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PEDIATRICIANS REVISION EXAM CHAPTER 3
A 17-year-old with type 1 diabetes mellitus tells the school nurse about recently starting to drink alcohol with friends on weekends. The most appropriate intervention by the nurse is to A. tell the adolescent not to drink alcohol. B. ask the adolescent about the reasons for drinking alcohol. C. teach the adolescent about the effects of alcohol on type 1 diabetes mellitus and how to prevent problems associated with alcohol intake. D. recommend counseling so that the adolescent understands the serious consequences of alcohol consumption. - C. teach the adolescent about the effects of alcohol on type 1 diabetes mellitus and how to prevent problems associated with alcohol intake. The nurse is taking a proactive approach. The adolescent is provided with information to facilitate the management of the illness. Telling someone not to drink will not help should the person choose to continue drinking. Asking the adolescent why the drinking is occurring will provide information to the nurse but will not address the information that the adolescent needs to have about managing the disease. Counseling can be included in the teaching plan. Which of the following phrases describes a characteristic of most neonatal seizures? A. Generalized seizure B. Tonic-clonic seizure C. Well-organized seizure
D. Subtle and barely discernible seizure - D. Subtle and barely discernible seizure Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting, eye rolling, and arching of the back. The newborn's central nervous system is not sufficiently developed to maintain a generalized seizure. The newborn's central nervous system is not sufficiently developed to maintain a tonic-clonic (generalized) seizure. The newborn's central nervous system is not sufficiently developed to maintain a well-organized seizure. What is a clinical manifestation of increased intracranial pressure (ICP) in infants? A. Shrill, high-pitched cry B. Photophobia C. Pulsating anterior fontanel D. Vomiting and diarrhea - A. Shrill, high-pitched cry A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants. The characteristic cry occurs secondary to the pressure being placed on the meningeal nerves, causing pain. Photophobia is not indicative of increased ICP in infants. A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a bulging anterior fontanel. Vomiting is one of the signs of increased ICP in children, but when present with diarrhea, it is more indicative of a gastrointestinal disturbance.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe brain damage. Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes. Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes. The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing intervention is to A. continue to monitor temperature. B. initiate a pain assessment. C. apply a hypothermia blanket. D. administer aspirin stat. - C. apply a hypothermia blanket. Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely important to institute temperature-lowering interventions such as hypothermia blankets and tepid water baths immediately. The temperature needs to be monitored, but lowering the temperature is the priority. Pain assessments should be ongoing, but this is not the priority at this time. Lowering the body temperature is the priority. Aspirin should never be administered to a child, because of the risk of Reye syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not effective with temperatures as high as 105º F (40. 5ºC). The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain
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. requires astute nursing assessment and management. Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain. Pain can occur in the comatose child. The child can be in pain while comatose. The family can provide insight into the child's different responses, but the nurse should be monitoring physiologic and behavioral manifestations. What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? A. Suction the child frequently. B. Provide environmental stimulation. C. Turn the head side to side every hour. D. Avoid activities that cause pain or crying. - Avoid activities that cause pain or crying. Nursing interventions should focus on assessment and interventions to minimize pain. These activities can cause the ICP to increase. Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase ICP. Environmental stimulation should be minimized because it can increase ICP.
The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration- deceleration head injuries because the A. anterior fontanel is not yet closed. B. nervous tissue is not well developed. C. scalp of head has extensive vascularity. D. musculoskeletal support of head is insufficient. - D. musculoskeletal support of head is insufficient. The relatively large head size coupled with insufficient musculoskeletal support increases the risk to infants of acceleration-deceleration head injuries. The lack of closure of the anterior fontanel is not relevant to the development of acceleration-deceleration head injuries in infants. The lack of well-developed nervous tissue is not relevant to the development of acceleration-deceleration head injuries in infants. The vascularity of the scalp is not relevant to the development of acceleration- deceleration injuries in infants. The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. The most appropriate nursing action is to A. notify the practitioner immediately. B. assess for level of consciousness (LOC). C. observe closely for signs of increased intracranial pressure (ICP). D. administer pain medication and assess for response. - A. notify the practitioner immediately.
The worsening of symptoms may indicate that the ICP is increasing. The practitioner should be notified immediately because this is considered a medical emergency. Assessing for the LOC should be done as part of the assessment. The nurse is noting signs of potentially increased ICP as described; therefore, this has already been completed. Pain medication should not be given, because it can often mask the signs of increasing ICP. The priority nursing intervention is to consult with the practitioner immediately. The postoperative care of a preschool child who has had a brain tumor removed should include A. recording of colorless drainage as normal on the nurse's notes. B. close supervision of the child while he or she is regaining consciousness. C. positioning the child on the right side in the Trendelenburg position. D. no administration of analgesics. - B. close supervision of the child while he or she is regaining consciousness The child needs to be observed closely, with careful and frequent assessment of the vital signs and monitoring for signs of increasing intracranial pressure. Any changes should be reported immediately to the practitioner. Colorless drainage may be leakage of cerebrospinal fluid from the incision site. This needs to be reported to the practitioner immediately. The child should not be positioned in the Trendelenburg position postoperatively. Analgesics can be used for postoperative pain as needed.
