting. Which of the following is an appropriate nursing intervention? A. Discourage oral intake of fluids. B. Administer antiemetic before chemotherapy begins. C. Administer antiemetic as soon as symptoms begin. D. Explain to Todd and his parents that nausea and vomiting cannot be prevented. Correct Answer The correct answer is B. Rationale: E. Frequent intake of fluids in small amounts should be encouraged to maintain hydration and because smaller portions are better tolerated. F. An initial dose of antiemetic should be given before chemotherapy to prevent the child from ever experiencing nausea and vomiting, thus preventing an anticipatory response. G. The nurse should anticipate a nausea and vomiting response to the chemotherapy and prevent this response by administering the antiemetic before symptoms occur. H. Nausea and vomiting can be prevented by providing an antiemetic before administering chemotherapy and around the clock for as long as nausea and vomiting typically last.
Brain Tumor
Kimberly, a 4-year-old girl, is brought to the emergency department for evaluation because of headache and vomiting upon waking up for the past 2 weeks. Kimberly is admitted to the hospital with a probable brain tumor.
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- Discuss why the most common presenting symptoms of a brain tumor are headache and vomiting. Correct Answer The correct answer is: The headache occurs from traction on pain-sensitive areas, such as the large blood vessels and cranial nerves, and possibly from dural stretching. The headache is worse in the morning from the compression of these structures during sleep. It typically subsides or improves during the day. Vomiting occurs from increased intracranial pressure that compresses the brainstem, directly stimulating the vomiting center in the medulla. (In infants, whose sutures are still open, there may not be any early symptoms.)
- The treatment of choice is total removal of the tumor surgically. Discuss some preoperative teaching that should be given to the child and family. Correct Answer The correct answer is: o Deliver information in small amounts. o Be honest about the surgical procedure (may or may not be able to remove the whole tumor; presurgical conditions such as ataxia and headaches may persist or be temporarily worse after surgery). o Let them know that the child's hair will be shaved before surgery (consider braiding the hair if it is long; show the child how he or she looks at different stages of the shaving process; offer a cap or scarf to cover the head; consider a wig). o Discuss the size of the dressing after the surgery (it usually covers the entire scalp). o Give a brief explanation of how the child will feel and where he or she will be after surgery (the child will usually will be sleepy and have a headache and will be in the intensive care unit).
- In the postoperative period all of the following are normal findings except o a comatose child. o decreased muscle strength. o colorless drainage on the dressing. o a depressed gag, blink, or swallow reflex.
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resulting in a head injury. She has been diagnosed with diabetes insipidus (DI) because of the head injury.
- What are other causes of DI besides head injury? Correct Answer The correct answer is: The most common cause is idiopathic. Other causes include tumor, granulomatous disease, infection, vascular anomaly, and some drugs. 2. Identify the symptoms below that are associated with DI. (Select all that apply.) A. Excessive urination B. Compensatory insatiable thirst C. Dehydration D. Electrolyte imbalance E. Circulatory collapse Correct Answer The correct answers are A, B, C, D, and E.
- What medication is given to Jody for the treatment of DI? The correct answer is: Vasopressin.
- Why is this medication given? Correct Answer The correct answer is: DI causes hyposecretion of the antidiuretic hormone (ADH), known as vasopressin. Replacement is needed to manage DI. 5. What effects are seen from altered pituitary secretion in a child with a head injury? Match the correct disorder with the symptom. (Answers can be used more than once.)
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A. Syndrome of inappropriate antidiuretic hormone (SIADH) B. DI Increased urinary output Increased specific gravity Decreased serum sodium Increased serum sodium
- Correct Answer 7. The correct answers are B, A, A, B.
Chapter 33: The Child with Endocrine Dysfunction
Diabetes Mellitus
Jennifer is a 13-year-old girl who is the youngest child in the Taylor family. She has two older brothers who live at home and attend college in their hometown. Jennifer is in the eighth grade, is active in school sports, and maintains a B average. Her parents are both lawyers with full-time positions. Jennifer is described by her mother as being cheerful, honest, and personable. After a routine urinalysis, she was detected as having glycosuria and is admitted to the hospital for a workup for diabetes mellitus.
