Exam 1 Review NURS 330 UPDATED ACTUAL Questions and
CORRECT Answers
basilar skull fracture What kind of skull fracture has the following s/s?
change in metal status / behavior of child What is often the first sign of increased ICP in children?
Headache Name signs of increased ICP in children.
Nausea
Vomiting
Seizures
Diplopia
Drowsiness
Increased sleeping
Lethargy
Diminished physical activity and motor performance
Change in mental status → first sign seen!
Bulging fontanel Name some signs of increased ICP in infants.
Irritability and restlessness
Increased sleeping
High pitched cry
Poor feeding
Setting-sun sign (eyes look downward)
everything What increases ICP (generally)?
- any kind of stimuli
c spine When a patient comes in with a head injury, assume they have an injury to the ___
until they’re clear to not have that.
irregular respirations What is Cushing's Triad? What does it often indicate? Is this an early or late sign in
HTN with widened pulse pressure infants and children?
bradycardia
--> indicates increased ICP
(late sign)
FALSE T/F:
For the child’s safety and yours - do not hold a child It is best practice to hold a child down and attempt to restrain them during a
down or attempt to restrain them during a seizure. seizure.
respirations followed by pulse (then rest of VS) What vital sign should be taken first? Followed by?
FLACC If a pediatric child is nonverbal, what pain assessment tool should be used?
, 1-10 numeric scale If pt. is school aged and cognitively intact, what pain assessment tool should be
used?
PKU! What disorder would a high Guthrie Blood Test level indicate?
Diagnosis: every newborn should be screened for PKU at
least 24 hours after beginning breast milk
Guthrie Blood Test screens for serum phenylalanine
levels greater than 4 mg/dL (normal: 1.6 mg/dL)
acetaminophen For pain or fever in children we give ___ (after 6 mo, can give ___→ NEVER give kids
ibuprofen ___).
aspirin
risk of Reyes syndrome Among other things, why should children never be given aspirin unless prescribed
by the HCP?
straight back School-aged child positioned for ear drop instillation; nurse straightens the
down and back auditory canal by pulling the cartilaginous portion of the pinna _.
Child younger than age 3 years ready for ear drop instillation; the nurse
straightens the auditory canal by pulling the cartilaginous portion of the pinna ___
and ___. Child can be held by parent.
3-4 mo When should the moro newborn reflex disappear?
3-4 mo When should the tonic neck newborn reflex disappear?
4 mo When should the startle newborn reflex disappear?
3-4 (but may persist for up to 12 mo) When should the rooting newborn reflex disappear?
by 12 mo When should the Babinksi newborn reflex disappear?
by 3 mo When should infants be able to hold their head well beyond the plane of their
bodies?
by 4 mo When should infants be able to life their head and front portion of their chest?
by 4-6 mo At what age in infancy should head control be well established?
~5 mo When should infants be able to turn from abdomen to back?
by 6 mo When should infants be able to turn from back to abdomen?
by 7 mo When should infants be able to sit leaning forward on hands?
by 8 mo When should infants be able to sit well unsupported?
by 10 mo When should infants be able to go from prone to sitting?
CORRECT Answers
basilar skull fracture What kind of skull fracture has the following s/s?
change in metal status / behavior of child What is often the first sign of increased ICP in children?
Headache Name signs of increased ICP in children.
Nausea
Vomiting
Seizures
Diplopia
Drowsiness
Increased sleeping
Lethargy
Diminished physical activity and motor performance
Change in mental status → first sign seen!
Bulging fontanel Name some signs of increased ICP in infants.
Irritability and restlessness
Increased sleeping
High pitched cry
Poor feeding
Setting-sun sign (eyes look downward)
everything What increases ICP (generally)?
- any kind of stimuli
c spine When a patient comes in with a head injury, assume they have an injury to the ___
until they’re clear to not have that.
irregular respirations What is Cushing's Triad? What does it often indicate? Is this an early or late sign in
HTN with widened pulse pressure infants and children?
bradycardia
--> indicates increased ICP
(late sign)
FALSE T/F:
For the child’s safety and yours - do not hold a child It is best practice to hold a child down and attempt to restrain them during a
down or attempt to restrain them during a seizure. seizure.
respirations followed by pulse (then rest of VS) What vital sign should be taken first? Followed by?
FLACC If a pediatric child is nonverbal, what pain assessment tool should be used?
, 1-10 numeric scale If pt. is school aged and cognitively intact, what pain assessment tool should be
used?
PKU! What disorder would a high Guthrie Blood Test level indicate?
Diagnosis: every newborn should be screened for PKU at
least 24 hours after beginning breast milk
Guthrie Blood Test screens for serum phenylalanine
levels greater than 4 mg/dL (normal: 1.6 mg/dL)
acetaminophen For pain or fever in children we give ___ (after 6 mo, can give ___→ NEVER give kids
ibuprofen ___).
aspirin
risk of Reyes syndrome Among other things, why should children never be given aspirin unless prescribed
by the HCP?
straight back School-aged child positioned for ear drop instillation; nurse straightens the
down and back auditory canal by pulling the cartilaginous portion of the pinna _.
Child younger than age 3 years ready for ear drop instillation; the nurse
straightens the auditory canal by pulling the cartilaginous portion of the pinna ___
and ___. Child can be held by parent.
3-4 mo When should the moro newborn reflex disappear?
3-4 mo When should the tonic neck newborn reflex disappear?
4 mo When should the startle newborn reflex disappear?
3-4 (but may persist for up to 12 mo) When should the rooting newborn reflex disappear?
by 12 mo When should the Babinksi newborn reflex disappear?
by 3 mo When should infants be able to hold their head well beyond the plane of their
bodies?
by 4 mo When should infants be able to life their head and front portion of their chest?
by 4-6 mo At what age in infancy should head control be well established?
~5 mo When should infants be able to turn from abdomen to back?
by 6 mo When should infants be able to turn from back to abdomen?
by 7 mo When should infants be able to sit leaning forward on hands?
by 8 mo When should infants be able to sit well unsupported?
by 10 mo When should infants be able to go from prone to sitting?
