Page 1 Pediatric HESI unit 4
which intervention is a priority when caring for a child a. assessing the level of consciousness every hour
who sustained a head injury 12 hours earlier? diminishing level of consciousness is an early indicator of neurological
a. assessing the level of consciousness every hour damage, evidence of a subdural hemorrhage may take hours or days to
b. promoting rest by fostering a quiet environment develop.
c. asking about the circumstances that led to the
injury
d. administering the prescribed opioid for complaints
of a headache
Pediatric HESI unit 4 1
,Page 2 Pediatric HESI unit 4
an 8 year old boy is found to have a mild concussion b
and is to be discharged home. The parent is
instructed to check their child for responsiveness
every 2 hours and to wake hi for this assessment after
he goes to sleep. They call the nurse and say they are
afraid to allow him to go to sleep. How would the
nurse respond?
a. you can bring him to the hospital before bedtime, if
you prefer
b. if your son becomes difficult to awaken bring him
to the hospital.
c. theres no need to worry because you son is past
the critical period.
d. awakening your son throughout the night is no
longer necessary
Pediatric HESI unit 4 2
,Page 3 Pediatric HESI unit 4
a child is admitted to the pediatric intensive care unit b
with acute bacterial meningitis. Which intervention checking LOC is part of the total neurological check, it can reveal increasing
would the nurse include in the plan of care? ICP as result of cerebral inflammation.
a. offering clear liquids when the child is awake
b. checking the child level of consciousness hourly
c. assessing the childs BP every 4 hours
d. administering the prescribed oral antibiotic
medication
Which clinical manifestation would the nurse b
recognize as a sign of neurologic injury when vomiting commonly accompanies a head injury because of increased ICP
assessing a 7 month old infant injured in an
automobile accident?
a. babinki reflex
b. persistent vomiting
c. heart rate of 110 bpm
d. temp of 99.6
Pediatric HESI unit 4 3
, Page 4 Pediatric HESI unit 4
which clinical finding would the nurse recognize as a d
sign that an infants ICP has increased? anterior fontanel would be widened and tense due to increased volume of
a. hypoactive reflexes cerebrospinal fluid
b. increased pulse rate the pulse rate would be decreased
c. decreased BP reflexes hyperactive
d. tension of anterior fontanel BP increased
which assessment finding alerts the nurse to suspect b
increasing ICP in infant? increased ICP exerts pressure on the vomiting center in the brain resulting in
a. sunken eyes projective vomiting
b. projectile vomiting
c. depressed fonatanels
d. narrowing pulse pressure
which nursing care would the nurse provide for an d
infant the first 24 hours after surgical placement of a shunt may become obstructed leading to accululation of CSF and increased
ventriculoperitoneal shunt for hydrcephaus? ICP
a. medicating the infant for pain
b. placing the infant in high fowlers
c. positioning the infant on the side that has the shunt
d. monitoring the infant for increasing ICP
Pediatric HESI unit 4 4
which intervention is a priority when caring for a child a. assessing the level of consciousness every hour
who sustained a head injury 12 hours earlier? diminishing level of consciousness is an early indicator of neurological
a. assessing the level of consciousness every hour damage, evidence of a subdural hemorrhage may take hours or days to
b. promoting rest by fostering a quiet environment develop.
c. asking about the circumstances that led to the
injury
d. administering the prescribed opioid for complaints
of a headache
Pediatric HESI unit 4 1
,Page 2 Pediatric HESI unit 4
an 8 year old boy is found to have a mild concussion b
and is to be discharged home. The parent is
instructed to check their child for responsiveness
every 2 hours and to wake hi for this assessment after
he goes to sleep. They call the nurse and say they are
afraid to allow him to go to sleep. How would the
nurse respond?
a. you can bring him to the hospital before bedtime, if
you prefer
b. if your son becomes difficult to awaken bring him
to the hospital.
c. theres no need to worry because you son is past
the critical period.
d. awakening your son throughout the night is no
longer necessary
Pediatric HESI unit 4 2
,Page 3 Pediatric HESI unit 4
a child is admitted to the pediatric intensive care unit b
with acute bacterial meningitis. Which intervention checking LOC is part of the total neurological check, it can reveal increasing
would the nurse include in the plan of care? ICP as result of cerebral inflammation.
a. offering clear liquids when the child is awake
b. checking the child level of consciousness hourly
c. assessing the childs BP every 4 hours
d. administering the prescribed oral antibiotic
medication
Which clinical manifestation would the nurse b
recognize as a sign of neurologic injury when vomiting commonly accompanies a head injury because of increased ICP
assessing a 7 month old infant injured in an
automobile accident?
a. babinki reflex
b. persistent vomiting
c. heart rate of 110 bpm
d. temp of 99.6
Pediatric HESI unit 4 3
, Page 4 Pediatric HESI unit 4
which clinical finding would the nurse recognize as a d
sign that an infants ICP has increased? anterior fontanel would be widened and tense due to increased volume of
a. hypoactive reflexes cerebrospinal fluid
b. increased pulse rate the pulse rate would be decreased
c. decreased BP reflexes hyperactive
d. tension of anterior fontanel BP increased
which assessment finding alerts the nurse to suspect b
increasing ICP in infant? increased ICP exerts pressure on the vomiting center in the brain resulting in
a. sunken eyes projective vomiting
b. projectile vomiting
c. depressed fonatanels
d. narrowing pulse pressure
which nursing care would the nurse provide for an d
infant the first 24 hours after surgical placement of a shunt may become obstructed leading to accululation of CSF and increased
ventriculoperitoneal shunt for hydrcephaus? ICP
a. medicating the infant for pain
b. placing the infant in high fowlers
c. positioning the infant on the side that has the shunt
d. monitoring the infant for increasing ICP
Pediatric HESI unit 4 4
