Chapter 38: Neurologic Disorder
A pregnant client asks if there is any danger to the development of her fetus in the first few weeks of her pregnancy. How should the nurse respond?
"During the first 3 to 4 weeks of pregnancy, brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma." Rationale: Brain and spinal cord development occur during the first 3 to 4 weeks of gestation. Infection, trauma, teratogens (any environmental substance that can cause physical defects in the developing embryo and fetus), and malnutrition during this period can result in malformations in brain and spinal cord development and may affect normal central nervous system (CNS) development. Good health before becoming pregnant is important but must continue into the pregnancy. Hardening of bones occurs during 13 to 16 weeks' gestation, and the respiratory system begins maturing around 23 weeks' gestation.
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education?
"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Rationale: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.
The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status?
"She has been irritable for the last hour....seems like she is just upset for some reason." Rationale: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope?
"Use this information to teach family and friends." Rationale: Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions.
The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught?
"Watch for changes in his behavior or eating patterns." Rationale: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.
The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply.
> eye opening > verbal response > motor response Rationale: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.
A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply.
> oxygen gauge and tubing > suction at bedside > padding for side rails Rationale: When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.
What information is most correct regarding the nervous system of the child?
As the child grows, the gross and fine motor skills increase. Rationale: As the child grows, the quality of the nerve impulses sent through the nervous system develops and matures. As these nerve impulses become more mature, the child's gross and fine motor skills increase in complexity. The child becomes more coordinated and able to develop motor skills.
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:
Battle sign Rationale: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.
The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question?
Initiate an IV of 0.9% NS to run at 250 ml/hr. Rationale: Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.
A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially?
Institute droplet precautions in addition to standard precautions. Rationale: Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Encouraging the mother to hold and comfort the child is an intervention but not the priority one; the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread. Educating the family about preventing bacterial meningitis would be appropriate later once the initial infection has been controlled. Palpating the fontanels (fontanelles) is used to assess for hydrocephalus.
In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care?
Risk for injury related to seizure activity Rationale: The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.
A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate?
Teach the child and his parents to keep a headache diary. Rationale: A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.
The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session?
Tell me your concerns about your child's shunt. Rationale: Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.
The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history?
a neural tube defect Rationale: Folic acid supplementation has been found to reduce the incidence of neural tube defects by 50%. The fact that the mother has not used folic acid supplements puts her baby at risk for spina bifida occulta, one type of neural tube defect. Neonatal conjunctivitis can occur in any newborn during birth and is caused by virus, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.
The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history?
a neural tube defect Rationale: Folic acid supplementation has been found to reduce the incidence of neural tube defects by 50%. The fact that the mother has not used folic acid supplements puts her baby at risk for spina bifida occulta, one type of neural tube defect. Neonatal conjunctivitis can occur in any newborn during birth and is caused by virus, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.
The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem?
head trauma Rationale: A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Positional plagiocephaly is caused by an infant's head remaining in the same position for too long.
The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching?
"I need to watch for any new bruises or bleeding and let my health care provider know about it." Rationale: Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to watch for any signs of bruising, bleed, or infection and notify their health care provider if this happens. Administer this medication with food to minimize GI upset. This medication can cause drowsiness, so do not give any sleep-inducing or other sedative type medications. Antiseizure medication does not cure seizures; it only controls the seizures. Lifelong antiseizure medication may be needed.
While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education?
"I will cradle her in my arms after the procedure for at least 30 minutes." Rationale: During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.
The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority?
Assess the client's respiratory status. Rationale: The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway.
A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform?
Assess the level of consciousness (LOC). Rationale: Decreased LOC is frequently the first sign of a major neurologic problem after head trauma. The nurse would assess the client's LOC before notifying the health care provider. The child may need to be placed on fall precaution, depending on the results of the assessment. The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary.
To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority?
Cerebral edema Rationale: The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Renal failure and cardiogenic shock aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse will be correct in telling the parent which information in regard to seizures?
Convulsive activity often occurs in seizures. Rationale: During seizures, convulsive activity is typically noted. Breath-holding spells are typically provoked by pain or the child being upset, have a normal EEG pattern, and are typically outgrown by the time the child reaches preschool age.
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?
Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Rationale: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?
Positive Kernig sign Rationale: A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy.
The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority?
Risk for injury Rationale: A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures are the most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to an inability to swallow. All of these symptoms would make Risk for injury the highest priority.
A nurse in the emergency department (ED) is assessing a 2-year-old male child. The parents state the child "has been very feverish the past few days, and today the child developed a purple rash on the chest. The child is now very sleepy."
The assessment reveals the child is lethargic but opens eyes and answers yes and no to questions. The child is unable to lie with hips flexed and straighten the leg out, and states their neck hurts when trying to move it. Vital signs: temperature, 102.4°F (39.1°C); heart rate, 120 beats/min; blood pressure, 78/45 mm Hg; respirations, 28 breaths/min; oxygen saturation, 92% on room air. Rationale: The client's temperature of 102.4°F (39.1°C) indicates a fever. This will require the nurse to follow up to determine the underlying cause for the fever. A purple (purpuric) rash appearing during a febrile state requires follow-up, because it may indicate meningitis. The child reporting a stiff neck may indicate meningeal irritation. The child's inability to straighten the leg when lying flat with hips flexed indicates meningeal irritation; it is referred to as a positive Kernig sign. Lethargy indicates decreased level of consciousness; the nurse should closely monitor the child's level of consciousness. The child's oxygen saturation of 92% on room air indicates decreased oxygen levels.
The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is:
ensuring the parents know how to properly give antibiotics. Rationale: Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected. Maintaining cerebral perfusion is important for a child with hydrocephalus, but the priority intervention for the parents at this time concerns the infection. Establishing seizure precautions is an intervention for a child with a seizure disorder. Encouraging development of motor skills would be appropriate for a microcephalic child.
