The Client with Guillain-Barré Syndrome (Infectious Polyneuritis)

44.

1. Most children with sore throat have some diffi culty swallowing, so it is important for the nurse to determine the extent of diffi culty to aid in determining what action is necessary. Typically a sore throat precedes the paralysis of this disorder.

Muscle tenderness is an initial symptom. Distal muscle weakness follows proximal muscle weak- ness, ultimately progressing to paralysis. Diet his- tory and diffi culty urinating will not contribute to assessment of the cause of a sore throat or diffi culty swallowing. After determining the extent of diffi - culty swallowing, the nurse can obtain information about exposure to illness.

CN: Health promotion and maintenance;

CL: Analyze

45.

2. With Guillain-Barré syndrome, progressive ascending paralysis occurs. Therefore, the nurse should assess the child’s muscle strength bilaterally to determine the extent of involvement and progres- sion of the illness. Assessing the child’s ability to follow simple commands evaluates brain function.

Range-of-motion exercises are an important part of treatment, but they are not a priority initially.

Although the child may need diversional activities later, they also are not an initial priority.

CN: Physiological adaptation;

CL: Synthesize

Billings_Part 2_Chap 2_Test 7.indd 291

Billings_Part 2_Chap 2_Test 7.indd 291 8/7/2010 10:04:40 AM8/7/2010 10:04:40 AM

in vital signs and pupils typically follow changes in LOC. Motor strength is primarily assessed as a voluntary function. With changes in levels of con- sciousness there may be motor changes.

CN: Physiological adaptation; CL: Apply

54.

2. The unconscious child is positioned to prevent aspiration of saliva and minimize intrac- ranial pressure. The head of the bed should be elevated, and the child should be in either the semi- prone or the side-lying position. Lying prone with hips and knees slightly elevated increases intrac- ranial pressure, as does lying on the back in the Trendelenburg position. The semi-Fowler’s position with arms at the side is not the best choice.

CN: Physiological adaptation;

CL: Synthesize

55.

3. Mannitol is an osmotic diuretic used to reduce intracranial pressure. The use of the drug is controversial and should be reserved to cases which do not respond to other treatments or when brain herniation is likely. Children this sick should be on intracranial pressure (ICP) monitoring. The best indicator that the drug has produced the desired results is a reduction in the ICP. Improved levels of consciousness should follow reduced ICP. While the drug will cause increased urine output, that measurement in and of itself does not indicate suc- cessful treatment. Because the drug is being used for head injuries, not to improve urine output in acute renal failure, the child may not have visible edema.

CN: Pharmacological and parenteral therapies; CL: Evaluate

The Client with a Brain Tumor

56.

2. A decreasing level of consciousness, decer- ebrate positioning, or Cushing’s triad (elevated sys- tolic blood pressure, decreased pulse, and decreased respiratory rate) indicates that there is pressure on the brain stem and the client could require intuba- tion and cardiac resuscitation unless the physician can order a medication or surgical procedure to reduce the intracranial pressure. Raising the head of the bed could offer some reduction in the intrac- ranial pressure by increasing venous blood return from the head, but it is not the priority at this time.

An analgesic administered at this time would mask the sign of decreasing level of consciousness and hinder assessment. An oximeter would measure the oxygen level in the blood, but not necessarily in the brain.

CN: Physiological adaptation;

CL: Synthesize to coerce a child into compliance. Although the

mother is attempting to comply with the discharge plan, bribery is an inappropriate technique to foster compliance. Missing therapy sessions delays recov- ery. The parents need to help set the child’s sched- ule to ensure that she gets adequate rest to be able to follow her treatment plan.

CN: Physiological adaptation;

CL: Evaluate

The Client with a Head Injury

50.

2. For the child with serious head trauma, a nasogastric tube is inserted initially to decompress the stomach and to prevent vomiting and aspiration.

