HESI Case Study Pediatric - Intracranial Questions And Correct Detailed Answers (Verified Answers) Already Graded A+.

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HESI Case Study Pediatric - Intracranial Questions And Correct Detailed Answers (Verified Answers) Already Graded A+.

• Which of the following strategies should the nurse incorporate into the neurological

assessment of Casey?

Correct Answer: Prioritize assessment of level of alertness.

• The mother asks the nurse why her child is having x-rays. Which response is best for

the nurse to provide?Correct Answer: "It is important to assess for other injuries that may have been sustained in the car accident."

• Laboratory studies are prescribed for Casey. Which prescription should the nurse

question?

Correct Answer: 24-hour urine collection.

• Which seizure precautions should the nurse plan to implement?

Correct Answer: Padding the side rails.

• While providing care for a child with an epidural hematoma, which nursing

interventions are most essential? (SATA)

Correct Answer:

• Maintain the airway and monitor O2 saturation.• Implement seizure precautions.• Frequent neurological assessment.• Monitor fluid status and osmolality.

• The nurse wishes to document her neurological assessment findings. Which data

should the nurse included in documenting Casey's ocular findings?

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Correct Answer: Lid lag for both eyes and dilated pupils (7 mm).

• While conducting Casey's neurological assessment, the nurse notes possible

damage to cranial nerve III as evidence by which of the following symptoms?

Correct Answer: Ptosis and dilated pupils.

• The nurse recognizes that signs of increased intracranial pressure (ICP) in Casey

differ from signs in older children. Which symptoms is most characteristic of ICP in infants?

Correct Answer: Separated cranial sutures.

• To prepare Casey's parents for her CT scan, which explanation by the nurse is

accurate?Correct Answer: "A nurse from the ED will remain with Casey to monitor her constantly."

• The nurse recognizes that epidural hematoma's have which characteristic?

Correct Answer: Rapid brain decompression.

• Several diagnostic tests are prescribed for Casey. Which test should the nurse

question?

Correct Answer: Lumbar puncture.

• The nurse can allay anxiety by providing the parents with accurate preoperative

education. Which statement is accurate?Correct Answer: Casey will have an IV placed for fluids and medication and she may initially have a tube in her throat.

• Which strategies are appropriate ways to involve the family in Casey's care? (SATA)

Correct Answer:

• Bringing a familiar blanket from home for the baby.• Providing interpretation to the infant's behavioral cues.• Holding and rocking the infant.• Participating in multidisciplinary discharge planning meeting.

• The nurse provides anticipatory guidance to the family of 6-month-old Casey. The

family should be counseled to seek neurological evaluation if which of the following behaviors are not achieved at age 9 months?

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Correct Answer: Understand "no," uses a pincer grasp, plays peek-a-boo.

• The nurse recognized these signs as indicating which diagnosis?

Correct Answer: Basilar skull fracture.

• Which is the most appropriate nursing action to assess if the ear drainage in CSF?

Correct Answer: Check for glucose via dipstick.

• The nurse develops a plan of care for John. Due to the presence of a basilar skill

fracture, it is critical that the plan includes assessing for early signs of which complications?

Correct Answer: Meningitis and swallowing difficulties.

• In the post emergency phase, what are the priorities of care for the unconscious

child?Correct Answer: Use of the pediatric coma scale to frequently assess neurological status.

• John's heart rate changes from 80 to 65 bpm, his pupils are less reactive to light,

and his response to pain is diminished. Which conclusion regarding this assessment is accurate?

Correct Answer: Late signs of increased intracranial pressure.

• Nursing care of the child with a subarachnoid catheter (Richmond bolt) includes

which nursing action?Correct Answer: Monitor the level of the collection chamber when the drain is unclamped.

• Since John is to receive Norcuron, which nursing interventions should be included

in the plan of care?

Correct Answer: Prepare a dose of Narcan to be kept the bedside.

• Nursing measures to manage John's hyperthermia include which action?

Correct Answer: Place a cooling blanket under John.

• While John is in deep coma, which is the appropriate nursing care to maintain the

airway?Correct Answer: Suction only as needed via the endotracheal tube to clear the airway.

• In addition to routine skin care, the unconscious child requires what special

hygiene measures?

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Correct Answer: Artificial tears to eyes every 1 to 2 hours.

• Which of the following are appropriate stimulation strategies the nurse can teach

parents to implement?

Correct Answer: Read John his favorite stories.

• John is anxious and frightened about the MRI. Which measures are most

appropriate for the nursing to implement to psychologically prepare 4-year-old John for the MRI?

Correct Answer: Show John a picture of the "space rocket" machine.

• The nurse prepares a discharge teaching plan. Which critical concepts are most

important for the nurse to incorporate in the plan?

Correct Answer: Provide information about support groups.