Peds - Ch. 38: Alteration in Intracranial Regulation/Neurologic Disorder

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." Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Meningococcal conjugate vaccine protects against four types of meningitis. There is nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the infection, or that the adolescent's immune system is compromised.

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.

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.

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

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 caring for an 8-year-old girl who was in a car accident. What would lead the nurse to suspect a concussion?

The child is easily distracted and can't concentrate. A child with a concussion will be distracted and unable to concentrate. Signs and symptoms of contusions include disturbances to vision, strength, and sensation. Vomiting and bruising behind the ear are signs of a subdural hematoma. Bleeding from the ear and otorrhea are signs of a basilar skull fracture.

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.

The nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client?

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 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 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 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 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.

The young boy was involved in a motor vehicle accident and was admitted to the pediatric intensive care unit with changes in level of consciousness and a high-pitched cry. Which are late signs of increased intracranial pressure? Select all that apply.

-The child's heart rate is 56 beats per minute. -The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. -The child's pupils are fixed and dilated. Late signs of increased intracranial pressure are: decerebrate posturing, bradycardia, and pupils that are fixed and dilated. The other options are early signs of increased intracranial pressure.

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.

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.

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. 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.

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.

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.

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 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 caring for a child admitted with focal onset impaired awareness seizure (complex partial seizure). Which clinical manifestation would likely have been noted in the child with this diagnosis?

The child was rubbing the hands and smacking the lips. With the focal onset impaired awareness seizure, formerly called complex partial seizure, the child is confused or their awareness is affected during the seizure. The seizure begins in a small area of the brain and changes or alters consciousness. These seizures can have motor and non-motor symptoms. 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.Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part.

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

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. A closed posterior fontanel (fontanelle) would be frequently seen by this age.

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.

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 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.

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.

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.

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 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 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 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.

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, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

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

hydrocephalus Hydrocephalus results from an imbalance in the production and absorption of cerebrospinal fluid. In hydrocephalus, cerebrospinal fluid accumulates within the ventricular system and causes the ventricles to enlarge and increases in intracranial pressure. Anencephaly, encephalocele and spina bifida occulta are all neural tube defects.

The nurse is caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion?

trouble focusing when reading Signs and symptoms for cerebral contusions include disturbances to vision, strength, and sensation. A child suffering a concussion will be distracted and unable to concentrate. Vomiting is a sign of a subdural hematoma. Bleeding from the ear is a sign of a basilar skull fracture.

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.

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 preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child?

Use a doll with electrodes attached to the head. An electroencephalogram (EEG) is a test to measure the electrical activity of the brain. It is conducted by attached electrodes over sections of the head and obtains an electrical reading via a monitor. There is no pain involved in the procedure, but the child must lie still. The best way for the nurse to explain the procedure to the child is via a doll with attached electrodes that the child can play with, feel, and manipulate. This helps to reduce the child's anxiety and aids in cooperation. Videos can help with the education process but they do not allow for interaction and physical touching. The child can take a nap during the procedure but this does not prepare the child for the procedure. Assuring the child that the procedure will not hurt should be included in the educational process because it is not the best way to prepare the child.

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 concerns 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 near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history?

a neural tube defect Folic acid supplementation has been found to reduce the incidence of neural tube defects by 50%. The fact that the mother has not used folic acid supplements puts her baby at risk for spina bifida occulta, one type of neural tube defect. Neonatal conjunctivitis can occur in any newborn during birth and is caused by virus, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.