Chapter 46: Cerebral Dysfunction NCLEX

B (The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not part of the Glasgow Coma Scale.)

The Glasgow Coma Scale consists of an assessment of: a. Pupil reactivity and motor response. b. Eye opening and verbal and motor responses. c. Level of consciousness and verbal response. d. Intracranial pressure (ICP) and level of consciousness.

C (Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.)

The initial clinical manifestation of generalized seizures is: a. Being confused. b. Feeling frightened. c. Losing consciousness. d. Seeing flashing lights.

D (H. influenzae type B meningitis has virtually been eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.)

The mother of a 1-month-old infant tells the nurse that she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on knowing that: a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.

C (After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The child's position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding.)

A 10-year-old boy has been hit by a car while riding his bicycle in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be to: a. Place on side. b. Take blood pressure. c. Stabilize neck and spine. d. Check scalp and back for bleeding.

C, D, E (Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.)

Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply): a. Low-pitched cry. b. Sunken fontanel. c. Drowsiness d. Irritability. e. Distended scalp veins. f. Increased blood pressure.

C (All children who have a near-drowning experience should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur up to 24 hours after the incident. Stating that, "He still needs a little extra oxygen" does not respond directly to the mother's concern. Why is her child still receiving oxygen? The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary.)

A 3-year-old child is hospitalized after a near-drowning accident. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply is: a. "He still needs a little extra oxygen." b. "I'm sure he is fine, but the doctor wants to make sure." c. "The reason for this is that complications could still occur." d. "It is important to observe for possible central nervous system problems."

C (The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.)

A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

C (A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure-free for 2 years and has a normal electroencephalogram. Medications must be gradually reduced to minimize the recurrence of seizures. Seizure medications can be safely discontinued. The risk of recurrence is greatest within the first year.)

A child has been seizure-free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which intervention in the response? a. Medications can be discontinued at this time. b. The child will need to take the drugs for 5 years after the last seizure. c. A stepwise approach will be used to reduce the dosage gradually. d. Seizure disorders are a lifelong problem. Medications cannot be discontinued.

D (Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved.)

A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests: a. Diabetic coma. b. Brainstem injury. c. Upper respiratory tract infection. d. Leaking of cerebrospinal fluid (CSF).

A, C, D (The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.)

A nurse should expect which cerebrospinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis (Select all that apply)? a. Elevated white blood cell (WBC) count b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBCs)

B (A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and to promote comfort and relieve anxiety. Gathering information about the child's previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and resultant increased intracranial pressure.)

A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. The most appropriate nursing action is to: a. Discuss with parents the child's previous experiences with pain. b. Discuss with practitioner what analgesia can be safely administered. c. Explain that analgesia is contraindicated with a head injury. d. Explain that analgesia is unnecessary when child is not fully awake and alert.

A (The child's history of the fall, brief loss of consciousness, and vomiting four times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child's age, and is necessary to determine whether a brain injury has occurred.)

A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she "seems fine." The nurse should explain that the toddler: a. May have a brain injury. b. May start having seizures. c. Needs this because of her age. d. Probably has a skull fracture.

C (Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible. Hospitalization is not necessary. The wound cleansing, passive immunization, and immune globulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine.)

A young child's parents call the nurse after their child was bitten by a raccoon in the woods. The nurse's recommendation should be based on knowing that: a. The child should be hospitalized for close observation. b. No treatment is necessary if thorough wound cleaning is done. c. Antirabies prophylaxis must be initiated. d. Antirabies prophylaxis must be initiated if clinical manifestations appear.

A (Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.)

An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem b. Subdural hemorrhage c. Skull fracture d. Epidural hemorrhage

C (Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.)

An appropriate nursing intervention when caring for an unconscious child should be to: a. Change the child's position infrequently to minimize the chance of increased intracranial pressure (ICP). b. Avoid using narcotics or sedatives to provide comfort and pain relief. c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated.

A (When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in his or her mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on his or her side, facilitating drainage.)

An important nursing intervention when caring for a child who is experiencing a seizure is to: a. Describe and record the seizure activity observed. b. Restrain the child when seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration.

A, E, F (Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping the shunt reservoir, administering sedation, and maintaining Trendelenburg position are not interventions associated with this condition.)

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care (Select all that apply)? a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.

B (The nurse should assess the child with a head injury and decreasing level of consciousness (LOC) first. Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his or her surroundings would be of least worry to the nurse.)