Medications would be administered intravenously in the initial period. The tube will not be used to obtain gastric specimens. Nutrition is not a priority initially. Later on, the tube may be used to adminis- ter feedings.

CN: Reduction of risk potential;

CL: Apply

51.

1. Because a basilar skull fracture can involve the frontal and ethmoid bones, inserting a naso- gastric tube carries the risk of introducing the tube into the cranial cavity through the fracture. An oral gastric tube is preferred for a client with a basilar skull fracture. The tube would not be placed into the duodenum. Gastric aspirate is not routinely tested for blood unless there is an indication to suggest bleeding, such as a falling hemoglobin or visible blood in the drainage.

CN: Reduction of risk potential;

CL: Synthesize

52.

3. As a rule, children demonstrate more rapid and more complete recovery from coma than do adults. However, it is extremely diffi cult to predict a specifi c outcome. Reassuring the parents that they will be kept informed helps open lines of communication and establish trust. Telling the parents that children do not do well would be extremely negative, destroying any hope that the parents might have. Telling the parents that chil- dren recover rapidly may give the parents false hopes. Telling the parents to talk to the doctor ignores the parents’ concerns and interferes with trust-building.

CN: Physiological adaptation;

CL: Synthesize

53.

2. The level of consciousness (LOC) is the best indicator of brain function. If the child’s condi- tion deteriorates, the nurse would notice changes in LOC before any other changes and should notify the physician that these changes are occurring. Changes

Billings_Part 2_Chap 2_Test 7.indd 292

Billings_Part 2_Chap 2_Test 7.indd 292 8/7/2010 10:04:41 AM8/7/2010 10:04:41 AM

tumor. It is more often a sign of diabetes insipidus following a closed head injury. Increased appetite occurs during a growth spurt and is not necessarily a sign of a brain tumor. Increased pulse is a nonspe- cifi c sign and can occur with many illnesses, cardiac anomalies, fever, or exercise.

CN: Physiological adaptation;

CL: Analyze

62.

3. After surgery for an infratentorial tumor, the child is usually positioned fl at on either side, with the head and neck in midline and the body slightly extended. Pillows against the back, not the head, help maintain position. Such a position helps avoid pressure on the operative site. Placing the child in a prone or semi-Fowler’s position will cause pressure on the operative site. The Trende- lenburg position is usually contraindicated because keeping the head below the level of the heart increases intracranial pressure as well as the risk of hemorrhage.

CN: Physiological adaptation;

CL: Synthesize

63.

1. Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure.

Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation.

Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not pro- duce it.

CN: Reduction of risk potential;

CL: Evaluate

64.

3. Glucose in this clear, colorless fl uid indi- cates the presence of cerebrospinal fl uid. Excessive fl uid leakage should be reported to the physician.

The nurse should not change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon. Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures. The nurse should notify the physician after testing the fl uid for glucose.

CN: Reduction of risk potential;

CL: Synthesize

65.

1. It is not uncommon for a child to be concerned about a change in appearance when the entire head or only part of the head has been shaved. The child should be encouraged to partici- pate in decisions about her care when possible. Ask- ing her if she would like to wear a hat is one way to encourage this participation. Reassuring the child that her hair will grow back does not address the

57.

1. This client is experiencing neurological changes consistent with increasing intracranial pressure (ICP). The nurse should fi rst notify the physician. The physician may intubate the child to ensure a patent airway. The nurse should not lower the head of the bed as this will cause increased ICP.

The nurse should ensure an adequate fl uid balance.

The physician will likely order hypertonic saline to draw fl uid from the brain.

CN: Management of care; CL: Synthesize

58.

3. A child who has symptoms of vomit- ing, headaches, and problems walking needs to be evaluated by a health care provider to determine the cause. Unexplained headaches and vomiting along with complaints of diffi culty walking (e.g., ataxia) may suggest a brain tumor. Evaluation by an eye doctor would be appropriate once a complete medi- cal evaluation has been accomplished. Psychologi- cal counseling may be indicated for this adolescent, but only after medical evaluation to determine that she is physically healthy. Meeting with the child’s teachers would be appropriate after medical evalua- tion.

