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Silvestri Chapter 30 Ed#55A

Silvestri Chapter 30 Ed#55A

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Published by Linda Kuglarz

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Published by: Linda Kuglarz on Oct 14, 2008
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Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 030 (edited file)—"Neurological, Cognitive, and Psychosocial Disorders"10/14/08, Page 1 of 9, 2 Figure(s), 0 Table(s), 4 Box(es)
30: Neurological, Cognitive, and Psychosocial Disorders
PRACTICE QUESTIONS
1. A nurse is assisting in collecting data on a 6-month-old infant with a diagnosis of hydrocephalus. The nurse checks for the major symptom associated with hydrocephalus bydoing which of the following?1. Testing the urine for protein2. Taking the apical pulse3. Palpating the anterior fontanel4. Taking the blood pressureAnswer: 3Rationale: An elevated or bulging anterior fontanel indicates an increase in cerebrospinal fluidcollection in the cerebral ventricle. Proteinuria, apical pulse, and blood pressure changes are notspecifically associated increasing cerebrospinal fluid in the brain tissue.Test-Taking Strategy: Use the principles associated with excessive fluid buildup in the cranialcavity and note the age of the infant. Additionally, correlate “hydrocephalus” in the question,with “anterior fontanel” in option 3. Review the symptoms associated with hydrocephalus if youhad difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Child HealthReference: Price, D., & Gwin, J. (2005).
Thompson’s pediatric nursing 
(9th ed.). Philadelphia:W.B. Saunders, p. 105.2. A mother arrives at the emergency room with her 5-year-old child and states that the child felloff a bunk bed. A head injury is suspected, and the nurse checks the child for signs of increasedintracranial pressure (ICP). Which of the following is a late sign of increased ICP?1. Bulging fontanel2. Altered level of consciousness3. Nausea4. Widening pulse pressureAnswer: 4Rationale: Late signs of increased ICP include tachycardia leading to bradycardia, apnea,systolic hypertension, widening pulse pressure, and posturing. A bulging fontanel is a sign of increased ICP in an infant. Nausea and altered level of consciousness are signs of increased ICPin a child. Options 1, 2, and 3 are not late signs.Test-Taking Strategy: Note the age of the child and that the question asks for the “late” sign.Option 1 can be eliminated because the fontanels are closed in a child. Knowledge of the earlyand late signs will direct you to the correct option from those remaining. Review these signs if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data Collection
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 030 (edited file)—"Neurological, Cognitive, and Psychosocial Disorders"10/14/08, Page 2 of 9, 2 Figure(s), 0 Table(s), 4 Box(es)
Content Area: Child HealthReference: Leifer, G. (2003).
 Introduction to maternity and pediatric nursing 
(4th ed.).Philadelphia: W.B. Saunders, pp. 560-562.3. A nurse is caring for a child with Reye’s syndrome. The nurse understands that the major symptom associated with Reye’s syndrome is:1. Persistent vomiting2. Protein in the urine3. A history of a staphylococcus infection4. Symptoms of hyperglycemiaAnswer: 1Rationale: Persistent vomiting is a major symptom associated with intracranial pressure.Options 2, 3, and 4 are incorrect. Protein is not present in the urine. Reye’s syndrome is relatedto a history of viral infections, and hypoglycemia is a symptom of this disease.Test-Taking Strategy: Note the key words,
major symptom
. Recalling that increased ICP is anassociated characteristic will direct you to option 1. Review the symptoms of Reye’s syndromeand the signs of increased ICP if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Child HealthReference: Price, D., & Gwin, J. (2005).
Thompson’s pediatric nursing 
(9th ed.). Philadelphia:W.B. Saunders, p. 304.4. A child is diagnosed with Reye’s syndrome. The nurse assists in preparing a nursing care planfor this child and suggests which of the following?1. Providing a quiet atmosphere with dimmed lights2. Checking for hearing loss3. Monitoring output4. Changing body position every 2 hoursAnswer: 1Rationale: The major elements of care are to maintain effective cerebral perfusion and controlintracranial pressure. Decreasing stimuli in the environment would decrease the stress on thecerebral tissue and neuron responses. Cerebral edema is a progressive part of this disease process. Hearing loss and output are not affected. Changing the body position every 2 hourswould not affect the cerebral edema and intracranial pressure directly. The child should be in ahead-elevated position to decrease the progression of the cerebral edema and promote drainageof cerebrospinal fluid.Test-Taking Strategy: Focus on the pathophysiology associated with Reye’s syndrome to answer the question. Recalling the effects of environmental stimuli, the responses of the brain cells tostimuli, and how cerebral edema can result will direct you to option 1. Review the symptoms of Reye’s syndrome and the signs of increased ICP if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Child Health
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 030 (edited file)—"Neurological, Cognitive, and Psychosocial Disorders"10/14/08, Page 3 of 9, 2 Figure(s), 0 Table(s), 4 Box(es)
References: Leifer, G. (2003).
 Introduction to maternity and pediatric nursing 
(4th ed.).Philadelphia: W.B. Saunders, p. 545.Price, D., & Gwin, J. (2005).
Thompson’s pediatric nursing 
(9th ed.). Philadelphia: W.B.Saunders, p. 304.5. Which of the following, if noted by the nurse, would indicate a potential complicationassociated with a tonic-clonic seizure?1. Blood on the pillow2. Blanched toenails3. Migraine headaches4. High-pitched cryAnswer: 1Rationale: The complications associated with seizures include airway compromise, extremityand teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on thetongue. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanchingdoes not occur. Migraine headaches are not common in children with seizures. Seizures do notcause a high-pitched cry, unless a tumor or intracranial pressure is the cause of the seizurediagnosis.Test-Taking Strategy: Use knowledge of tonic-clonic activity and the involuntary tightening of all the body muscles that occurs during seizure activity when answering this question. Recallthat the tongue can get easily caught by the child’s teeth when the seizure activity occurs. Thiscauses injury, swelling, and bleeding of the tongue tissue. Review the complications associatedwith seizures if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Child HealthReference: Price, D., & Gwin, J. (2005).
Thompson’s pediatric nursing 
(9th ed.). Philadelphia:W.B. Saunders, p. 241.6. A nurse plans for a safe environment when caring for an infant at risk for a seizure. In the plan of care, the seizure precautions would include placing which of the following items at the bedside?1. A suction apparatus and an airway2. Oxygen with a tracheotomy set3. Emergency cart4. Airway and a tracheotomy setAnswer: 1Rationale: Seizures cause tightening of all body muscles followed by tremors. Obstructiveairway and increased oral secretions are the major complications during and following theseizure. Option 2 and 4 are incorrect because inserting a tracheostomy is not done. Suctioning ishelpful to prevent choking and cyanosis. Option 3 is incorrect, because this cart would not beleft at the bedside, but would be available in the treatment room or on the nursing unit.Test-Taking Strategy: Use the process of elimination. Recalling that seizures produce excessiveoral secretions and airway obstruction will direct you to option 1. Review the plan of careassociated with seizure precautions if you had difficulty with this question.

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