Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder

The mother of a 6-month-old states that she does not understand how her child has contracted botulism. What is the best response by the nurse?

"Botulism is caused by contaminated food. Honey is a common source."

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."

The nurse is assisting to 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."

The nurse instructs the parents of a child with Guillain-Barré syndrome on care that will be needed once the child is discharged home. Which statement made by the parents indicates that teaching has been effective?

"Our child might experience weakness even after recovering from the illness."

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

The health care provider orders phenytoin 4 mg/kg/day in three divided doses for a child who has a seizure disorder. The child weighs 35 lb and the medication is available at 30mg/5mL. What is the amount in mL for one dose of this child's medication? Round to the nearest tenth.

3.5 mL

What information is most correct regarding the nervous system of the child?

As the child grows, the gross and fine motor skills increase.

The nurse is caring for a child who is having a seizure. What is the appropriate action by the nurse?

Attempt to turn the child on their side to prevent aspiration.

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.

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent what information in regard to seizures?

Convulsive activity occurs.

The nurse caring for a child with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema.

False

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.

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.

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 which?

The midbrain

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 neurological status every 2 hours.

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."

The nurse is collecting data from the caregivers of a child admitted with seizures. Which statement indicates the child most likely had an absence seizure?

"He was just staring into space and was totally unaware."

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."

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse?

"The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

A 1-year-old 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?"

A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room?

A private room near the nurses' station.

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

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

Haemophilus influenzae meningitis is usually spread by which of the following methods of transmission?

Droplet

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

Absence seizures are marked by what clinical manifestation?

Loss of motor activity accompanied by a blank stare.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

Moving the infant's head every 2 hours

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 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

The nurse is caring for a 4-year-old with meningitis. A primary nursing goal would be to

reduce the pain related to nuchal rigidity.

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n)

steroid.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?

Intracranial hemorrhaging

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."

The nurse is completing a nursing history on a female client who has just found out she is 6 weeks' pregnant. She reports that over the last 2 months she has been drinking excessive amounts of alcohol every weekend and smokes a half-pack of cigarettes per day. What is the nurse concerned with given this information? Select all that apply.

- Brain development in the fetus - Spinal cord development in the fetus

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 nurse is observing an infant who may have acute bacterial meningitis. Which finding might the nurse look for?

Irritability, fever, and vomiting

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

Positive Kernig sign

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)

A nurse is providing information to the parents of a child diagnosed with absence seizures. What information would the nurse expect to include when describing this type of seizure? Select all that apply.

- This type of seizure is more common in girls than it is in boys. - You might see a blank facial expression after a sudden stoppage of speech. - This type of seizure is usually short, lasting for no more than 30 seconds. - You might have mistaken this type of seizure for lack of attention.

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.