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

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?" 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.

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?

"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.

What finding is consistent with increased ICP in the child?

Bulging fontanel Children with increased ICP exhibit bulging fontanels. They typically have a decreased appetite, are restless, and have trouble sleeping.

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 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.

True or False. The nurse caring for a child with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema.

False Antibiotics or antivirals are used to treat infectious disease processes. Glucocorticoids and diuretics are used to reduce cerebral edema.

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." 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 mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate?

"During delivery, your vaginal wall put pressure on the baby's head." Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

The nurse is assisting to position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure?

"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 their 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.

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." 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 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 his 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 nurse has just admitted a 17-year-old diagnosed with bacterial meningitis. The parents of the adolescent tell the nurse, "We just don't understand how this could have happened. Our child has always been healthy and also 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." Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Questioning them about being sure would not be the best response unless there was reason to believe their information was not accurate. There is nothing to lead the nurse to believe that a different strain of bacteria caused the infection, or that the the child's immune system is compromised

The mother of a 12-year-old with Reye syndrome approaches the nurse wanting to know how this happened to her child, saying, "I never give my kids aspirin!" What could the nurse say to begin educating the woman?

"Sometimes it's hard to tell what products may contain aspirin." Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. The parent needs to be receptive to further education, and raising the possibility the child was responsible does not accomplish that goal. Don't state the obvious, but also don't minimize the situation. Encouraging the mother to ask for information and offering explanations in terms she will understand are important, but this response does not address the mother's assertion.

The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate?

"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 1-year-old has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents?

"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, let the parents adjust to their baby's appearance and adapt your teaching to their questions, comments, and knowledge level.

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." Families need and want information they can share with relatives, childcare 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 boy may be able to bike ride and swim with proper precautions.

A child is home with the caregivers following a treatment for a head injury. If the child makes which of the following statements, the caregiver should contact the care provider.

"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 naueauted is not a reason to notify the provider.

The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? Select all that apply.

-Incontinence of urine or stool -Time the seizure started -Eye position and movement -Factors present before seizure started Following a seizure, the nurse documents: time the seizure started, what the child was doing when the seizure began, any factor present just before the seizure (bright light, noise), part of the body where seizure activity began, movement and parts of the body involved, any cyanosis, eye position and movement, incontinence of urine or stool, time seizure ended, and child's activity after the seizure. Who was with the child or the number of seizures the child has had are not relevant documentation regarding observation of this seizure.

To test for Kernig's sign, the client's leg is raised with the knee flexed and then extended at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig's sign. This is a common finding in meningitis.

. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees.

. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents and to prevent tearing or breakdown of the skin integrity at the site. Any opening in the sac greatly increases the risk of infection of the central nervous system. Choking and inability to tolerate stimulation are not priority problems with this defect. Delayed growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period.

A myelomeningocele is a type of spina bifida that results from failure of the neural tube to close during embryonic development. With a myelomeningocele, protrusion of the meninges, cerebrospinal fluid, nerve roots, and a portion of the spinal cord occurs. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. Initial care of the newborn with myelomeningocele involves prevention of infection

Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside but would be available in the treatment room or nearby on the nursing unit.

A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements.

The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or the face or neck. Myoclonic seizures are brief, random contractions of a muscle group that can occur on one or both sides of the body.

Absence seizures are brief episodes of altered awareness or momentary loss of consciousness. No muscle activity occurs except eyelid fluttering or twitching.

. On noting watery discharge from the child's nose, the nurse should test the drainage for glucose using an agency-approved reagent strip. If the results are positive, the nurse will contact the primary health care provider

After a head injury, bleeding from the nose or ears necessitates further evaluation. A watery discharge from the nose (rhinorrhea) that tests positive for glucose is likely to be cerebrospinal fluid (CSF) leaking from a skull fracture.

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) 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 eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform?

Assess the child's level of consciousness. Decreased level of consciousness is frequently the first sign of major neurologic problems after head trauma. While body temperature is an important indicator of infection, it is not a priority here. Preventing harm by setting the side rails is more important for a seizure client. The child's eyes will correct themselves when ICP is reduced.

