ch. 45
Which questions does the nurse ask the parents in an effort to identify the possible causes of cerebral dysfunction in a child? Select all that apply.
"Which neurologic disorders are present in the family?" "What was the child's Apgar score at birth?" "Was the child attacked by animals or insects?" "How often did you consume alcohol during pregnancy?" rational: The nurse asks about neurologic disorders in the child's family members to identify the possibility of genetic influences. The child's Apgar score helps the nurse understand any complications present at the time of birth that may have resulted in cerebral dysfunction. The nurse also assesses for any infections caused by animal or insect encounters. The nurse assesses prenatal influences on the child by asking about alcohol consumption patterns during pregnancy. The nurse assesses the smoking habits of the parents in case the child is at risk for bronchial diseases.
Which condition will the nurse anticipate in a child who demonstrates fixed and dilated pupils after a head trauma?
Respiratory arrest rational: Fixed and dilated pupils after a head trauma indicate high chances of respiratory arrest
Which constituents of the cranium should remain the same at all times in order to maintain a constant intracranial pressure (ICP)? Select all that apply.
Brain Cerebrospinal fluid Blood
Which type of skull fracture occurs when the bone is broken locally into several irregular fragments and results in a pressure on the brain?
Depressed rational: Depressed fracture is suspected when the child's head looks misshapen. The bone is broken locally into several irregular fragments that are pushed inward, resulting in a pressure on the brain
A 12-month-old infant has been prescribed lumbar puncture to confirm the diagnosis of meningitis. The nurse is teaching the parents of the child about the rationale behind the procedure. What does the nurse incorporate in the teaching? A lumbar puncture is used to:
Determine the causative agent. rational: Organisms that cause meningitis are often harbored in the cerebrospinal fluid. The lumbar puncture helps determine if meningitis is present and if the causative agent is bacterial or viral
Which diagnostic tests does the nurse evaluate to confirm cerebral dysfunction in a child with increase intracranial pressure (ICP)? Select all that apply.
Electroencephalogram (EEG) Visual evoked potentials Computed tomography (CT) Magnetic resonance imaging (MRI) rational: EEG provides important information about the brain, such as suppressed cortical function, hematoma, or brain death. Visual evoked potentials are helpful to evaluate visual abnormalities from the retina to the visual cortex. A CT scan and MRI scans are used to visualize the soft tissues and solid matter and help to diagnose the disease.
Which nursing interventions are included in the plan of care of a child, after a supratentorial craniotomy? Select all that apply.
Elevating the child's bed by 20 to 30 degrees Placing the child in a side-lying position Providing a dimly lit environment in the room rational: After a supratentorial craniotomy, the nurse elevates the child's bed by 20 to 30 degrees and places the child in a side-lying position. This facilitates cerebrospinal fluid (CSF) drainage and decreases excessive blood flow to the brain to prevent hemorrhage. The child is sensitive to bright lights, so the nurse provides a dimly lit environment in the room
Which interventions does the nurse implement in the plan of care for a child with bacterial meningitis? Select all that apply.
Ensuring a quiet environment in the room Placing the child in a side-lying position Assessing whether the child is febrile rational: The nurse ensures that the environment is quiet and peaceful, because the child is sensitive to noise. The child is placed in a side-lying position because of nuchal rigidity. The nurse assesses whether the child is febrile, because it indicates infection. The child is sensitive to bright lights, so exposure to sunlight is avoided. The nurse avoids lifting the child's head, because doing so increases pain and discomfort.
Which action does the nurse take when there is reduced urinary output in a comatose child?
Evaluates tests for syndrome of inappropriate antidiuretic hormone secretion rational: There is reduced urinary output when the child acquires the syndrome of inappropriate antidiuretic hormone secretion (SIADH). It indicates overhydration, hyponatremia, and hypoosmolality in the child. The nurse does not obtain a prescription to increase fluids because these are immediately restricted to treat SIADH. The nurse does not increase the child's feedings because it may cause vomiting. The child is placed in a side-lying position and the bed is elevated to facilitate venous drainage and avoid jugular compression.
Which measurement scale does the nurse use to assess the level of consciousness (LOC) in a child?
Glasgow Coma Scale (GCS) rational: The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values are assigned to the levels of responses in each part. The sum of the numeric values provides an objective measurement of the child's LOC
What teaching does the nurse give to the parents about the computed tomography (CT) scan that is prescribed for a child with head trauma? "This scan:
Helps detect the severity of the trauma." rational: The severity of an injury is not evident during a clinical examination, but it is detected through a CT scan
Which tumors cause an obstruction of normal cerebrospinal fluid flow and increased intracranial pressure (ICP)?
Infratentorial rational: Infratentorial tumors cause an obstruction of normal cerebrospinal fluid flow and increased ICP. The tumors occur in the area of the brain below the tentorium cerebelli and involve the cerebellum or brainstem
What does the nurse advise the parents of a child who is prescribed a metaiodobenzylguanidine (MIBG) scan?
It helps to know if the tumor has spread to the bone marrow and soft tissue rational: An MIBG scan is used to detect whether the tumor has spread to the bone marrow and soft tissue. The objective of the test is to locate the primary site and areas of metastasis
Which diet does the nurse recommend for a child for management of epilepsy?
Ketogenic diet rational: The ketogenic diet is a high-fat, low-carbohydrate, and adequate-protein diet that helps to utilize glucose as the primary energy source. This helps develop a state of ketosis and reduce seizures.
Which diagnostic tests does the nurse evaluate to confirm the presence of bacterial meningitis in a child who shows symptoms of infection such as headache, photophobia, and nuchal rigidity? Select all that apply.