- Compare type 1 and type 2 diabetes mellitus on the following characteristics: A. Age of onset B. Percentage of population of persons with diabetes C. Nutritional status D. Islet cell antibodies E. Insulin therapy Correct Answer The correct answer is:
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Rationale: A basic daily meal plan provides a consistent balance of energy-yielding nutrients and a consistent calorie intake. Providing for compensatory changes anticipates a need for extra food during extra activity and extra insulin when eating extra food. Hyperglycemia is avoided by omitting rapidly absorbed simple sugars from regular meal planning. Finally, hypoglycemia is avoided by providing snacks and reasonably consistent meal timing. o What is the expected daily insulin management for Jennifer? Correct Answer The correct answer is: Twice-daily doses of regular and NPH insulin (before breakfast and before evening meal) Rationale: A twice-daily insulin regimen is the conventional method of control. The management regimen usually includes a rapid-acting (regular) insulin and intermediate-acting (NPH) insulin to provide consistent blood glucose levels. o What are two ways that Jennifer can monitor the effectiveness of insulin therapy? Correct Answer The correct answer is: Serum glucose and urine glucose testing Rationale: Urine testing for glucose does not provide optimum results because glucose does not appear in the urine until serum glucose levels are well above the optimum range. Urine testing for ketones is recommended during an illness and whenever blood glucose is 240 mg/dl or higher. Blood glucose monitoring provides an excellent method of insulin adjustment; children adjust their insulin regimen to maintain a serum glucose level between 80 and 120 mg/dl. o What are the developmental implications of this diagnosis for Jennifer? Correct Answer The correct answer is: She needs a good understanding of the management of diabetes (formal
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operations). She may have some rebellion and anger because of being different from her peers, but with a supportive family she can progress positively with her identity. Her close friends are an important factor in her compliance with a diabetic regimen. Formal operational thinking occurs between 11 and 14 years and includes being able to think in abstract terms, think about possibilities, and think through hypotheses. Early adolescents desire conformity to group norms and seek peer affiliation to counter instability generated by rapid change. Close friendships with members of the same sex emerge. o What is the effect of increased exercise on Jennifer's insulin needs? Correct Answer The correct answer is: Reduces insulin need (lowers blood glucose) Rationale: Glucose is the body's source of energy during exercise; therefore, as glucose is broken down and used as energy, less insulin is needed to transport glucose into the cells.
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- In which stage of bone healing would you categorize this child when admitted to the patient care unit? Correct Answer The correct answer is: Stage 1, hematoma formation Rationale: Stage 1 begins at impact and lasts for the first 24 hours. The final result of this stage is the activation of osteoblastic activity.
- Describe the stage of Randy's bone healing 7 days after the injury. Correct Answer The correct answer is: Stage 3, callus formation Rationale: From days 6 to 21, a provisional callus develops, bridging the fractured ends of the bone and holding the bone together; this will not support the body weight.
- What is the average time necessary for the healing of Randy's femoral shaft? Correct Answer The correct answer is: 6 to 8 weeks Rationale: The approximate time for healing of a femoral shaft for a child in the later childhood stage of development is 6 to 8 weeks.
- What clinical manifestations would alert you to the possibility of compartment syndrome? Correct Answer The correct answer is: Deficit of neuromuscular status or weakness and pain; tenseness Rationale: Compartment syndrome occurs when increased pressure within a closed space (e.g., the muscles and nerves of the upper and lower extremities) compromises circulation to the muscles and nerves within this space. The symptoms reflect a deficit or deterioration of neuromuscular status in the anatomic area surrounding the involved structures.
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- What is the pathogen most frequently associated with infection of the bone (osteomyelitis)? Correct Answer The correct answer is: Staphylococcus aureus Rationale: Osteomyelitis is often secondary to a bloodstream infection and can be caused by any bacterial organism; however, S. aureus is the most common pathogen.
- Randy's mother has indicated that her son is "always on the go" and "never sits still." Recommend three activities that would meet Randy's developmental needs while in traction. The correct answer is: Activities to promote industry and concrete operations, such as: o Fishing game (fishing pole magnet, with a paper clip on "fish") o Traction action (pretend decorations such as circus, spaceship, sky) o Traction basketball (Nerf ball) o Walkie-talkies o Punching bag Rationale: Industry and concrete operations are the goals for the cognitive developmental stage of early adolescence.
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D. Bone scan Correct Answer The correct answer is C. Rationale: A-D. The definitive diagnosis is confirmed by MRI, which demonstrates osteonecrosis.
- Joey is upset after the pediatrician describes the treatment for his disease. He wants to finish the baseball season because he is the best hitter on the team. What is the treatment plan for Joey? A. Joey will have to have an operation. B. Joey will have to undergo chemotherapy. C. Joey's activities will be restricted to prevent weight bearing. D. Joey will be placed in a full body cast for several months. Correct Answer The correct answer is C. Rationale: A-D. Joey will need to rest and avoid weight bearing on the right leg to help reduce inflammation and restore motion. He also may need to use a brace, leg cast, or leather harness sling to prevent weight bearing on the affected limb.
- Joey's mother is worried that Joey will never be able to run and play again. What do you know about this disorder that would be appropriate to share with Joey's mother at this time? Correct Answer The correct answer is: Although the disease is self-limiting, the outcome of therapy depends on early and efficient treatment. Younger children have the best prognosis. In many cases, if the child complies with instructions to rest and avoid weight bearing, the prognosis is excellent.
Your Answer
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Chapter 34: The Child with Musculoskeletal or Articular Dysfunction
Osteomyelitis
Matt, 2 years old, is brought to the pediatrician's office for an examination because he is unable to walk. He cries when his leg is moved. After blood tests and an x-ray examination, the physician determines that Matt has osteomyelitis.
- Describe the two sources for acquiring osteomyelitis. Correct Answer The correct answer is: o Exogenous—Acquired by invasion of bone by direct extension from outside as a result of penetrating wound, open fracture, or contamination during surgery o Hematogenous—Spread of organisms from preexisting focus, such as furuncles, skin abrasions, impetigo, otitis media, tonsillitis, infected burns, or poor injection technique
- What signs and symptoms might be seen in a child with acute osteomyelitis? Correct Answer The correct answers are: o Irritability, restlessness o Elevated temperature o Rapid pulse o Dehydration o Localized tenderness o Increased warmth and diffuse swelling over affected bone