Children with meningitis are sensitive to noise, bright lights, and other external stimuli because of the irritation on the meningeal nerves. The nurse should keep the room as quiet as possible with a minimum of external stimuli, including lighting. After consultation with the practitioner, pain medications can be used on an as- needed basis. A school-age child will have closed sutures; therefore, the head circumference cannot change. The head circumference is not relevant to a child of this age. The child is placed in a side-lying position, with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that increase discomfort and put tension on the neck. A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. Based on the nurse's knowledge of seizures, the nurse recognizes this as A. absence seizure. B. generalized seizure. C. status epilepticus. D. simple partial seizure. - C. status epilepticus. Status epilepticus is a generalized seizure that lasts more than 30 minutes. This is considered a medical emergency and requires immediate treatment. Absence seizures are generalized seizures that are characterized by brief losses of consciousness, blank staring, and fluttering of the eyelids. Generalized seizures are the most common form of seizures. They include tonic- clonic (grand mal) seizures and absence (petit mal) seizures. Tonic-clonic seizures have tonic-clonic activity and loss of consciousness and involve both hemispheres of the brain.
Simple partial seizures are characterized by varying sensations and motor behaviors. The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. An important part of the discussion with the parents is that A. parental protection is essential until the child reaches adulthood. B. mental retardation is to be expected with hydrocephalus. C. shunt malfunction or infection requires immediate treatment. D. most usual childhood activities must be restricted. - C. shunt malfunction or infection requires immediate treatment. Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions. The development of mental retardation depends on the extent of damage before the shunt was placed. Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions. A child is admitted to the pediatric intensive care unit for a submersion injury. The child's parents express guilt over the submersion injury to the nurse. The most appropriate response by the nurse is A. "You will need to watch your child more closely in the future." B. "Why did you let your child almost drown?" C. "Your child will be fine, so don't worry."
A 3-year-old child is status post shunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.) A. Personality change B. Bulging anterior fontanel C. Vomiting D. Dizziness E. Fever - A. Personality change, C. Vomiting, E. Fever
Personality change can be a sign of shunt malformation related to increased intracranial pressure.
Vomiting can be a sign of shunt malformation related to increased intracranial pressure.
Fever can be a sign of shunt malformation and is a very serious complication.
The anterior fontanel closes between 12- 18 months of age.
Dizziness is difficult to assess in a 3-year-old and is not necessarily a sign of shunt malformation.
Level of consciousness - the most important indicator of neurologic health. Various levels include full consciousness, confusion, disorientation, lethargy, obtundation, stupor, coma, and persistent vegetative state. The purpose of the neurologic examination - to establish an accurate, objective baseline of neurologic information. Complete neurologic examination includes level of consciousness; posture; motor, sensory, cranial nerve, and reflex testing; and vital signs. Nursing care of the unconscious child focuses on : - ensuring respiratory management; performing neurologic assessment; monitoring ICP; supplying adequate nutrition and hydration; providing drug therapy; promoting elimination,
hygienic care, proper positioning, exercise, and stimulation; and providing family support. Head injury - a pathologic process involving the scalp, skull, meninges, or brain as a result of mechanical force. Fractures resulting from head injuries may be classified as depressed, compound, basilar, and diastatic Epidural (extradural) hematoma - a hemorrhage into the space between the dura and the skull. As the hematoma enlarges, the dura is stripped from the skull; this accumulation of blood results in a mass effect on the brain, forcing the underlying brain contents downward and inward as it expands. subdural hemorrhage - bleeding between the dura and the arachnoid membrane, which overlies the brain and the subarachnoid space. The hemorrhage may be from two sources: (1) tearing of the veins that bridge the subdural space and (2) hemorrhage from the cortex of the brain caused by direct brain trauma. Subdural hematomas are much more common than epidural hematomas and occur most often in infancy, with a peak incidence at 6 months. cerebral edema - expected after craniocerebral trauma ; Cerebral edema peaks at 24 to 72 hours after injury and may account for changes in a child's neurologic status. Cerebral edema associated with traumatic brain injury may be a result of two different mechanisms: cytotoxic edema or vasogenic edema. Primary head injury - involves features that occur at the time of trauma, including fractured skull, contusions, intracranial hematoma, and diffuse injury. Secondary complications include hypoxic brain damage, increased ICP, infection, cerebral edema, and posttraumatic syndromes.
