Alteration in Intracranial Regulation/Neurologic Disorders

The nurse who is concerned about increased intracranial pressure in an infant should assess for: A. Irritability. B. Photophobia. C. Pulsating anterior fontanel. D. Vomiting and diarrhea.

A. Irritability. Irritability is one of the changes that may indicate increased intracranial pressure. Photophobia does not indicate increased intracranial pressure in infants. Frequently pulsations are visible in the anterior fontanel. It is not an indication of increased intracranial pressure. Vomiting is one of the signs in children but, when present with diarrhea, indicates a gastrointestinal disturbance.

The nurse is planning care for a school-age child with bacterial meningitis. The plan should include: A. Keeping environmental stimuli at a minimum. B. Avoiding giving pain medications that could dull sensorium. C. Measuring head circumference to assess developing complications. D. Having child move head side to side at least every 2 hours.

A. Keeping environmental stimuli at a minimum. Children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nurse should keep the room as quiet as possible, with a minimum of external stimuli. After consultation with the practitioner, pain medications can be used if necessary. A school-age child will have closed sutures. Head circumference should not change. The child is placed in side-lying position with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that would increase discomfort.

The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest: A. Neurologic health. B. Severe brain damage. C. Decorticate posturing. D. Decerebrate posturing.

A. Neurologic health. The Moro, tonic neck, and withdrawing reflexes are usually present in infants under 3 to 4 months of age. Therefore, the presence of these reflexes indicates neurologic health. These are expected reflexes in a 2-month-old. Decorticate posturing indicates severe dysfunction of the cerebral cortex. Decerebrate posturing indicates dysfunction at the level of the midbrain.

The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and pupils are unequal and sluggish. The MOST appropriate nursing action is to: A. Notify the health care provider immediately. B. Document level of consciousness. C. Observe closely for signs of increased intracranial pressure (ICP). D. Administer pain medication and assess for response.

A. Notify the health care provider immediately. The worsening of symptoms may indicate that the ICP is increasing. The practitioner should be notified immediately. The health care provider should be notified first before documenting. The nurse is already noting signs of potentially increased ICP. Pain medication should not be given. Consultation with the practitioner should occur first.

A 3-year-old child is status postshunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.) A. Personality change B. Bulging anterior fontanel C. Vomiting D. Dizziness E. Fever

A. Personality change C. Vomiting E. Fever

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. The MOST appropriate nursing assessment in this case is: A. Reactivity of pupils. B. Doll's head maneuver. C. Oculovestibular response. D. Funduscopic examination to identify papilledema.

A. Reactivity of pupils. Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. Doll's head maneuver should not be performed if there is a cervical spine injury. This is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness.

The postoperative care of a preschool child who has had a brain tumor removed should include which information? A. Colorless drainage is to be expected. B. Close supervision is needed while the child is regaining consciousness. C. Positioning is on the side in the Trendelenburg position. D. Analgesics are contraindicated because of altered consciousness.

B. Close supervision is needed while the child is regaining consciousness. Colorless drainage may be leakage of cerebral spinal fluid from the incision site. This needs to be reported as soon as possible. The child needs to be observed closely. Vital signs must be assessed carefully, and signs of increasing ICP need to be monitored. The child should not be positioned in the Trendelenburg position after surgery. Analgesics can be used for postoperative pain.

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. The PRIORITY of nursing care is to: A. Initiate isolation precautions as soon as the diagnosis is confirmed. B. Initiate isolation precautions as soon as the causative agent is identified. C. Administer antibiotic therapy as soon as it is ordered. D. Administer sedatives/analgesics on a preventive schedule to manage pain.

C. Administer antibiotic therapy as soon as it is ordered. Isolation should be instituted as soon as diagnosis is anticipated. Isolation should be instituted as soon as diagnosis is anticipated. This is the priority action. Antibiotics are begun as soon as possible to prevent death and avoid resultant disabilities. Antibiotics are the priority function; pain should be managed if it occurs.

The temperature of an adolescent who is unconscious is 105° F. The PRIORITY nursing action is to: A. Continue to monitor temperature. B. Initiate a pain assessment. C. Apply a hypothermia blanket. D. Administer acetaminophen or ibuprofen.

