Chapter 49: Nursing Care of a Family when a Child has a Neurologic Disorder

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply.

In addition to the adolescent's complaints and history, other findings suggesting bacterial meningitis include complaints of a stiff neck, photophobia, headache, positive Brudzinski sign, and vomiting.

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.

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.

In completing a neurologic assessment on a preschool-aged client, a nurse plans to assess for stereognosis. Which technique demonstrates the nurse is performing the assessment properly?

Ask the child to close the eyes and hold out a hand; place a key in the hand. Then ask the child to identify the object.Stereognosis refers to the ability of a child to recognize an object by touch; it is a test of sensory interpretation. For this, ask a child to close his or her eyes; then place a familiar object and ask the child to identify it. Graphesthesia is the ability to recognize a shape that has been traced on the skin. Kinesthesia is the ability to distinguish movement. To measure motor integration, ask a child to perform a complex motor skill, such as folding a piece of paper and putting it into an envelope.

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 client's 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.

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.

A nurse is caring for a 17-year-old child with Guillain-Barré syndrome who has been in the hospital with this condition for 3 weeks. Which nursing intervention will the nurse implement to prevent deep vein thrombosis (DVT) in this child?

applying support stockings daily. Treatment of Guillain-Barré syndrome is supportive until the paralysis peaks at 3 weeks and then is followed by gradual recovery. The child should be given subcutaneous fractionated or unfractionated heparin and support stockings until the child is able to walk independently to prevent deep vein thrombosis (DVT). This is a continuous intervention to prevent DVT. Rubbing the legs and performing assisted range-of-motion exercises are good interventions but not as helpful in preventing DVT. Because the child would likely still be paralyzed at 3 weeks, the child would not be able to perform leg exercises.

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 with a seizure disorder has been prescribed phenytoin to control the seizures. While providing teaching about the medication, what dietary instructions should the nurse provide the parent?

"Increase your child's intake of whole milk and orange juice."Phenytoin is a drug used to control seizures. There are several things a parent needs to be taught about the drug. One fact is that it requires a correct therapeutic level, so laboratory tests will be necessary. Another is that it can cause gingival hyperplasia, so good mouth care and oral hygiene are essential. The third thing is that it interferes with vitamin D, so an intake of food containing vitamin D is essential in the diet. The foods that have the highest amount of vitamin D are fatty fish such as salmon. The most common foods a child could eat to increase vitamin D are whole milk, orange juice, yogurt, cheese, and eggs. Spinach and broccoli are both high in vitamin C, not vitamin D. Beans contain no vitamin D. They are high in iron, B6, and magnesium.

A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis?

Sunlight is "too bright"Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus.

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.

During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents?

The child shouldn't participate in activities that could be hazardous if a seizure occurs. Until seizure control is certain, clients shouldn't participate in activities (such as riding a bicycle) that could be hazardous if a seizure were to occur. Plasma levels need to be monitored periodically over the course of drug therapy; daily monitoring isn't necessary. Dosage changes are usually based on plasma drug levels as well as seizure control. Anticonvulsant drugs should be withdrawn over a period of 6 weeks to several months, never immediately, as doing so could precipitate status epilepticus.

The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with?

"What happened just before the seizures?"Asking what happened just before the seizure will suggest whether the episode was a seizure or a breath-holding event, which is frequently precipitated by an expression of anger or frustration. Cyanotic breath holding can be accompanied by clinical movements, as can seizures. Both types of events render the child unconscious. One would expect concerned, caring treatment from the parents regardless of the cause.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse?

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

The nurse 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?

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.

A 10-year-old boy has been experiencing complex partial seizures and has not responded well to medication. Surgery is planned to remove brain tissue at the seizure foci. Which diagnostic test would be the most accurate in identifying the seizure foci?

Positron emission tomography (PET). The diagnostic technique of positron emission tomography (PET) involves imaging after injection of positron-emitting radiopharmaceuticals into the brain. These radioactive substances accumulate at diseased areas of the brain or spinal cord. PET is extremely accurate in identifying seizure foci. Brain scans identify possible tumor, subdural hematoma, abscess, or encephalitis. Echoencephalography is often used in neonatal ICUs to monitor intraventricular hemorrhages and other problems frequently encountered by preterm infants. Myelography is the x-ray study of the spinal cord following the introduction of a contrast material into the CSF by lumbar puncture to reveal the presence of space-occupying lesions of the spinal cord.

The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse?

Remove any blankets or heavy clothing and replace with a thin sheet. The child should not have any blankets or clothing that would elevate the temperature further. Removing them is helpful in allowing the heat to dissipate. The child should not be placed in a bathtub because he or she may suffer another seizure and slip underwater. Using ice packs or alcohol can be a shock to an immature nervous system. Antipyretics should be administered as a suppository rather than PO to reduce the risk of aspiration while the child is in the postictal or drowsy state following the seizure.

A 9-year-old girl who is suspected of having an infection of the central nervous system (CNS) is undergoing a lumbar puncture to withdraw cerebrospinal fluid (CSF) for analysis. The nurse knows that the needle will be introduced into the subarachnoid space at the level of which of the following vertebrae?

L4 or L5. Lumbar puncture, the introduction of a needle into the subarachnoid space (under the arachnoid membrane) at the level of L4 or L5 to withdraw CSF for analysis, is used most frequently with children to diagnose hemorrhage or infection in the CNS or to diagnose an obstruction of CSF flow.

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.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse?

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

A nurse is performing a complete neurological examination of a 7-year-old boy. She will now test his cerebellar function. Which of the following tests would be appropriate for this purpose?

Ask the boy to touch each finger on one hand with the thumb of that hand in rapid succession.Tests for cerebellar function are tests for balance and coordination, such as asking the child to touch each finger on one hand with the thumb of that hand in rapid succession. Motor function is measured by evaluating muscle size, strength, and tone. Begin by comparing the size and symmetry of extremities. If in doubt about either of these, measure the circumference of the calves and thighs or upper and lower arms with a tape measure. If children's sensory systems are intact, they should be able to distinguish light touch, pain, vibration, hot, and cold. Have a child close his eyes and then ask him to point to the spot where you touch him with an object. Orientation, which is one measure of cerebral function, refers to whether children are aware of who they are, where they are, and what day it is (person, place, and time).

What is a true statement regarding status epilepticus?

It is a common neurologic emergency in children.Status epilepticus is a common neurological emergency in children. Children younger than 3 years of age are most likely to develop status epilepticus. The most common cause of status epilepticus in children is febrile seizures. Status epilepticus occurs when seizures last longer than 30 minutes or recur without return of consciousness between seizures.

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply.

The nurse should pad the crib sides and keep sharp or hard items out of the crib. The nurse should also position the child to one side to prevent aspiration of saliva or vomitus and have oxygen and suction equipment readily available for emergency use. The nurse should teach family caregivers seizure precautions so they can handle a seizure that occurs at home. The nurse should not put anything in the child's mouth; doing so could cause injury to the child or to the nurse. It is important for the nurse to promptly inform other members of the care team when a child is experiencing seizure activity, but leaving the bedside to do so would be unsafe.

During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve?

Trigeminal. To test the trigeminal nerve, the nurse would note the strength of the infant's suck on a pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would be assessed during spontaneous crying or smiling. The accessory nerve is assessed when the infant is in the sitting position and symmetry of the head position is noted.