S/S ICP
1. Decreased LOC (confusion, lethargy, disorientation).
2. Pupillary dysfunction, slow reaction to light leading to fixed pupils.
3. Hemiparesis or hemiplegia; later decorticate or decerebrate positioning.
4. Projectile vomiting without nausea.
5. Increased blood pressure, bradycardia, and altered respiratory pattern.
Source: Pearson p. 962
Three Positions Contraindicated with Increased ICP
1.Extreme neck or hip flexion/extension
2.Maintaining the head of the bed at an angle less than 30 degrees (Flat or Prone)
3.Body not midline or in neutral position (Coughing, Sneezing, Straining)
Source: ATI: Adult Surgical Nursing.
NCLEX QUESTIONS
1. The parents of a child, age 5, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:
a. Still depends on the parents
b. Rebels against scheduled activities
c. Is highly sensitive to criticism
d. Loves to tattle
Answer C
2. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?
a. Nursery schools
b. Toilet Training
c. Safety guidelines
d. Preparation for surgery
Answer C
3. Nurse Betina should begin screening for lead poisoning when a child reaches which age?
a. 6 months
b. 12 months
c. 18 months
d. 24 months
Answer C
4. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
a. A reduced white blood cell count
b. A decreased platelet count
c. Shallow respirations
d. Tachypnea
Answer D
5. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching?
a. “Well follow these instructions until our child’s symptoms disappear.”
b. “Our child must maintain these dietary restrictions until adulthood.”
c. “Our child must maintain these dietary restrictions lifelong.”
d. “We’ll follow these instructions until our child has completely grown and developed.”
Answer C
6. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expects to find?
a. Closed anterior fontanel and open posterior fontanel
b. Open anterior and fontanel and closed posterior fontanel
c. Closed anterior and posterior fontanels
d. Open anterior and posterior fontanels
Answer C
7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:
a. Cerebral edema
b. Dehydration
c. Heart failure
d. Hypovolemic shock
Answer A
8. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?
a. Encouraging the infant to hold a bottle
b. Keeping the infant on bed rest to conserve energy
c. Rotating caregivers to provide more stimulation
d. Maintaining a consistent, structured environment
Answer D
9. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:
a. Bananas
b. Latex
c. Kiwifruit
d. Color dyes
Answer B
10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional intake?
a. Allow the child to feed herself
b. Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon character
c. Only serve the child’s favorite foods
d. Allow the child to eat at a small table and chair by herself
Answer A
11. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?
a. 5% glucose
b. 10% glucose
c. 15% glucose
d. 17% glucose
Answer B
12. David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best indicates that the child is free from pain?
a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play
Answer D
13. When planning care for a 8-year-old boy with Down syndrome, the nurse should:
a. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age
b. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
c. Assess the child’s current developmental level and plan care accordingly
d. Direct all teaching to the parents because the child can’t understand
Answer C
14. Nurse Victoria is teaching the parents of a school-age child. Which teaching topic should take priority?
a. Prevent accidents
b. Keeping a night light on to allay fears
c. Explaining normalcy of fears about body integrity
d. Encouraging the child to dress without help
Answer A
15. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority?
a. Changing the linens on the clients’ beds
b. Restocking the bedside supplies needed for a dressing change on the upcoming shift
c. Documenting the care provided during her shift
Answer C
1. Decreased LOC (confusion, lethargy, disorientation).
2. Pupillary dysfunction, slow reaction to light leading to fixed pupils.
3. Hemiparesis or hemiplegia; later decorticate or decerebrate positioning.
4. Projectile vomiting without nausea.
5. Increased blood pressure, bradycardia, and altered respiratory pattern.
Source: Pearson p. 962
Three Positions Contraindicated with Increased ICP
1.Extreme neck or hip flexion/extension
2.Maintaining the head of the bed at an angle less than 30 degrees (Flat or Prone)
3.Body not midline or in neutral position (Coughing, Sneezing, Straining)
Source: ATI: Adult Surgical Nursing.
NCLEX QUESTIONS
1. The parents of a child, age 5, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:
a. Still depends on the parents
b. Rebels against scheduled activities
c. Is highly sensitive to criticism
d. Loves to tattle
Answer C
2. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?
a. Nursery schools
b. Toilet Training
c. Safety guidelines
d. Preparation for surgery
Answer C
3. Nurse Betina should begin screening for lead poisoning when a child reaches which age?
a. 6 months
b. 12 months
c. 18 months
d. 24 months
Answer C
4. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
a. A reduced white blood cell count
b. A decreased platelet count
c. Shallow respirations
d. Tachypnea
Answer D
5. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching?
a. “Well follow these instructions until our child’s symptoms disappear.”
b. “Our child must maintain these dietary restrictions until adulthood.”
c. “Our child must maintain these dietary restrictions lifelong.”
d. “We’ll follow these instructions until our child has completely grown and developed.”
Answer C
6. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expects to find?
a. Closed anterior fontanel and open posterior fontanel
b. Open anterior and fontanel and closed posterior fontanel
c. Closed anterior and posterior fontanels
d. Open anterior and posterior fontanels
Answer C
7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:
a. Cerebral edema
b. Dehydration
c. Heart failure
d. Hypovolemic shock
Answer A
8. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?
a. Encouraging the infant to hold a bottle
b. Keeping the infant on bed rest to conserve energy
c. Rotating caregivers to provide more stimulation
d. Maintaining a consistent, structured environment
Answer D
9. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:
a. Bananas
b. Latex
c. Kiwifruit
d. Color dyes
Answer B
10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional intake?
a. Allow the child to feed herself
b. Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon character
c. Only serve the child’s favorite foods
d. Allow the child to eat at a small table and chair by herself
Answer A
11. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?
a. 5% glucose
b. 10% glucose
c. 15% glucose
d. 17% glucose
Answer B
12. David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best indicates that the child is free from pain?
a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play
Answer D
13. When planning care for a 8-year-old boy with Down syndrome, the nurse should:
a. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age
b. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
c. Assess the child’s current developmental level and plan care accordingly
d. Direct all teaching to the parents because the child can’t understand
Answer C
14. Nurse Victoria is teaching the parents of a school-age child. Which teaching topic should take priority?
a. Prevent accidents
b. Keeping a night light on to allay fears
c. Explaining normalcy of fears about body integrity
d. Encouraging the child to dress without help
Answer A
15. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority?
a. Changing the linens on the clients’ beds
b. Restocking the bedside supplies needed for a dressing change on the upcoming shift
c. Documenting the care provided during her shift
Answer C