C. Apply a hypothermia blanket. The temperature needs to be monitored, but it also needs to be lowered. This should be ongoing; lowering the body temperature is the priority action. Brain damage can occur at temperatures this high. It is extremely important to institute temperature-lowering interventions, such as hypothermia blankets and tepid water baths. Antipyretics are not useful in cases of hyperthermia.

The MOST appropriate nursing interventions when caring for a child experiencing a seizure include: (Select all that apply.) A. Restraining the child when a seizure occurs to prevent bodily harm. B. Placing a padded tongue between the teeth if they become clenched. C. Avoid suctioning the child during the seizure. D. Describing and documenting the seizure activity observed. E. Applying supplemental oxygen after inserting an artificial oral airway.

C. Avoid suctioning the child during the seizure. D. Describing and documenting the seizure activity observed. The priority nursing intervention is to observe the child and seizure, and document the activity observed. The child should not be restrained, because this may cause an injury. Nothing should be placed in the child's mouth, because this may cause an injury not only to the child but also to the nurse. To prevent aspiration, the child should be placed on the side if possible to facilitate drainage.

The nurse is caring for a 2-year-old girl who is unconscious but stable following a car accident. Her parents are staying at the bedside most of the time. An appropriate nursing intervention is to: A. Suggest that the parents go home until she is alert enough to know that they are present. B. Use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns. C. Encourage the parents to hold, talk, and sing to her as they usually would. D. Position her with proper body alignment and head of bed lowered 15 degrees.

C. Encourage the parents to hold, talk, and sing to her as they usually would. This is not recommended. The daughter may be able to hear that they are present. Oral care is essential in the unconscious child. Mouth care should be done at least twice daily. The parents should be encouraged to interact with their daughter. Senses of hearing and tactile perception may be intact, and stimulation of these senses is important. The head of the bed should be elevated, not lowered.

The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain: A. Cannot occur if the child is comatose. B. May occur if the child regains consciousness. C. Requires astute nursing assessment and management. D. Is best assessed by family members who are familiar with the child.

C. Requires astute nursing assessment and management. Pain can occur in the comatose child. The child can be in pain while comatose. Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must be focused on physiologic and behavioral manifestations. The family can provide insight into different responses, but the nurse should be monitoring physiologic and behavioral manifestations.

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. In the discussion the nurse should include that: A. Parental protection is essential until the child reaches adulthood. B. Cognitive impairment is to be expected with hydrocephalus. C. Shunt malfunction or infection requires immediate treatment. D. Most usual childhood activities must be restricted.

C. Shunt malfunction or infection requires immediate treatment. Limits should be appropriate to the developmental age of the child. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed. Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the developmental age of the child. Except for contact sports, the child will have few restrictions.

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is: A. Absence seizure. B. Generalized seizure. C. Status epilepticus. D. Simple partial seizure.

C. Status epilepticus. Absence seizures are brief losses of consciousness. Generalized seizures are the most common of seizures. They have a tonic phase of approximately 10 to 20 seconds. They involve both hemispheres of the brain. Status epilepticus is a generalized seizure that lasts more than 30 minutes. Simple partial seizures are characterized by varying sensations.

What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? A. Suctioning child frequently B. Providing environmental stimulation C. Turning head side to side every hour D. Avoiding activities that cause pain or crying

D. Avoiding activities that cause pain or crying Suctioning is a distressing procedure. In addition the resultant decrease in carbon dioxide can increase ICP. Environmental stimulation should be minimized. The child's head should not be turned side to side. If the jugular vein is compressed, ICP can rise. Nursing interventions should focus on assessment and interventions to minimize pain. These activities can cause the intracranial pressure to increase.

Why are infants particularly vulnerable to acceleration-deceleration head injuries? A. The anterior fontanel is not yet closed. B. The nervous tissue is not well developed. C. The scalp of the head has extensive vascularity. D. Musculoskeletal support of head is insufficient.

D. Musculoskeletal support of head is insufficient. These do not have an effect on this type of injury. These do not have an effect on this type of injury. These do not have an effect on this type of injury. The relatively large head size coupled with insufficient musculoskeletal support increases the risk to the infant.