neuroblastoma depend on the location and stage of the disease; a "silent" tumor. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site, usually the lymph nodes, bone marrow, skeletal system, skin, or liver Meningitis can be caused by a variety of organisms, but the three main types are - (1) bacterial, or pyogenic, caused by pus-forming bacteria, especially meningococci, pneumococci, and group B streptococci; (2) viral, or aseptic, caused by a wide variety of viral agents; and (3) tuberculous, caused by the tuberculin bacillus. The majority of children with acute febrile encephalopathy have either bacterial meningitis or viral meningitis as the underlying cause Bacterial meningitis - an acute inflammation of the meninges and cerebrospinal fluid Nursing care of the child with meningitis includes - administering antibiotics, taking isolation precautions, removing environmental stimuli, ensuring correct positioning, monitoring vital signs, administering intravenous (IV) therapy, promoting adequate fluid and nutritional status, and providing supportive care to the family. Acute bacterial meningitis - a medical emergency that requires early recognition and immediate therapy to prevent death and avoid residual disabilities. The child is isolated from other children, usually in an intensive care unit for close observation. An IV infusion is started to facilitate administration of antimicrobial agents, fluids, antiepileptic drugs, and blood, if needed. The child is placed on a cardiac monitor and in respiratory isolation.
vaccines that reduce the incidence of bacterial meningitis - Routine immunization of infants with Haemophilus influenzae type b and pneumococcal conjugate aseptic meningitis - • Many different viruses cause aseptic meningitis. The onset may be abrupt or gradual. The initial manifestations are headache, fever, malaise, and gastrointestinal symptoms. Signs of meningeal irritation develop 1 or 2 days after the onset of illness. Onset is more insidious in infants and toddlers. Signs and symptoms are vague and are often thought to be associated with a minor illness Encephalitis - an inflammatory process of the CNS that is caused by a variety of organisms, including bacteria, spirochetes, fungi, protozoa, helminths, and viruses. Encephalitis may result from direct invasion of the CNS by a virus or from involvement of the CNS after viral disease. treatment of Encephalitis - • Patients suspected of having encephalitis are hospitalized promptly for observation. Treatment is primarily supportive and includes conscientious nursing care, control of cerebral manifestations, and adequate nutrition and hydration, with observations and management as for other cerebral disorders. Reye syndrome (RS) - a disorder defined as a metabolic encephalopathy associated with other characteristic organ involvement. It is characterized by fever, profoundly impaired consciousness, and disordered hepatic function most important aspect of successful management of the child with RS - early diagnosis and aggressive therapy. Cerebral edema with increased ICP
affected and are characterized by localized motor symptoms; somatosensory, psychic, or autonomic symptoms; or a combination of these. postictal state - the period after a seizure Generalized seizures - categorized as tonic-clonic, absence, atonic and akinetic, myoclonic, and infantile spasms. The generalized tonic-clonic seizure, formerly known as grand mal, is the most dramatic of all seizure manifestations of childhood Absence seizures - formerly called petit mal or lapses, are generalized seizures. They have a sudden onset and are characterized by a brief loss of consciousness, a blank stare, and automatisms. The process of diagnosis in a child suspected of having epilepsy includes - (1) determining whether epilepsy or seizures exist and not an alternative diagnosis; and (2) defining the underlying cause, if possible. goal of treatment of seizure disorders - to control the seizures or to reduce their frequency and severity, discover and correct the cause when possible, and help the child live as normal a life as possible. Long-term care of the child with recurrent seizure disorders includes physical care and education on the importance of drug therapy and problems related to emotional aspects of the disorder.
Status epilepticus - a continuous seizure that lasts more than 30 minutes or a series of seizures from which the child does not regain a premorbid level of consciousness. Febrile seizures - the most common type of childhood seizure. Long-term antiepileptic therapy is usually not required for children with simple febrile seizures Headaches - are a common complaint of children and are associated with different pathologic conditions, including extracranial disease, intracranial disease, vascular abnormalities, psychogenic disorders, or a combination of the above. Migraine headaches - occur in children as well as in adults. Typical symptoms include nausea, vomiting, and abdominal pain, which are relieved by sleep. Toddlers may be seen with episodic pallor, decreased activity, and vomiting. The onset of a migraine headache in a young child is typically in the afternoon and may be bifrontal, temporal, and bilateral or unilateral. Children may vomit repetitively during a migraine headache. management of Migraine headaches - general measures (education, a headache diary to identify and eliminate precipitating factors, and documented response to treatment), abortive treatment, and prophylactic treatment. At the onset of the headache, the child should rest or sleep in a quiet, dark room when feasible. Migraine therapy, if administered early in the course of the headache, may provide rapid relief. Acetaminophen or ibuprofen is often effective if given early
