Ch. 38 Intracranial regulation/neuro disorders
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). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1364
The nurse is caring for a child who was injured in a bike accident. The nurse determines that a child is experiencing late signs of increased intracranial pressure based on which assessment findings? Select all that apply. Bradycardia Fixed dilated pupils Irregular respirations Increased blood pressure Sunset eyes
Bradycardia Fixed dilated pupils Irregular respirations Late signs of increased intracranial pressure include bradycardia, fixed and dilated pupils, and irregular respirations. Increased blood pressure and sunset eyes are early signs of increased intracranial pressure. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1333
Absence seizures are marked by what clinical manifestation? Brief, sudden onset of increased tone of the extensor muscle Loss of motor activity accompanied by a blank stare Sudden, brief jerks of a muscle group Loss of muscle tone and loss of consciousness
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1344
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. Call the doctor if she gets a persistent headache. Her autoregulation mechanism to absorb spinal fluid has failed. Always keep her head raised 30º.
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1355
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) sickle cell disease congenital heart defect meningitis
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1369
The nurse assesses a child and finds that the child's pupils are pinpoint. What does this finding indicate? brain stem dysfunction seizure activity brain stem herniation intracranial mass
brain stem dysfunction Explanation: Pinpoint pupils are commonly observed in poisonings, brain stem dysfunction, and opiate use. Dilated but reactive pupils are seen after seizures. Fixed and dilated pupils are associated with brain stem herniation. A single dilated but reactive pupil is associated with an intracranial mass. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1331
The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? tachypnea hyperthermia poor handwriting hypertension
hypertension Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1333
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? moving the infant's head every 2 hours measuring the intake and output every shift massaging the scalp gently every 4 hours giving the infant small feedings whenever he is fussy
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1356
A nurse is reviewing the results of a lumbar puncture of a child. The nurse identifies which results as being abnormal? Select all that apply. specific gravity of 1.011 trace amounts of protein trace amounts of glucose cloudy in color granulocytes are present
specific gravity of 1.011 cloudy in color granulocytes are present Normal appearance of cerebrospinal fluid (CSF) is clear and colorless. The presence of granulocytes suggests a cerebrospinal fluid infection. Normal specific gravity is 1.004 to 1.008. Trace amounts of protein, glucose, lymphocytes, and body salts are normal. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1334
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? cerebral angiography lumbar puncture video electroencephalogram computed tomography
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1335
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." "Lay him down after feeding." "You'll see a big difference after the surgery." "You won't need to change diapers often."
"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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1352
The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply. increased head circumference pulse rate of 60 beats/min and regular vomiting blood pressure decreased from baseline parent states, "My infant does not act right."
increased head circumference pulse rate of 60 beats/min and regular vomiting parent states, "My infant does not act right." Signs of increased intracranial pressure include bulging fontanel ([fontanelle] increased head circumference), decreased pulse, vomiting, increased blood pressure and behavior changes. The nurse must listen to the parents if concerns about behavior are mentioned. The blood pressure would increase, not decrease. The nurse would alert the health care provider immediately of these signs so intervention can be started if needed. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1333
A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure? semi-Fowler position with a parent at the bedside supine on a parent's lap prone on the bed with a parent or caregiver on either side of the bed high-Fowler position while sitting on the parent's lap
semi-Fowler position with a parent at the bedside Proper positioning for an infant after a ventricular tap is to place the child in a semi-Fowler position to prevent additional drainage from the puncture site. Allow the parents or caregivers to comfort the child. Placing the child in the prone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1341
The nurse is caring for a child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What action(s) by the nurse should be performed now? Select all that apply. Check the child's temperature. Check tubing clamps to ensure they are open. Ensure the tubing is not kinked. Ensure the drip chamber is below the child's clavicles. Encourage the child to cough and deep breathe to facilitate drainage.
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 to 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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1355
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Onset and character of fever Degree and extent of nuchal rigidity Signs of increased intracranial pressure (ICP) Occurrence of urine and fecal contamination
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1333
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. Diazepam Lorazepam Fosphenytoin Gabapentin Carbamazepine
Diazepam Lorazepam Fosphenytoin Explanation: 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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1346
The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant? placing the infant supine in the crib after feeding the infant placing the infant in an infant car seat after feeding the infant placing the infant prone in the crib after feeding the infant placing the infant in a Sims position in the crib after feeding the infant
placing the infant in an infant car seat after feeding the infant Explanation: Placing a child or infant in the semi-Fowler position can help reduce cerebral edema and pressure. Using an infant child seat helps to simulate the raised head of the bed. In the supine position, the client is completely flat on his or her spine. Prone is face down and flat. Sims is a side-lying position with one leg flexed. All of the described positions place the client flat, not with the head raised; that would be in the semi-Fowler position. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1333
A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."
