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

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 child's immune system is compromised.

A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement?

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

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 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 the 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.

Antibiotic therapy to treat meningitis should be instituted immediately after which event?

collection of cerebrospinal fluid (CSF) and blood for culture Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of IV therapy aren't, by themselves, appropriate times to begin antibiotic therapy.

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.

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching?

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

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

The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns?

IX Cranial nerve IX (glossopharyngeal) would be assessed to test the swallowing and gag reflex. Cranial nerve VIII is the acoustic nerve which is involved in hearing. Cranial nerve VII is the facial nerve and controls facial muscles, salivation and taste. Cranial nerve VI is the abducens nerve and controls and is related to eye movements.

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question?

Initiate an IV of 0.9% NS to run at 250 ml/hr. Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform?

assess the level of consciousness (LOC) Decreased LOC is frequently the first sign of a major neurologic problem after head trauma. The nurse would assess the client's LOC before notifying the health care provider. The child may need to be placed on fall precaution, depending on the results of the assessment. The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary.

The nurse is 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 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.

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.

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 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?

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 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.

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify this as a neural tube defect.

Arnold-Chiari malformation Arnold-Chiari malformation is a deformity of the cerebellar tonsils being displaced into the upper cervical canal. Anencephaly is a neural tube defect. Encephalocele is a neural tube defect. Spina bifida occulta is a neural tube defect.

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply.

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

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

convulsive activity often occurs during seizures During seizures, convulsive activity is typically noted. Breath-holding spells are typically provoked by pain or the child being upset, have a normal EEG pattern, and are typically outgrown by the time the child reaches preschool age.

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

intercranial 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.

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 will 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 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.

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 of 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.

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 3 cans of diet soda 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.

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 child admitted with complex partial seizures. Which clinical manifestation would likely have been noted in the child with this diagnosis?

The child was rubbing the hands and smacking the lips. *Complex partial seizures, also called psychomotor seizures, change or alter consciousness. They cause memory loss and staring and nonpurposeful movements, such as hand rubbing, lip smacking, arm dropping, and swallowing*. In the tonic phase of tonic-clonic seizures, the child's muscles contract, the child may fall, and the child's extremities may stiffen. During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination. Simple partial motor seizures cause a localized motor activity such as shaking of an arm, leg, or other part of the body.

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

risk for injury related to seizure activity The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

A 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.

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 birth weight does not suggest caput succedaneum. Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele.

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 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.

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 nurse is caring for a child admitted with simple partial motor seizures. Which clinical manifestation would likely have been noted in the child with this diagnosis?

The child had shaking movements on one side of the body. Simple partial motor seizures cause a localized motor activity, such as shaking of an arm, leg, or other part of the body. These may be limited to one side of the body. Myoclonic seizures are characterized by a sudden jerking of a muscle or group of muscles, often in the arms or legs, without loss of consciousness. Complex partial seizures may cause nonpurposeful movements, such as hand rubbing and lip smacking. During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination.

Absence seizures are marked by what clinical manifestation?

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.

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 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 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 in a car seat after feeding the infant 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.

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

brainstem Decerebrate posturing is seen with injuries occurring at the level of the brain stem. Decorticate posturing occurs with damage of the cerebral cortex. 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.

The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority?

assess the clients respiratory status The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway.

A 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 (fontanelles) is used to assess for hydrocephalus.

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.

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." 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.

After experiencing a head injury the child keeps falling asleep when no one is rousing him. When documenting this in the medical record which term is most appropriate?

obtunded Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Stupor exists when the child only responds to vigorous stimulation. Lethargic refers to being without energy and relaxed.

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education?

"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

The nurse is educating a child and his family about what to expect during the child's electroencephalogram (EEG) exam. Which statement by a parent suggests a need for further education?

"I will make sure my child goes to bed early every night before the exam" During an EEG, the client needs to be cooperative and quiet. Typically, parents are asked to keep their child up later the night before so that the child will fall asleep during the procedure. The room is also darkened to help them rest. If the child is unable to remain still, sedation may be used. The EEG reflects the electrical patterns of the brain.

The parents of a child with a history of seizures who has been taking phenytoin (Dilantin) ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate?

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

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?

"The shunt is the old 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 to 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 sign and symptoms of increased ICP, which include irritability and vomiting. Increased ICP indicates the shunt is not functioning properly.

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught?

"Watch for changes in his behavior or eating patterns" Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

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 Levels of consciousness in order from most alert to least alert are orientated to person, place, and time (full consciousness); confusion (disorientation); obtundation; stupor; and finally coma.