The nurse has received report on four children. Which child should the nurse assess first? a. A school-age child in a coma with stable vital signs b. A preschool child with a head injury and decreasing level of consciousness c. An adolescent admitted after a motor vehicle accident who is oriented to person and place d. A toddler in a persistent vegetative state with a low-grade fever

D (The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing indicates neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.)

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is: a. Posturing. b. Focal neurologic signs. c. Vital signs. d. Level of consciousness.

D (Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Delirium is a state of mental confusion and excitement marked by disorientation to time and place. The doll's head maneuver is a test for brainstem or oculomotor nerve dysfunction.)

The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema b. Doll's head maneuver c. Delirium d. Periodic and irregular breathing

C, D, E (Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.)

The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed (Select all that apply)? a. Headache b. Photophobia c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone

B (The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.)

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. Eye trauma. b. Neurosurgical emergency. c. Severe brainstem damage. d. Indication of brain death.

B, D, E (Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.)

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)? a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations

D (The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient's level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15.)

The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 b. 13 c. 11 d. 15

B (For CT scans, the child will not be allowed to move and must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure.)

The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which statement should the nurse include? a. "Pain medication will be given." b. "The scan will not hurt." c. "You will be able to move once the equipment is in place." d. "Unfortunately no one can remain in the room with you during the test."

A (Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.)

The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an adequate airway. b. Perform neurologic assessment. c. Monitor intercranial pressure. d. Determine whether a neck injury is present.

B (Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes and ticks. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis.)

The vector reservoir for agents causing viral encephalitis in the United States is: a. Tarantula spiders. b. Mosquitoes and ticks. c. Carnivorous wild animals. d. Domestic and wild animals.

D (Although the etiology of Reye's syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye's syndrome; thus use of aspirin is avoided. No immunization currently exists for Reye's syndrome. Reye's syndrome is not correlated with head injuries or bacterial meningitis.)

What action may be beneficial in reducing the risk of Reye's syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza

A (Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing ROM exercises are important interventions in the care of a critically ill or comatose child. Careful monitoring of intake and output is a priority.)

When caring for the child with Reye's syndrome, the priority nursing intervention is to: a. Monitor intake and output. b. Observe for petechiae. c. Prevent skin breakdown. d. Do range-of-motion (ROM) exercises.

B (Most cases of Reye's syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye's syndrome.)

When taking the history of a child hospitalized with Reye's syndrome, the nurse should not be surprised that a week ago the child had recovered from: a. Measles. b. Varicella. c. Meningitis. d. Hepatitis.

A (Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.)

Which clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure

A (For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.)

Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol b. Atropine sulfate c. Epinephrine hydrochloride d. Sodium bicarbonate

A (To reduce fear and enhance cooperation during the MRI, the child should be made aware that the head will be restricted to obtain accurate information. Drinking fluids is usually done for neurologic procedures. A child should lie flat after a lumbar puncture, not after an MRI. Electrodes are attached to the head for an electroencephalogram.)

Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. "Your head will be kept from moving during the procedure." b. "You will have to drink a special fluid before the test." c. "You will have to lie flat after the test is finished." d. "You will have electrodes placed on your head with glue."

C (A CT scan provides visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and tissue discrimination that is unavailable with any other techniques.)

Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan b. Echoencephalography c. Computed tomography (CT) scan d. Magnetic resonance imaging (MRI)

B (A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.)

Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.

C (A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.)

Which statement is most descriptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient, reversible neuronal dysfunction. d. A slight lesion develops remote from the site of trauma.

C (Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.)

Which term is used to describe a child's level of consciousness when the child can be aroused with stimulation? a. Stupor b. Confusion c. Obtundation d. Disorientation

B (Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.)

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

A (The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake.)

Which test is never performed on a child who is awake? a. Oculovestibular response b. Doll's head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions

C (Diastatic skull fractures are traumatic separations of the cranial sutures. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture has the bone exposed through the skin. A depressed fracture has the bone pushed inward, causing pressure on the brain.)

Which type of fracture describes traumatic separation of cranial sutures? a. Basilar b. Compound c. Diastatic d. Depressed

C (Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electrical discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.)

Which type of seizure involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

A (Absence seizures may go unrecognized because little change occurs in the child's behavior during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable.)

Which type of seizure may be difficult to detect? a. Absence b. Simple partial c. Generalized d. Complex partial