PEDS CAPSTONE REVIEW
ASSESSMENT – COMPLETE Q&A
SOLUTION GUIDE
post surgery:
-avoid having baby suck on nipple or pacifier
-place baby laterally or on stomach to help prevent aspiration and facilitate drainage
-apply restraints to prevent baby from disturbing operative site
-Keep the infant pain-free to decrease crying and stress on repair
-Feed w/ cups, Avoid sucking on nipple or pacifier
-monitor I/O's daily
-Change position frequently to facilitate breathing & place on abdomen in immediate
post-op period
-Maintain IV fluids until infant able to eat & drink - correct answers ✔✔cleft palate post
op care
, -implement droplet precautions right away
-maintain for at least 24 hours following initiation of abx
-keep pt npo if there is a decreased LOC (r/f aspiration)
-dark quiet environment (photophobia)
-admx medications (abx, corticosteroids)
-mx for signs of increased ICP
-Position the client without a pillow, and slightly elevate the head of the bed. The client
can also be positioned side-lying to reduce neck discomfort.
-keep room cool
-Presence of petechial or purpuric-type rash requires immediate medical attention -
correct answers ✔✔meningitis care
-changes in vital signs
-altered mental status
-increased intracranial pressure
-alterations of pupillary response
-posturing
-bradycardia
-decreased motor response
-decreased sensory response
-Cheyne-Stokes respirations
-coma - correct answers ✔✔A nurse is caring for a child with a closed head injury. What
clinical manifestations would suggest deterioration in this client's condition?
-ABGs,
-blood alcohol and toxicology screening,
-CBC with differential
-liver function tests;
-cervical spine x-rays to rule out cervical spine injury,
-CT and/or MRI of head and/or neck might be performed with and without contrast if
indicated
-measurement of ICP - correct answers ✔✔A child has been admitted to the emergency
department with a closed head injury. Identify the lab and diagnostic tests that will be
ordered.
-Mannitol to treat cerebral edema
-Antibiotics: Use r/t CSF leakage, laceration, or penetration injuries
-Analgesics: Used of HA/pain management
-Corticosteroids: Used to decrease cerebral edema
-Antiepileptics: Used to prevent/treat seizures - correct answers ✔✔A child has been
admitted to the emergency department with a closed head injury. What medications
should the nurse anticipate the provider to prescribe and why?
-Eyes that appear crossed or an eye that seems to wander
ASSESSMENT – COMPLETE Q&A
SOLUTION GUIDE
post surgery:
-avoid having baby suck on nipple or pacifier
-place baby laterally or on stomach to help prevent aspiration and facilitate drainage
-apply restraints to prevent baby from disturbing operative site
-Keep the infant pain-free to decrease crying and stress on repair
-Feed w/ cups, Avoid sucking on nipple or pacifier
-monitor I/O's daily
-Change position frequently to facilitate breathing & place on abdomen in immediate
post-op period
-Maintain IV fluids until infant able to eat & drink - correct answers ✔✔cleft palate post
op care
, -implement droplet precautions right away
-maintain for at least 24 hours following initiation of abx
-keep pt npo if there is a decreased LOC (r/f aspiration)
-dark quiet environment (photophobia)
-admx medications (abx, corticosteroids)
-mx for signs of increased ICP
-Position the client without a pillow, and slightly elevate the head of the bed. The client
can also be positioned side-lying to reduce neck discomfort.
-keep room cool
-Presence of petechial or purpuric-type rash requires immediate medical attention -
correct answers ✔✔meningitis care
-changes in vital signs
-altered mental status
-increased intracranial pressure
-alterations of pupillary response
-posturing
-bradycardia
-decreased motor response
-decreased sensory response
-Cheyne-Stokes respirations
-coma - correct answers ✔✔A nurse is caring for a child with a closed head injury. What
clinical manifestations would suggest deterioration in this client's condition?
-ABGs,
-blood alcohol and toxicology screening,
-CBC with differential
-liver function tests;
-cervical spine x-rays to rule out cervical spine injury,
-CT and/or MRI of head and/or neck might be performed with and without contrast if
indicated
-measurement of ICP - correct answers ✔✔A child has been admitted to the emergency
department with a closed head injury. Identify the lab and diagnostic tests that will be
ordered.
-Mannitol to treat cerebral edema
-Antibiotics: Use r/t CSF leakage, laceration, or penetration injuries
-Analgesics: Used of HA/pain management
-Corticosteroids: Used to decrease cerebral edema
-Antiepileptics: Used to prevent/treat seizures - correct answers ✔✔A child has been
admitted to the emergency department with a closed head injury. What medications
should the nurse anticipate the provider to prescribe and why?
-Eyes that appear crossed or an eye that seems to wander
