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

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 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.

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?

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.

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.

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.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?

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 caring for a 12-month-old infant diagnosed with Haemophilus influenzae meningitis. Which clinical manifestation would likely have been noted in this child?

Children with meningitis may have a characteristic high-pitched cry, fever, and irritability. Other symptoms include headache, nuchal rigidity (stiff neck) that may progress to opisthotonos (arching of the back), and delirium.

The nurse is preparing a care plan for a toddler diagnosed with cerebral palsy (CP). Which intervention would be appropriate for the nursing diagnosis of Risk for disuse syndrome related to spasticity of muscle groups? Select all that apply.

Dopaminergic drugs such as carbidopa/levodopa can help to reduce muscle rigidity and spasticity. Benzodiazepines also help with smoother muscle movement and reduce spasticity. Exercises and games, done daily, can help to prevent contractures from disuse. Interventions such as education about the disease and speech therapy are appropriate for clients with cerebral palsy but are not appropriate for the nursing diagnosis of Risk for disuse syndrome related to spasticity of muscle groups.

The mother of a child newly diagnosed with an intellectual disability tells the nurse that her partner disagrees with the diagnosis and believes that the child is perfectly normal. The mother shares with the nurse that she finds this reaction frustrating and confusing. Which action by the nurse would be appropriate in supporting this mother?

Reassure the mother that her partner's reaction is a normal stage in the grieving process. The family's first reaction to learning that the child may have cognitive impairment is grief because this is not the perfect child of their dreams. A parent may feel shame, assuming that he or she cannot produce a perfect child. Some rejection of the child is almost inevitable at least in the initial stages, but this must be worked through for the family to cope.

A nurse is performing a neurologic examination of a 5-year-old child. She asks the boy to close his eyes, and then she places a crayon in his hand and asks him to identify it. Which type of ability is the nurse testing for in this boy?

Stereognosis refers to the ability of a child to recognize an object by touch; it is a test of sensory interpretation. For this, ask the child to close his eyes; then place a familiar object, such as a key, a penny, or a bottle cap, in his hand and ask him to identify it. Graphesthesia is the ability to recognize a shape that has been traced on the skin. Orientation refers to whether children are aware of who they are, where they are, and what day it is (person, place, and time). Kinesthesia is the ability to distinguish movement. Have a child close his eyes and extend his hands in front of him. Raise one of his fingers and ask him whether it is up or down.

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?

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 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?

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.

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.

While observing a child, the nurse notes that the child's arms and legs are extended and pronated. During shift hand-off, the nurse reports potential damage to:

The observations indicate decerebrate posturing, which occurs with damage to the midbrain. Decorticate posturing as evidenced by arm adduction, elbow flexion with arms over the chest, and wrist flexion with fisted hands indicates damage to the cerebral cortex. Damage to the cranial nerves would be manifested by defects in motor and/or sensory function, depending on the cranial nerves affected. Meningeal irritation, as with bacterial meningitis, is manifested by opisthotonos in an infant. With this position, the head and neck are hyperextended to relieve discomfort.

The nurse is assessing a child who has suffered a head injury. Which assessment finding would indicate loss of midbrain functioning?

arms adducted and extended with pronation of wrists with fingers flexed Decerebrate posturing, rigid extension, and adduction of the arms and pronation of the wrists with flexed fingers occurs when the midbrain is not functional. Cerebral loss is shown mainly by decorticate posturing (the child's arms are adducted and flexed on the chest with wrists flexed, hands fisted). Deep tendon reflexes decrease with level of consciousness, but this does not specifically indicate lack of midbrain functioning. No response to verbal statements may indicate a decreased level of consciousness, but it does not indicate lack of midbrain functioning.

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 child's room Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation.

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." what needs follow up?

lethargic, neck hurts, 102.4F, 92%, and unable to lie with hips flexed and straighten the leg out The client's temperature of 102.4°F (39.1°C) indicates a fever. This will require the nurse to follow up to determine the underlying cause for the fever. A purple (purpuric) rash appearing during a febrile state requires follow-up, because it may indicate meningitis. The child reporting a stiff neck may indicate meningeal irritation. The child's inability to straighten the leg when lying flat with hips flexed indicates meningeal irritation; it is referred to as a positive Kernig sign. Lethargy indicates decreased level of consciousness; the nurse should closely monitor the child's level of consciousness. The child's oxygen saturation of 92% on room air indicates decreased oxygen levels.

The nurse is caring for a child diagnosed with Sturge-Weber syndrome. Which assessment finding supports this diagnosis?

port-wine birthmark on the upper part of the face

Put the following events of a tonic-clonic eizure in correct order:

prodromal tonic clonic postictal

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.

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?

"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 before a seizure occurs, which will most likely happen as the temperature rises.

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 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."

The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant?

Placing a child or infant in the semi-Fowler position can help reduce cerebral edema and pressure. Using an infant child seat helps to simulate the raised head of the bed. In the supine position, the client is completely flat on his or her spine. Prone is face down and flat. Sims is a side-lying position with one leg flexed. All of the described positions place the client flat, not with the head raised; that would be in the semi-Fowler position.

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 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.

When caring for an infant who is hospitalized with Haemophilus influenzae meningitis, an important nursing intervention for the child would be for the nurse to:

check the child's neurologic status every 2 hours. The nursing interventions for the child with meningitis are related to the goals for this child, which include monitoring for complications related to neurologic compromise, preventing aspiration, keeping the child safe from injury during a seizure, and monitoring fluid balance. During a seizure, stay with the child, protect the child from injury, but do not restrain him or her. To prevent aspiration, position the child in a side-lying position, watch for and remove excessive mucus as much as possible, and use suction sparingly. Every 2 hours, observe the child for seizure activity, vital signs, neurologic changes, and change in level of consciousness. The child is placed on fluid restrictions if he or she has decreased urinary output, hyponatremia, increased weight, nausea, and irritability.

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.

time seizure started, factors present, before seizure started, eye position and movement, incontinence of urine or stool Following a seizure, the nurse documents the following: time the seizure started; what the child was doing when the seizure began; any factor present just before the seizure (bright light, noise); part of the body where seizure activity began; movement and parts of the body involved; any cyanosis; eye position and movement; incontinence of urine or stool; time seizure ended; and child's activity after the seizure. Who was with the child or the number of seizures the child has had are not relevant to document regarding observation of this seizure.

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP?

Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP.

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 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 nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position?

Lying on one side, with the back curved Lumbar puncture involves placing a needle between the lumbar vertebrae into the subarachnoid space. For this procedure, the nurse should position the client on one side with the back curved because curving the back maximizes the space between the lumbar vertebrae, facilitating needle insertion. Prone and seated positions don't achieve maximum separation of the vertebrae.

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?

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. Placing the child in the prone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure.

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?

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.

An 8-year-old child has just been diagnosed with Sturge-Weber syndrome. Which parental teaching is important at this time? Select all that apply.

a port-wine birthmark on the upper face is common safety is important due to seizure activity school counselors are often helpful for learning deficits blindness may be caused due to glaucoma dropping objects may occur due to numbness

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).

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?

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; therefore, an eye patch is not necessary.

The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as:

Sunsetting is when the sclera of the eyes is showing over the top of the iris. Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements. Doll's eye is a maneuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction.

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

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.