The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating decerebrate posturing. The nurse is aware that this type of posturing is the result of injury to what area?

Brain stem Decerbrate posturing is seen with injuries occurring at the level of the brain stem, (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Decorticate posturing occurs with damage of the cerebral cortex, Adduction of the arms at the shoulders, Abnormal flexion of the upper extremities and extension and adduction of the lower extremities . Both types of posturing are characterized by extremely rigid muscle tone. Injuries to the frontal lobe of the brain and the mid-cervical spine would not cause these types of posturing.

A 4-year-old child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child, which will be the first change noted in the presence of increasing intercranial pressure?

Change in level of consciousness A change in the level of consciousness is the initial finding in the client who is experiencing an increase in intracranial pressure.

A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)?

Cloudy appearance In the CSF of clients diagnosed with bacterial meningitis, the pressure is elevated, the appearance is cloudy, and the leukocytes are elevated. A decreased sugar content is noted.

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent what information in regard to seizures?

Convulsive activity occurs. During seizures convulsive activity is typically noted. During a breath-holding spell, the child is bradycardiac, cyanosis occurs at the onset, and the EEG is normal.

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?

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.

Keeping the infant content and maintaining adequate nutrition are not priority care for an infant with eczema. Antibiotic ointment should be applied only for treatment of a secondary infection as prescribed by a primary health care provider.

Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent or control secondary infections.

The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse?

Gather appropriate equipment and signage for respiratory isolation precautions. Children with meningitis are placed on respiratory precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the infection to other family members or health care providers. While a child is on respiratory isolation, they will typically not be allowed out of their rooms to play. Due to pain when their neck is flexed, most children are most comfortable without a pillow. Reducing stimulation can help to promote rest for the child.

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 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.

Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome. Decreasing stimuli and providing rest decrease stress on the brain tissue.

If vomiting occurs in Reye's syndrome, it is caused by cerebral edema and is a sign of intracranial pressure.

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. 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 is used to assess for hydrocephalus.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?

Intracranial hemorrhaging Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection

Lindane is a pediculicide product that may be prescribed to treat scabies. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the children at risk for central nervous system toxicity and seizures.

Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members should be treated simultaneously. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk.

Until meningitis is ruled out, the child is placed in isolation on droplet precautions because the disease is spread by airborne means. Strict intake and output should be maintained.

Medication to treat acute bacterial meningitis is administered intravenously, not orally. A culture and sensitivity is done to determine if the diagnosis is bacterial or viral

it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

Meningitis is an infectious process of the central nervous system caused by bacteria and viruses

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

Moving the infant's head every 2 hours 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. Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.

A 12-year-old child has suffered a concussion after being in an automobile accident. What will be included in the plan of care/treatment? Select all that apply.

Observation of level of consciousness. Rest. The concussion is a common head injury. The injury is caused by a bump, blow, jolt, jarring, or shaking and results in disruption or malfunction of the electrical activities of the brain. Treatment includes rest and monitoring for neurologic changes that could indicate a more severe injury.

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the levels of consciousness in the order that reflects this progression.

Oriented to person, place, and time Disorientation Obtundation Stupor Coma

. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen.

A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use?

Place a cap or similar covering on the infant's head. Using an infant cap can help parents deal with the malformed appearance of their child. Because the child was born with a small or missing brain, the baby will likely die within hours or days. Monitoring for increased intracranial pressure (ICP) or neurologic status are not necessary interventions.

HAART consists of the combination of 2 nucleoside analogues, which target viral replication during the reverse transcription phase of the cell cycle, and a protease inhibitor, which targets viral replication at a different phase.

Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection in the client with acquired immunodeficiency syndrome.

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?

Positive Kernig sign 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

. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid

Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. I

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 A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures is 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 inability to swallow. All of these symptoms would make Risk for injury the highest priority.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be the most important to include in this child's plan of care?

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 the history of seizures does not impact the airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development.

Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site.

In caring for a child with a seizure disorder, the primary goal of treatment is:

The child will be free from injury during a seizure. Keeping the child free from injury is the highest priority goal. The other choices are important, but keeping the child safe is higher than the anxiety or knowledge deficit concerns. The physical always is a priority over the psychological.

