Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder

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? A. cerebral edema B. left-sided heart failure C. renal failure D. Cardiogenic shock

A. cerebral edema 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.

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? A. "What type of fluids did your child take when he had a fever?" B. "Did you use any medications, like Aspirin, for the fever?" C. "How high did his temperature rise when he was ill?" D. "Did you give your child any acetaminophen, such as Tylenol?"

B. "Did you use any medications, like Aspirin, for the fever?" 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.

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? A. Delayed growth and development related to physical restrictions B. Risk for injury related to seizure activity C. Risk for acute pain related to surgical procedure D. Ineffective airway clearance related to history of seizures

B. Risk for injury related to seizure activity 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.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? A. giving the infant small feedings whenever he is fussy B. moving the infants head Q2 C. measuring I&O Qshift D. massaging the scalp gently Q4

B. moving the infants head Q2 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.

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? A. lumbar puncture B. computed tomography C. video electroencephalogram D cerebral angiography

C. video electroencephalogram 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.

Which of these age groups has the highest actual rate of death from drowning? A. preschool children B. school-aged children C. infants D. toddlers

D. toddlers

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 _________________ followed by ______________________________.

Ensure proper oxygenation; adminster IM or IV benzodiazepine 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 nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate for administration? Select all that apply. A. Fosphenytoin B. Diazepam C. Carbamazepine D. Lorazepam E. Gabapentin

A. Fosphenytoin B. Diazepam D. Lorazepam Commonly used medications for treating status epilepticus include lorazepam, diazepam, and fosphenytoin. Gabapentin and carbamazepine are anticonvulsants used to treat and prevent seizures in general.

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? A. "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine." B. "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." C. "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." D. "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."

D. "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." 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.

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? A. assess LOC B. notify the PCP C. place a patch over the client's affected eye D. place the child on fall precaution

A. assess LOC 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.

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? A. "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." B. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." C. "I need to set an alarm to wake up and check his temperature during the night when he is sick." D. "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully."

B. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." 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 parents of a child with a history of seizures who has been taking phenytoin ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate? A. "A drop in the plasma drug level will lead to a toxic state." B. "Small increments in dosage lead to sharp increases in plasma drug levels." C. "The capacity to metabolize the drug becomes overwhelmed over time." D. "Large increments in dosage lead to a more rapid stabilizing therapeutic effect."

B. "Small increments in dosage lead to sharp increases in plasma drug levels." Within the therapeutic range for phenytoin, small increments in dosage produce sharp increases in plasma drug levels. The capacity of the liver to metabolize phenytoin is affected by slight changes in the dosage of the drug, not necessarily the length of time the client has been taking the drug. Large increments in dosage will greatly increase plasma levels, leading to drug toxicity.

A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents? A. "I will be watching hemoglobin and hematocrit closely." B. "The surgery was successful. Do you have any questions?" C. "This only happens in 1 out of 2,000 births." D. "I told you yesterday there would be facial swelling."

B. "The surgery was successful. Do you have any questions?" Often what parents need most is someone to listen to their concerns. Although this is a good time for education, the parents are more concerned about the success of the surgery than their infant's appearance. Watching the hemoglobin, hematocrit and swelling are important nursing functions but they do not address the parents' psychosocial needs. The parents do not need to be taught statistics about their infant's condition. They more than likely know this from health care provider visits, the Internet, and parent support groups. Following surgery, this knowledge is not what parents are concerned about. Parents want to know their infant is safe and well.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: A. rhinorrhea B. Battle sign C. raccoon eyes D. otorrhea

B. Battle sign 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 using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. A. posture B. eye opening C. motor response D. fontanels E. verbal response

B. eye opening C. motor response E. verbal response

Any individual taking phenobarbital for a seizure disorder should be taught: A. never to go swimming B. never to discontinue the drug abruptly C. to avoid foods containing caffiene D. to brush his or her teeth four times a day

B. never to discontinue the drug abruptly Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.

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? A. "I'm glad to know he will only need this medication for a short time to stop his seizures." B. "I will give the medication to him when I first wake him up in the morning." C. "I need to watch for any new bruises or bleeding and let my health care provider know about it." D. "This medication may cause him to have trouble sleeping. He may need something else to help him sleep."

C. "I need to watch for any new bruises or bleeding and let my health care provider know about it." 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.

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)? A. While turning the child's head to the left, the eyes turn to the right. B. While stimulating the child's foot, the big toe points upward and other toes fan outward. C. While assessing the child's pupils, there is no change in diameter in response to a light. D. While calling the child's name, the child stares straight ahead and does not turn to the sound.

C. While assessing the child's pupils, there is no change in diameter in response to a light. 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.

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? A. "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose." B. "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder." C. "Since the EEG was negative there must be some other cause for the seizures. The lumbar puncture is necessary to determine what the cause is." D. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

D. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures. A normal EEG does not rule out epilepsy because seizure activity rarely occurs during the actual testing time. A 24-hour or longer EEG can help in diagnosing a seizure disorder. Just telling the parents that it needs to be done, to be patient, or it is a routine does not address the parents' concerns.