The parents of a 10-month-old child bring the infant to the emergency department after finding the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone." Which assessments are priority for the nurse to complete? Select all that apply.

airway respiratory status circulation With a submersion injury, hypoxia is the primary problem. Therefore, assessment of the airway, breathing, and circulation (ABCs) are the primary assessments the nurse will complete. These guide implementation of resuscitative measures. Other assessments such as level of consciousness, vital signs, and pupillary response would be done once the child is stable. The nurse would also perform a complete assessment, looking for signs of abuse once the child is stable.

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 (AVM) 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.

To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority?

cerebral edema The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Renal failure and cardiogenic shock aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.

The nurse is caring for a 6-year-old child who has a history of febrile seizures and is admitted with a temperature of 102.2°F (39°C). What is the nurse's highest priority?

institute safety precautions A child who presents with an elevated temperature is at high risk for having a febrile seizure. Actions by the nurse include keeping the child in a safe situation to prevent any injury if the child should have a seizure. The fever should also be controlled. Age-appropriate activities and family teaching are important but they do not take priority over safety. An ill child can assist in care but may not be able to completely provide self-care.

While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority?

protect the child from hitting the arms against the bed Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care; however, this is not a priority. Dietary therapy is considered for clients with chronic seizure disorders who do not respond to medication therapy.

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 for 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.

Keeping the child free from injury is the priority goal. The other choices are important, but keeping the child safe is higher than preparing for home care or knowledge deficit concerns. The physical concerns are always priority over the psychological concerns when caring for clients.

the child will remain free from injury during a seizure Keeping the child free from injury is the priority goal. The other choices are important, but keeping the child safe is higher than preparing for home care or knowledge deficit concerns. The physical concerns are always priority over the psychological concerns when caring for clients.

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client?

use of anticonvulsant medications Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain?

video electroencephalogram 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.

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status?

"She has been irritable for the last hour....seems like she is just upset for some reason." Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope?

"use this information to teach family and friends" Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions.

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.

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

eye opening verbal response motor response The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education?

"I will cradle her in my arms after the procedure for at least 30 minutes" During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP?

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.

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 the 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.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)?

While assessing the child's pupils, there is no change in diameter in response to a light. To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination.

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

A child is diagnosed with aseptic meningitis. The child's mother states, "I don't know where she would have picked this up." The nurse prepares to respond to the mother based on the understanding that this disorder is most likely caused by:

enterovirus Aseptic meningitis is the most common type of meningitis, and if a causative organism can be identified, it is usually a virus such as enterovirus. E. coli is a cause of bacterial meningitis. H. influenzae type B is a cause of bacterial meningitis. Group B streptococcus is a cause of bacterial meningitis.

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 is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?

minimal or no alteration in muscle tone , with a brief loss of responsiveness or attention Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.

The nurse is assessing a child who has suffered a head injury. Which assessment finding would indicate loss of midbrain functioning?

arms abducted and adducted in pronation of wrists and fingers flexed Decerebrate posturing, rigid extension, and adduction of the arms and pronation of the wrists with flexed fingers occurs when the midbrain is not functional. Cerebral loss is shown mainly by decorticate posturing (the child's arms are adducted and flexed on the chest with wrists flexed, hands fisted). Deep tendon reflexes decrease with level of consciousness, but this does not specifically indicate lack of midbrain functioning. No response to verbal statements may indicate a decreased level of consciousness, but it does not indicate lack of midbrain functioning.

A client presents reporting headache that she describes as "throbbing pain on the left side of my head and sensitivity to light and motion." The nurse asks the client to describe the sequence of events before the onset of the headache. Which signs and symptoms described by the client are characteristic of the prodrome phase of a migraine headache? Select all that apply.

Neck stiffness Frequent yawning Loss of appetite The prodrome phase includes experiencing signs and symptoms that occur hours or days before the onset of the headache. Stiffness of the neck muscles, frequent yawning, or loss of appetite are common during the prodrome (or preheadache) phase. Seeing flashing lights is an aura, which is a warning sign of the impending onset of a migraine headache. Fatigue is common during the postdrome portion of a migraine.

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

"Sometimes it is hard to tell what products may contain aspirin" Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. Two common medications containing salicylates are bismuth subsalicylate and effervescent heartburn relief antiacid. The parent needs to be receptive to further education, and raising the possibility the child was responsible does not accomplish that goal. The nurse should not state the obvious, but also should not minimize the situation. Encouraging the parent to ask for information and offering explanations in terms the parent will understand are important, but this response does not address the parent's assertion. Telling the parent not to worry is offering platitudes and false reassurance. Giving the description of what complications could happen with the disease would be inappropriate. This would only exacerbate the parent's concern, and it does not address how the child ingested salicylates.

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

steroid Increased intracranial pressure (ICP) may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. The diuretic mannitol may be used to decrease edema. An anticonvulsant is used with increased ICP to prevent seizures. An antihistamine would not be warranted for the treatment of a head injury.