Which of these age groups has the highest actual rate of death from drowning?

Toddlers Toddlers and older adolescents have the highest actual rate of death from drowning.

The nurse is caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion?

Trouble focusing when reading Signs and symptoms for cerebral contusions include disturbances to vision, strength, and sensation. A child suffering a concussion will be distracted and unable to concentrate. Vomiting is a sign of a subdural hematoma. Bleeding from the ear is a sign of a basilar skull fracture.

Before the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture and because MMR also contains a small amount of the antibiotic neomycin

administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Before administerin

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):

steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers. head injury cause bleeding in the brain result in increased ICP. early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

A 9-year-old diagnosed with neurofibromatosis is being evaluated for the presence of a brain tumor. What tests may be ordered to diagnose this condition?

• Computed tomography • Magnetic resonance imaging Computed tomography is used for visualization of tumors, ventricles, brain tissue, CSF, hematomas, and cysts. Magnetic resonance imaging is also useful in tumor identification. Lumbar puncture is used to measure CSF pressure and collect CSF samples for laboratory tests. Electroencephalograms detect and locate abnormal electrical discharges produced in the brain. Radiology identifies the presence of fractures, widened skull sutures, calcifications, bone erosion, or skeletal anomalies

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess?

• Eye opening • Verbal response • 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?

• Oxygen gauge and tubing • Suction at bedside • Padding for side rails 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.

When assessing a neonate for seizures, what would the nurse expect to find?

• Tachycardia • Elevated blood pressure • Jitteriness • Ocular deviation Neonatal seizures may be difficult to recognize but may be manifested by tremors, jitteriness, tachycardia and elevated blood pressure, and ocular deviation. Tonic-clonic contractions typically are more common in older children.

Seven-year-old Isabelle 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 Isabelle 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 best for the nurse to say to this mother?

"This might or might not be a problem. Watch Isabelle 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." Reye syndrome(acute encephalopathy) 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 three to five 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.

Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.

A major priority of nursing care for a child suspected to have meningitis is to administer the prescribed antibiotic as soon as a culture is obtained. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons. The progression from flexion to extension posturing usually indicates deteriorating neurological function, not improvement, and warrants primary health care provider notification. A focused neurological examination is priority at this time, not a complete head to toe.

Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and an extension of the lower extremities with some internal rotation.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?

Signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life

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. 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.

The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be:

The child is in status epilepticus. Status epilepticus is the term used to describe a seizure that lasts longer than 30 minutes or a series of seizures in which the child does not return to his or her previous normal level of consciousness. The child likely is having generalized seizures, but the most accurate description of what is happening is status epilepticus. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes. With absence seizures the child loses awareness and stares straight ahead but does not fall.

A mother has brought her 5-month-old son to the clinic because he has been drowsy and unresponsive. The child has hydrocephalus and had a shunt placed about a month previously. Which symptom indicates that the shunt is infected?

The child is not responding or eating well. Poor feeding and decreased responsiveness are signs of an infection. The nurse might also observe localized inflammation along the shunt tract. Bulging or tense fontanels suggest a shunt malfunction that is causing increased intracranial pressure. A high-pitched cry suggests increased intracranial pressure due to a shunt malfunction. Decreased and uneven pupil reaction times are symptoms of a shunt malfunction that is causing increased intracranial pressure.

Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Confusion indicates that the ability to think clearly and rapidly is lost. Disorientation indicates that the ability to recognize place or person is lost. Full consciousness indicates that the child is alert, awake, oriented, and interacts with the environment.

The nurse notes that the level of consciousness has been documented as obtunded. Which finding should the nurse expect

After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on what evidence?

The swelling crosses the midline of the infant's scalp. The fact that the swelling crosses the midline of the infant's scalp indicates caput succedaneum. If the swelling is limited and does not cross the midline or suture lines, it would suggest cephalohematoma. Low birthweight does not suggest caput succedaneum. Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele

For painful or red injection sites, the nurse should instruct the mother to apply cold compresses for the first 24 hours for 20 minutes at a time and then to use warm or cold compresses as long as needed. The instructions in the remaining options are incorrect. It is not necessary for the mother to bring the child to the clinic immediately, and it is not necessary for the mother to contact the primary health care provider. Although it may be appropriate to monitor the child for a fever,

immunization of DPT (diphtheria, pertussis, tetanus) vaccine. One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red

A 9-year-old diagnosed with neurofibromatosis is being evaluated for the presence of a brain tumor. What tests may be ordered to diagnose this condition? Select all that apply.