Lumbar puncture Blood cell count Cerebrospinal fluid (CSF) glucose rational: Lumbar puncture helps to diagnose bacterial meningitis in a child by indicating an elevation in the spinal fluid pressure. The child's white blood cell count is also elevated. CSF glucose level is reduced as a result of bacterial consumption of glucose.
Which medication helps reduce intracranial pressure (ICP) elevations greater than 20 to 25 mm Hg in a child?
Mannitol (Osmitrol) Mannitol (Osmitrol) is an osmotic diuretic that is administered intravenously to lower the ICP in 1 to 5 minutes.
What does the nurse assess in a child who shows other symptoms of hydrocephalus such as sluggish pupils and dilation of scalp veins during crying?
Measures the child's head circumference rational: In hydrocephalus, the child's head circumference grows at an abnormal rate. The nurse measures the head circumference over 4 weeks and evaluates the measurements. Hydrocephalus is confirmed if the head circumference crosses at least one percentile line on the head measurement chart within 2 to 4 weeks
Which conditions can occur from infection in the nervous system? Select all that apply.
Meningitis Rabies Reye's syndrome rational: Meningitis is caused by a bacterial infection that causes acute inflammation of the meninges. Rabies is an acute infection of the nervous system caused by a virus. Reye's syndrome causes impaired consciousness and disordered hepatic function, which usually follows viral illness, such as influenza or varicella.
Which is a priority nursing action while providing care for a child who undergoes repeated subdural taps?
Monitor the child's hematocrit. rational: The nurse monitors the child's hematocrit to detect excessive blood loss from the procedure.
The nurse is caring for a 10-year-old child with a head injury. The nurse finds that the child does not exhibit the usual signs of a head injury, other than a headache, even though 10 hours have passed since the child sustained the injury. What is a priority nursing action in this context?
Monitor the level of consciousness for 2 hours. rational: Unlike an epidural hemorrhage, which develops inwardly against the less resistant brain tissue, a subdural hemorrhage tends to develop more slowly and spreads thinly and widely until it is limited by the dural barriers. Evidence of a subdural hemorrhage may take hours or days to develop. A decreasing level of consciousness is an early indication of neurologic damage. Therefore, assessing the child's level of consciousness at least every two hours is imperative.
The nurse is caring for a 5-year-old child who had a craniotomy. The nurse is assessing the neurologic status of the child. The nurse has checked the level of consciousness, pupillary activity, and reflexes. What else does the nurse assess in the patient?
Motor function rational: The nurse should observe for motor functions such as spontaneous activity, gait, and response to painful stimuli. This provides clues to the location and extent of cerebral dysfunction, if any. Assessment of motor function is an important component of a neurologic examination. Even subtle movements (e.g., the outward rotation of a hip) should be noted.
The nurse is assessing a 9-year-old child for the presence of Reye's syndrome (RS). What information about the child is most useful for the nurse during the assessment? The child:
Reports having a recent viral infection. rational: The etiology of RS is not well understood, but most cases follow a common viral illness, typically influenza or varicella
A ventriculoperitoneal (VP) shunt has been placed in an infant with hydrocephalus. What does the nurse include in the assessment to determine if the VP shunt is functioning properly?
Palpate the anterior fontanel. rational: A bulging fontanel is the most significant sign of increased intracranial pressure in an infant because the fontanels do not close until 18 months of age.
What action does the nurse take when caring for a child who is having a tonic-clonic seizure?
Places the child on the side rational: When a child is having a tonic-clonic seizure, the nurse places the child on the side to facilitate drainage and help maintain a patent airway
Which posttraumatic syndromes does the nurse assess for in a child after a head injury? Select all that apply.
Postconcussion syndrome Posttraumatic seizures Hydrocephalus rational: Postconcussion syndrome may occur within hours to days after a mild head injury and may result in loss of consciousness. Posttraumatic seizures may occur within the first few days after a severe head injury. Hydrocephalus is a structural complication that may occur as a result of head injuries
Which interventions does the nurse implement to prevent the elevation of intracranial pressure (ICP) in an unconscious child? Select all that apply.
Provides dim lights in the room Prevents sudden movements in the child Administers prescribed pain medications Monitors the child's temperature frequently
Which is an appropriate position to place a child who is unconscious for a long period?
Side-lying rational: The side-lying position in an unconscious child prevents aspiration of saliva, nasogastric secretions, and vomitus. The child is placed in a supine position with an elevated bed after supratentorial craniotomy to prevent hemorrhage. The prone position is not used in an unconscious patient, because it may cause obstruction of the airway. The dorsal recumbent position is used for procedures such as urinary catheterization.
Arrange the steps by which the sutures and fontanels are ossified in children.
The posterior fontanel is closed. There is a fibrous union of suture lines. The anterior fontanel is closed. There is a solid union of all sutures.
Magnetic resonance imaging (MRI) is used to
detect structural brain abnormalities or to assess cerebral edema.
Ibuprofen (Motrin) is used to reduce the temperature
during a febrile seizure.
Decerebrate posturing indicates
dysfunction at the level of the midbrain
The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest:
neurologic health. ratoinal: The Moro, tonic neck, and withdrawing reflexes are usually present in infants younger than 3 to 4 months of age. Therefore, the presence of these reflexes indicates neurologic health
Rectal diazepam (Valium) is used for
safe, quick, and effective treatment of status epilepticus
Electroencephalogram (EEG) helps identify
seizure activity
Decorticate posturing indicates
severe dysfunction of the cerebral cortex.
Phenytoin (Dilantin) is prescribed for
the management of status epilepticus