The nurse is teaching new parents about cephalohematoma. Which statement by the parents suggests the need for further teaching? A. "We should expect to see swelling on one side of our infant's scalp in a couple days." B. "A delivery assisted with forceps contributed to the cephalohematoma." C. "Most cases of cephalohematoma resolve and only require observation." D. "We should expect to see some discoloration on our child's scalp."

D. "We should expect to see some discoloration on our child's scalp." Characteristics of cephalohematoma include swelling that does not cross the midline and typically no discoloration. Causes of cephalohematoma include pressure against the mother's pelvis and commonly a forceps-assisted delivery. In most cases of cephalohematoma, only observation is necessary and resolution occurs within 2 to 9 weeks.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? A. Monitor temp Q4 B. Take V/S Q4 C. Encourage the parents to hold the child D. Decrease environmental stimulation

D. Decrease environmental stimulation A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

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? A. Encourage the mother to hold and comfort the infant. B. Educate the family about preventing bacterial meningitis. C. Palpate the child's fontanels (fontanelles). D. Institute droplet precautions in addition to standard precautions.

D. Institute droplet precautions in addition to standard precautions. 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.

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? A. Call the doctor if she gets a persistent headache. B. Her autoregulation mechanism to absorb spinal fluid has failed. C. Always keep her head raised 30º D. Tell me your concerns about your child's shunt

D. Tell me your concerns about your child's shunt 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.

Absence seizures are marked by what clinical manifestation? A. sudden, brief jerks of a muscle group B. loss of muscle tone and LOC C. brief, sudden onset of increased tone of the extensor muscle D. loss of motor activity accompanied by a blank stare

D. loss of motor activity accompanied by a blank stare An absence seizure consists of a sudden, brief arrest of the child's motor activity accompanied by a blank stare and loss of awareness. A tonic seizure consists of a brief onset of increased tone or muscle. A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. An atonic seizure involves a sudden loss of muscle tone and loss of consciousness.

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. incomplete myelinization B. facial deformities C. neonatal conjunctivitis D. neural tube defect

D. neural tube defect 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 helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? A. "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." B. "The child will be placed in the prone position with the nurse holding the child still." C. "The child will be held by the mother on her lap with his back toward the health care provider." D. "When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible."

A. "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." Correct positioning for a lumbar puncture is to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? A. Administer lorazepam IV as prescribed. B. Perform a glucose finger stick to determine the child's blood sugar level. C. Administer carbamazepine as prescribed. D. Observe and document the length of time of the seizure and type of movement observed.

A. Administer lorazepam IV as prescribed. A seizure lasting longer than 30 minutes is considered status epilepticus and is an emergency situation. An IV benzodiazepine such as lorazepam is administered to help stop the seizure. Checking blood glucose levels, monitoring length and type of seizure, and administration of anti-seizure medication such as carbamazepine all are correct interventions for clients with seizures, but these are not the priority action.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? A. head trauma B. positional plagiocephaly C. congenital hydrocephalus D. intracranial hemorrhaging

A. head trauma 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 educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate? A. "You won't need to change diapers often." B. "Take your time feeding your baby." C. "Lay him down after feeding." D. "You'll see a big difference after the surgery."

B. "Take your time feeding your baby." One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations.

A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement? A. "I am glad that my headache is getting better." B. "You look funny. Well, both of you do. I see two of you." C. "It will be nice when you will let me take a long nap. I am sleepy." D. "My stomach is upset. I feel like I might throw up."

B. "You look funny. Well, both of you do. I see two of you." The caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider.

The nurse is caring for an adolescent who suffered a thoracic spinal cord injury 8 weeks ago. While assessing the adolescent, the nurse notes a blood pressure of 185/95 mm Hg, heart rate of 130 beats/minute, flushed face, and a report of a severe headache. What is the priority action by the nurse? A. Place a fan pointing toward the adolescent's face to help reduce flushing. B. Place the adolescent in a high-Fowler position to reduce intracranial pressure. C. Notify the health care provider and request a prescription for an antihypertensive. D. Assess the adolescent's indwelling urinary catheter to see if it is obstructed.

D. Assess the adolescent's indwelling urinary catheter to see if it is obstructed. Autonomic dysreflexia is an emergent situation that is caused by a full bladder in a child with a spinal cord injury. It is characterized by extreme hypertension, tachycardia, flushed face and severe occipital headache. Assessing and emptying the bladder is the first action in treating this disorder. Placing the child in high-Fowler and providing a fan does not address the underlying cause of the autonomic dysreflexia. The nurse will need to notify the health care provider but should do this after assessing the client's bladder and indwelling bladder catheter.

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: A. encouraging development of motor skills B. maintaining effective cerebral perfusion C. establishing seizure precautions for the child D. ensuring the parents know how to properly give antibiotics

D. ensuring the parents know how to properly give antibiotics 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.