Nokea
The nurse is caring for a 3-year-old child with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?
- A. Temperature increase from 37.2?°C (99?°F) to 37.7?°C (100?°F)
- B. Increase in blood pressure with an attendant decrease in pulse
- C. Increase in respirations
- D. Equilateral pupils
Correct Answer: B
Rationale: Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.
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What symptom leads the nurse caring for a 5-month-old child with viral influenza to suspect the development of Reye's syndrome?
- A. Respirations drop from 18 to 14 breaths/minute
- B. Falling asleep after feeding
- C. Sudden vomiting without effort
- D. Development of a macular rash
Correct Answer: C
Rationale: A child with a viral infection is at risk for Reye's syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness.
Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.)
- A. Hypersensitivity to noise
- B. Irritability
- C. Ecchymotic ear canal
- D. Rolls head from side to side
- E. Temperature of 39.4?°C (103?°F)
Correct Answer: B,D,E
Rationale: Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.
A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
- A. Restlessness
- B. Sleepiness
- C. Nausea
- D. Anxiety
Correct Answer: B
Rationale: Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.
What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
- A. Assist the child to bed and then go for help.
- B. Move objects out of the child's immediate area.
- C. Stick a padded tongue blade between the child's teeth.
- D. Manually restrain the child.
Correct Answer: B
Rationale: During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.
Which situation would cause the nurse to suspect a hearing impairment?
- A. 3-month-old infant with a positive Moro (startle reaction) reflex
- B. 15-month-old toddler who is babbling
- C. 18-month-old toddler who is speaking one-syllable words
- D. 24-month-old toddler who communicates by pointing
Correct Answer: D
Rationale: The child who is not making verbal attempts by 24 months should undergo a complete physical examination.