"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1363
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Place multiple pillows in the room to assist with propping the child's head up. Provide information regarding policies of the unit's playroom for the parents to review. Gather appropriate equipment and signage for respiratory isolation precautions. Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized.
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1360
The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures? Understanding the side effects of medications Treating the child as though she did not have epilepsy Placing the child on her side on the floor Instructing her teacher how to respond to a seizure
Understanding the side effects of medications The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1348
The nurse is reinforcing teaching with the caregivers of a child who has had a head injury and is being discharged. Which statement made by the caregiver indicates an accurate understanding of the follow-up care for this child? "If he falls asleep, we will wake him up every 15 minutes." "We can give him acetaminophen for a headache, but no aspirin." "Even if the flashlight bothers him, we will check his eyes." "If he vomits again, we will bring him back immediately."
"Even if the flashlight bothers him, we will check his eyes." The child's pupils are checked for reaction to light every 4 hours for 48 hours. If the child falls asleep, he or she should be awakened every 1 to 2 hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The caregiver should observe the child for at least 6 hours for vomiting or a change in the child's level of consciousness. The caregiver should notify the health care provider immediately if the child vomits more than three times, but if the child vomits once, returning to the care provider immediately is not needed. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1365
The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction? "I will watch my baby for irritability and difficulty feeding." "My baby's cerebrospinal fluid is increasing intracranial pressure." "The VP shunt will help drain fluid from my baby's brain." "This shunt is the only surgery my baby will need."
"This shunt is the only surgery my baby will need." Hydrocephalus results from an imbalance in the production and absorption of CSF. In hydrocephalus, CSF accumulates within the ventricular system and causes the ventricles to enlarge, and increases in ICP subsequently occur. A VP shunt can be used to drain excess CSF, but it will need to be replaced as the child grows, requiring shunt revision surgery at various times during the client's life. The parent should be taught to monitor for signs and symptoms of increased ICP, which include irritability and vomiting. Increased ICP indicates the shunt is not functioning properly. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1353
During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? Dramatic increase in head circumference Pupil of one eye dilated and reactive Vertical nystagmus Posterior fontanel (fontanelle) is closed
Dramatic increase in head circumference A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain. Only one pupil that is dilated and reactive is a sign of an intracranial mass. Vertical nystagmus indicates brain stem dysfunction. A closed posterior fontanel (fontanelle) would be frequently seen by this age. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1354
The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? Decorticate posturing and fixed and dilated pupils Decreased pupil reaction and decreased respiration. Headache and sunset eyes Dizziness and irritability
Decorticate posturing and fixed and dilated pupils Decerebrate or decorticate posturing and fixed and dilated pupils are late signs of increased intracranial pressure. Decreased pupil reaction, decreased respirations, headache, sunset eyes, dizziness, and irritability are early signs of increased intracranial pressure. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1333
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?" "Did you give your child any acetaminophen, such as Tylenol?" "What type of fluids did your child take when he had a fever?" "How high did his temperature rise when he was ill?"
"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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1363
The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? "I will give the medication to him when I first wake him up in the morning." "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I need to watch for any new bruises or bleeding and let my health care provider know about it." "I'm glad to know he will only need this medication for a short time to stop his seizures."
"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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1346
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? Take vital signs every 4 hours Monitor temperature every 4 hours Decrease environmental stimulation Encourage the parents to hold the child
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1361
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? Report the findings to the pediatric health care provider. Reassess the head circumference in 24 hours. Document that the infant has microcephaly. Tell the parent the infant's brain is underdeveloped.
Report the findings to the pediatric health care provider. These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain. Waiting 24 hours to reassess will delay treatment. In microcephaly, the head circumference is small, but the fontanels (fontanelles) and suture line are palpable. Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder, Craniosynostosis, p. 1356.
The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? While turning the child's head to the left, the eyes turn to the right. While stimulating the child's foot, the big toe points upward and other toes fan outward. While calling the child's name, the child stares straight ahead and does not turn to the sound. While assessing the child's pupils, there is no change in diameter in response to a light.
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. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1365