CN: Physiological adaptation;

CL: Synthesize

59.

4. When a brain tumor is suspected, the child and parents are likely to be very apprehensive and anxious. It is unrealistic to expect to eliminate their fears; rather, the nurse’s goal is to decrease them.

Preparing both the child and family during hospital- ization can help them cope with some of their fears.

Although the nurse may be able to decrease some of the child’s anxiety, it would be impossible to elimi- nate it. Children with infratentorial tumors seldom have seizures, so seizure precautions are not indi- cated. Although introducing the child to other chil- dren is a positive action, this action would be more appropriate once the nurse has decreased some of the child’s and parents’ anxiety by preparing them.

CN: Psychosocial adaptation;

CL: Synthesize

60.

1. The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the physician immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the fi rst action is to notify the physician. Placing the child in a prone position will not relieve the herniation or release the arching.

CN: Management of care; CL: Synthesize

61.

1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor.

Clinical manifestations are the result of location and size of the tumor. Polydipsia is rare with a brain

Billings_Part 2_Chap 2_Test 7.indd 293

Billings_Part 2_Chap 2_Test 7.indd 293 8/7/2010 10:04:42 AM8/7/2010 10:04:42 AM

decreased gastrointestinal muscle innervation. The nurse evaluates this by auscultating the abdomen.

Because the client has a thoracic spinal cord injury, the client may not feel abdominal cramping. Addi- tionally, auscultation would provide no evidence of cramping. Hyperactive bowel sounds would be evi- denced with increased peristalsis; peristalsis would probably be diminished with this injury. Profuse diarrhea, resulting from increased peristalsis, would not be an expected fi nding. Diarrhea would be more commonly associated with a gastrointestinal infection.

CN: Physiological adaptation;

CL: Analyze

70.

3. Spinal shock causes a loss of refl ex activ- ity below the level of the injury, resulting in blad- der atony and fl accid paralysis. When the refl ex arc returns, it tends to be overactive, resulting in spasticity. The refl exes and bladder becomes hyper- tonic during this phase of spinal shock resolution;

sensation does not return. A widened pulse pressure is not associated with resolution of spinal shock.

CN: Physiological adaptation;

CL: Evaluate

71.

1. After a catastrophic injury, individuals commonly experience grief. Initially, the person experiences denial, the most common response.

With gradual awareness of the situation, anger com- monly occurs. The child is demonstrating anger, not rebellion, as he gradually becomes aware of his situation. Rebellion is the child’s way to maintain autonomy and individuality. It is a reaction to rigid rules. Examples include refusing to follow a treat- ment protocol when the child had no input and running away. Sensory overload would cause the child to be irritable and tired and to have diffi culty sleeping. Too much attention usually would lead to irritability, diffi culty sleeping, and mood swings.

CN: Psychosocial adaptation;

CL: Analyze

72.

1. The adolescent is exhibiting signs of autonomic dysrefl exia, a generalized sympathetic response usually caused by bladder or bowel dis- tention. Immediate treatment involves eliminating the cause. Because bladder distention is a common cause of this problem, the nurse should immediately determine the patency of the indwelling (Foley) catheter. Lowering the head below the knees would increase the blood pressure and is contraindicated because of the spinal cord injury. Lying fl at will not decrease blood pressure. Epinephrine is contraindi- cated because it elevates blood pressure and there- fore can exacerbate the problem.

CN: Physiological adaptation;

CL: Synthesize immediate change in appearance, and it ignores the

child’s current feelings. Explaining that this type of reaction is normal does not address the child’s feel- ings. The child needs to be able to express feelings and be involved in care as much as possible. Buying the child a wig as a surprise does not address the child’s feelings and does not allow her to participate in decision making. Rather, the parents should ask the child if she would like a wig and then work with the child to determine what kind of wig she would like.