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?
moving the infant's head every 2 hours Rationale: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.
Any individual taking phenobarbital for a seizure disorder should be taught:
never to discontinue the drug abruptly. Rationale: Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.
The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain?
video electroencephalogram Rationale: A video electroencephalogram can determine the precise localization of the seizure area in the brain. Cerebral angiography is used to diagnose vessel defects or space-occupying lesions. Lumbar puncture is used to diagnose hemorrhage, infection, or obstruction in the spinal canal. Computed tomography is used to diagnose congenital abnormalities such as neural tube defects.
An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done?
"I always keep phenobarbital with me in case of a fever." Rationale: Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature because seizures occur as the temperature rises.
The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond?
"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." Rationale: Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Meningococcal conjugate vaccine protects against four types of meningitis. There is nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the infection, or that the adolescent's immune system is compromised.
The nurse is caring for a 3-year-old child who experienced a febrile seizure for the first time. What statements by the parents of the child should the nurse address further? Select all that apply.
> "I am afraid that our 10-year-old will start having febrile seizures." > "It is so scary to think that our child will likely develop epilepsy now." Rationale: It is very unlikely that the 10-year-old child will develop febrile seizures. Febrile seizures usually affect children who are younger than 5 years of age, with the peak incidence occurring in children between 12 and 18 months old; it is rare to see febrile seizures in children younger than 6 months and older than 5 years of age. Children who experience one or more simple febrile seizures have a slightly greater risk of developing epilepsy than the general population, so it is not "likely" that the child will develop epilepsy.
A nurse on the neurology unit is monitoring an 8-year-old child admitted with seizures. The child experiences a prolonged tonic-clonic seizure.
The nurse should first ensure proper oxygenation followed by administer intravenous (IV) or intramuscular (IM) benzodiazepine Rationale: The nurse first ensures a patent airway and proper oxygenation using a blow-by method.The nurse then administers an antiepileptic medication such as benzodiazepines intravenously or intramuscularly for prolonged seizure activity. Nothing should be inserted into the child's airway when the child is seizing, not even suction. The nurse can place the child in a side-lying position to prevent the tongue from occluding the airway and help with secretions that may pool up in the back of the throat.The child should not receive anything orally when the child is seizing. The nurse should administer medications via intravenous push (IVP) or intramuscular (IM) during prolonged seizure activity.It is appropriate for the nurse to allow the child to sleep once the seizure has ended. The child should be placed in the left lateral recumbent recovery position.
A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which as a risk factor for hemorrhagic stroke?
arteriovenous malformations (AVMs) Rationale: Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke. Sickle cell disease is a risk factor for ischemic stroke. Congenital heart defects are risk factors for ischemic stroke. Meningitis or other infection is a risk factor for ischemic stroke.
The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse?
"Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Rationale: The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.
The nurse is preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child?
Use a doll with electrodes attached to the head. Rationale: An electroencephalogram (EEG) is a test to measure the electrical activity of the brain. It is conducted by attached electrodes over sections of the head and obtains an electrical reading via a monitor. There is no pain involved in the procedure, but the child must lie still. The best way for the nurse to explain the procedure to the child is via a doll with attached electrodes that the child can play with, feel, and manipulate. This helps to reduce the child's anxiety and aids in cooperation. Videos can help with the education process but they do not allow for interaction and physical touching. The child can take a nap during the procedure but this does not prepare the child for the procedure. Assuring the child that the procedure will not hurt is not the best way to prepare the child.
A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?
"Did you use any medications, like aspirin, for the fever?" Rationale: Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.
An infant is brought to the emergency department after falling off the parents' bed and hitting the head. The infant is diagnosed with a concussion and is safe to return home. Which instruction(s) does the nurse provide the parents for home care of this infant? Select all that apply.
> "Have someone in the home with your infant for the next 24 hours." > "Return to the emergency department if your infant vomits more than 2 times." > "Return to the emergency department if you notice your infant's pupils are different sizes." Rationale: Falls are the most common cause of head injuries in infants. A concussion is a type of closed head injury. It results in disruption or malfunction of the electrical activities of the brain. After diagnostic testing and physical assessment have ruled out a serious injury, the infant can be sent home. The parents are taught how to monitor for more serious neurological signs. They, or someone, should be with the infant for the first 24 hours after injury to monitor or respond to an emergent situation. The infant should be awakened every 2 to 4 hours during the first 24 hours. The infant should be able to respond appropriately from waking. The parents would be taught to return to the emergency department if the child vomits more than twice, has increased irritability, unequal pupil sizes, or has a seizure. Acetaminophen would not be administered because it can mask the symptoms.
The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)?
While assessing the child's pupils, there is no change in diameter in response to a light. Rationale: To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination.
The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger?
drinking three cans of diet cola Rationale: Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.
Which of these age groups has the highest actual rate of death from drowning?
toddlers Rationale: Toddlers and older adolescents have the highest actual rate of death from drowning.
The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my children aspirin!" What could the nurse say to begin educating the parent?
"Sometimes it is hard to tell what products may contain aspirin." Rationale: Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. Two common medications containing salicylates are bismuth subsalicylate and effervescent heartburn relief antiacid. The parent needs to be receptive to further education, and raising the possibility the child was responsible does not accomplish that goal. The nurse should not state the obvious, but also should not minimize the situation. Encouraging the parent to ask for information and offering explanations in terms the parent will understand are important, but this response does not address the parent's assertion. Telling the parent not to worry is offering platitudes and false reassurance. Giving the description of what complications could happen with the disease would be inappropriate. This would only exacerbate the parent's concern, and it does not address how the child ingested salicylates.
A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse?
"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Rationale: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.