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

A nurse in the emergency department (ED) is assessing a 2-year-old male child. The parents state the child "has been very feverish the past few days, and today the child developed a purple rash on the chest. The child is now very sleepy." Click to highlight the findings that will require immediate follow-up. The assessment reveals the child is lethargic but opens eyes and answers yes and no to questions. The child is unable to lie with hips flexed and straighten the leg out , and states their neck hurts when trying to move it. Vital signs: temperature, 102.4°F (39.1°C) ; heart rate, 120 beats/min; blood pressure, 78/45 mm Hg; respirations, 28 breaths/min ; oxygen saturation, 92% on room air .

The assessment reveals the child is lethargic but opens eyes and answers yes and no to questions. The child is unable to lie with hips flexed and straighten the leg out , and states their neck hurts when trying to move it. Vital signs: temperature, 102.4°F (39.1°C) ; heart rate, 120 beats/min; blood pressure, 78/45 mm Hg; respirations, 28 breaths/min ; oxygen saturation, 92% on room air .

A nurse on the neurology unit is monitoring an 8-year-old child admitted with seizures. The child experiences a prolonged tonic-clonic seizure. Complete the following sentence(s) by choosing from the lists of options. The nurse should first (ensure proper oxygenation, insert an airway into the client's mouth, suction the client's airway) followed by (administer IV or IM benzodiazepine, administer an antiepileptic by mouth, do not allow the client to sleep once the seizure has ended).

The nurse should first (ensure proper oxygenation) followed by (administer IV or IM benzodiazepine)

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? a. "Did you use any medications, like aspirin, for the fever?" b. "Did you give your child any acetaminophen, such as Tylenol?" c. "What type of fluids did your child take when he had a fever?" d. "How high did his temperature rise when he was ill?"

a. "Did you use any medications, like aspirin, for the fever?"

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. a. eye opening b. verbal response c. motor response d. fontanels d. posture

a. eye opening b. verbal response c. motor response

The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III? a. The nurse allows the child to smell objects and describe them b. A bright-colored toy is moved in the child's visual fields c. The nurse observes facial features and expressions for symmetry d. The nurse talks softly to the child to note the ability to hear

b. A bright-colored toy is moved in the child's visual fields

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent indicates to the nurse that additional teaching is needed? a. "I have ibuprofen available in case it is needed." b. "My child will likely outgrow these seizures by age 5." c. "I always keep phenobarbital with me in case of a fever." d. "The most likely time for a seizure is when the fever is rising."

c. "I always keep phenobarbital with me in case of a fever."

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? a. Onset and character of fever b. Degree and extent of nuchal rigidity c. Signs of increased intracranial pressure (ICP) d. Occurrence or urine and fecal contamination

c. Signs of increased intracranial pressure (ICP)

The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? a. "The child will be held by the mother on her lap with his back toward the health care provider." b. "When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible." c. "The child will be placed in the prone position with the nurse holding the child still." d. "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."

d. "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."

Antibiotic therapy to treat meningitis should be instituted immediately after which event? a. Admission to the nursing unit b. Initiation of IV therapy c. Identification of the causative organism d. Collection of cerebrospinal fluid (CSF) and blood for culture

d. 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? a. Administer lorazepam rectally to the client b. Refer the client to a neurologist c. Discuss dietary therapy with the client's caregivers d. Protect the child from hitting the arms against the bed

d. Protect the child from hitting the arms against the bed

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? a. "During delivery, your vaginal wall put pressure on the baby's head." b. "The forceps used during delivery cause this to happen>" c. "Your baby's head became blocked inside your vagina while you were pushing." d. "It's normal for this to happen, but they don't really know why."

a. "During delivery, your vaginal wall put pressure on the baby's head."

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? a. moving the infant's head every 2 hours b. measuring the intake and output every shift c. massaging the scalp gently every 4 hours d. giving the infant small feeding whenever he is fussy

a. moving the infant's head every 2 hours

The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? Select all that apply. a. Time the seizure started b. Factors present before seizure started c. Persons in attendance during seizure d. Number of seizures child has had in the last 48 hours e. Eye position and movement f. Incontinence of urine or stool

a. Time the seizure started b. Factors present before seizure started e. Eye position and movement f. Incontinence of urine or stool

The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the child questions. How should the nurse document the child's level of consciousness? a. fully conscious b. stupor c. obtunded d. decreased level of consciousness

c. obtunded