NUR243 PrepU ch16 Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder

The nurse helps 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."

A 1-year-old infant 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?"

The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session?

"What questions or concerns do you have about this device?"

The nurse is reinforcing teaching with the caregivers of a child being discharged from the urgent care setting following a mild head injury that occurred in a roller skating accident. What should the caregivers be instructed to do? Select all that apply.

-Wake the child every 1 to 2 hours to check level of consciousness. -Observe and report any vomiting that occurs within 6 hours. -Observe for and report to provider any double or blurred vision.

A 6-year-old child with hydrocephalus had a ventriculoperitoneal (VP) shunt placed 6 weeks ago and now has experienced a seizure, vomiting, and loss of appetite. Which intervention will target the child's priority need?

Administer intravenous antibiotics as prescribed

Any individual taking phenobarbital for a seizure disorder should be taught:

never to discontinue the drug abruptly

When assessing a neonate for seizures, what would the nurse expect to find? Select all that apply.

tachycardia elevated blood pressure jitteriness ocular deviation

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.

Gabapentin has been prescribed for a pediatric client. Which statement by the client indicates an understanding of teaching related to the medication?

"I can't take this medication within 2 hours of taking my antacid medication."

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 the 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.

Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis?

Avoid making noise when in the child's room. Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch.

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

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

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.

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

Collection of cerebrospinal fluid (CSF) and blood for culture

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.

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

A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority?

serum glucose level Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expend energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review

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

A pregnant client asks if there is any danger to the development of her fetus in the first few weeks of her pregnancy. How should the nurse respond?

"During the first 3 to 4 weeks of pregnancy, brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma." Brain and spinal cord development occur during the first 3 to 4 weeks of gestation. Infection, trauma, teratogens (any environmental substance that can cause physical defects in the developing embryo and fetus), and malnutrition during this period can result in malformations in brain and spinal cord development and may affect normal central nervous system (CNS) development. Good health before becoming pregnant is important but must continue into the pregnancy. Hardening of bones occurs during 13 to 16 weeks' gestation, and the respiratory system begins maturing around 23 weeks' gestation

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 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 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

The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and 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."

The parents of a child with a history of seizures who has been taking phenytoin 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."

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

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 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.

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 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 are 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 an inability to swallow.

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.

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 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication?

Use a soft toothbrush. Phenytoin is an anticonvulsant medication. It can be used in the management of seizure disorders. This medication is associated with gingival hyperplasia. This may result in tender and bleeding gums. The use of a soft toothbrush will reduce pain, bleeding and discomfort.

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?

brain stem 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.

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 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.

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

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. Odors, such as strong perfumes. Changes in sleeping patterns.

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.

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

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. 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

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

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

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 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.

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.

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.

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?

"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.

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.

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 assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III?

A bright-colored toy is moved in the child's visual fields. -Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement. -Cranial nerve I (olfactory nerve) controls the sense of smell. Asking the child to smell objects would be an assessment of this cranial nerve. -Cranial nerve VII (facial nerve) is assessed by monitoring symmetry of facial movements. -Cranial nerve VIII (acoustic nerve) is assessed by whispering

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;

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 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

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.

A school-aged child with seizures is prescribed phenytoin sodium, 75 mg four times per day. What instruction would the nurse give the parents regarding this medication?

The child will have to adhere to good tooth brushing A side effect of phenytoin sodium is gingival hyperplasia. Good tooth brushing helps prevent inflammation under the hypertrophied tissue. A seizure occurs as an electrical interference in the brain.

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 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 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

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.