CN: Psychosocial adaptation;

CL: Synthesize

66.

1. Parents of a child who has undergone neu- rosurgery can easily become overprotective. Yet the parents must foster independence in the convalesc- ing child. It is important for the child to resume age- appropriate activities, and parents play an impor- tant role in encouraging this. Statements about going back to school would be expected. Parents want the child to return to normal activities after a serious ill- ness or injury as a sign that the child is doing well.

CN: Psychosocial adaptation;

CL: Evaluate

The Client with a Spinal Cord Injury

67.

2. The adolescent’s signs and symptoms sug- gest a spinal cord injury. A client with suspected spinal cord injury should not be moved until the spine has been immobilized. Removing the helmet could further aggravate a spinal cord injury. The nurse could assess for abdominal trauma, but only if it can be done without moving the adolescent.

CN: Reduction of risk potential;

CL: Synthesize

68.

1. In spinal cord injury, temperature regu- lation is lost below T3. Body temperature must be maintained by adjusting room temperature or bed linens, such as covering the client’s legs with blankets. Coolness of the extremities is an expected fi nding. Therefore, it is not necessary to notify the physician immediately. Repositioning the client’s legs does not alleviate the temperature regulation problem and could be harmful, considering the cli- ent’s diagnosis. Moving the legs before the spine is stabilized could lead to further cord damage. Laying the client fl at will not increase the warmth to the legs and feet.

CN: Physiological adaptation;

CL: Synthesize

69.

3. A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and rectum. Paralytic ileus often occurs as a result of

Billings_Part 2_Chap 2_Test 7.indd 294

Billings_Part 2_Chap 2_Test 7.indd 294 8/7/2010 10:04:43 AM8/7/2010 10:04:43 AM

increases the safety of medication administration.

Any time steps are added to the medication admin- istration process there is one more place where an error might occur.

CN: Safety and infection control;

CL: Synthesize

75.

4. The coating on an extended release medication helps assure slow absorption of

the medication. If the nurse crushes the medication, the medication may enter the client’s system too quickly and result in toxic levels. The only appropri- ate action is to contact the prescriber and ask that the order be changed. Cutting the medication or trying to dissolve a whole tablet would have similar results as crushing it. Carbamazapine comes as an oral suspen- sion, but it is not extended release. Therefore, an order would be needed to address dosing if switch- ing to this form.

CN: Safety and infection control;

CL: Synthesize

76.

1. A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the post test will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way may be overlooked. If several nurses are observed not using the most current practice, it is quite pos- sible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not alone assure that the information is read.

CN: Reduction of risk potential;

CL: Create

Managing Care Quality and Safety

73.

4. Bacterial meningitis is caused by one of three organisms, Haemophilus infl uenzae type b, Neisseria meningitidis, or Streptococcus pneu- moniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet of the client. Droplet precautions require, in addition to standard precautions, that health care providers wear masks when coming into close contact with the client. Standard precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms and all heath care workers must wear respirators.

CN: Safety and infection control;

CL: Apply

74.

3, 4, 5. Using only oral syringes to admin- ister oral medications reduces the chance that the medication will be given intravenously. The use of smart pumps alone is not enough to prevent I.V.

fl uid administration. An additional measure pedi- atric fl oors can institute to prevent accidental fl uid overload is to use smaller I.V. fl uid bags, such as 250 mL. Whenever a medication comes in multiple concentrations and doses, there is risk of adminis- tering the wrong dose. The use of pediatric satel- lite pharmacies with pediatric pharmacists greatly

Billings_Part 2_Chap 2_Test 7.indd 295

Billings_Part 2_Chap 2_Test 7.indd 295 8/7/2010 10:04:43 AM8/7/2010 10:04:43 AM

296

The Child with Musculoskeletal

Health Problems