• Computed tomography • Magnetic resonance imaging Computed tomography is used for visualization of tumors, ventricles, brain tissue, CSF, hematomas, and cysts. Magnetic resonance imaging is also useful in tumor identification. Lumbar puncture is used to measure CSF pressure and collect CSF samples for laboratory tests. Electroencephalograms detect and locate abnormal electrical discharges produced in the brain. Radiology identifies the presence of fractures, widened skull sutures, calcifications, bone erosion, or skeletal anomalies

. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside but would be available in the treatment room or nearby on the nursing unit.

A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements

These seizures last only 5 to 10 seconds but may occur one after another several times a day. The child experiencing absence seizures may appear to be daydreaming. If the child is participating in group activities, they sometimes need help catching up with the group, especially if a seizure occurs. Decreasing grades is a sign of absence seizures, as well as lowered intellectual processes.

Absence seizures are very brief episodes of altered awareness. There is no muscle activity except eyelid fluttering or twitching. The child has a blank facial expression. T

A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis.

Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

Supporting the infant's head and neck when picking up the infant will prevent the hyperextension of the neck area and prevent the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant's head could put pressure on the neck vertebrae, causing injury.

Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid in the cerebral ventricular system. This characteristic causes the increase in the weight of the infant's head. The infant may experience significant head enlargement. Care must be exercised so that the head is well supported when the infant is fed or moved to prevent extra strain on the infant's neck, and measures must be taken to prevent the development of pressure areas.

Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate ICP. Increasing oral fluids and placing the infant in a side-lying position are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the primary health care provider.

anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased intracranial pressure (ICP) within the skull.

Temporal lobe herniation or uncal herniation refers to a shifting of the temporal lobe laterally across the tentorial notch. This produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil fixation, and death will result.

care for a child with a brain injury who has a temporal lobe herniation and increasing intracranial pressure. Which signs should the nurse identify as indicative of this type of injury

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 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.

In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in ICP. It is not necessary to check the blood pressure every 15 minutes.

Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP).

The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected. Being fussy is a concern only if other signs indicative of a complication are occurring.

If the shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant.

. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections

A lateral recumbent position with the knees flexed to the abdomen and the head bent with the chin resting on the chest is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space.

progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification

The classic signs/symptoms of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early manifestation and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs/symptoms.

signs of meningitis

Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema

An altered level of consciousness is an early sign of increased intracranial pressure (ICP). Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

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. 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).

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). Nasotracheal suctioning is contraindicated luid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. catheter, The child is maintained on NPO (nothing by mouth) status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications, if necessary. Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Urine concentrating ability is not well developed at the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure.

creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique

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. 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 is in regards to 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 is caring for a 6-year-old child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What actions by the nurse are indicated?

• Check tubing clamps to ensure they are open. • Ensure the tubing is not kinked. Nursing care of an external ventricular drainage device requires the nurse ensure all connections are secure and labeled. The amount of drainage requires close observation. If drainage is absent or minimal the nurse must assess the tubing to make certain it is not clamped or kinked. The level of the drip chamber must be set at the height of the child (at the clavicle). Taking the temperature will be useful to assess for the presence of infection but that is not currently a concern. Asking the child to cough and deep breathe should not be done. Deep breathing is beneficial for all postoperative clients, but coughing may increase pressures and should be avoided.

An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child?

• Request order for an antiemetic • Assess intake and output every shift • Request order for anticonvulsant This child likely has Reye syndrome and may require an anti-emetic for severe vomiting. The nurse should monitor the child's intake and output every shift for the development of fluid imbalance. The child may require an anticonvulsant due an increased intracranial pressure that may induce seizures. A distinctive rash is associated with the development of meningococcal meningitis. The nurse should monitor the Reye's syndrome child's laboratory values for indications that the liver is not functioning well