Module 5: Intracranial Regulation

Answer: 3 Rationale: Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

386. The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

ANS: C Monitor the child for increased confusion and report this adverse effect to the provider as it could indicate electrolyte imbalance.

A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the findings should the nurse monitor for as an adverse effect of mannitol? a. bradycardia b. weight loss c. confusion d. constipation

ANS: B Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain, excrete the catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines is detected in approximately 95% of children with adrenal or sympathetic tumors.

The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of neuroblastoma. What finding in the urine is expected with neuroblastomas? a. Ketones b. Catecholamines c. Red blood cells d. Excessive white blood cells

ANS: D Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately. Limits should be appropriate to the childs developmental age. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed.

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. What issues should be addressed? a. Most childhood activities must be restricted. b. Cognitive impairment is to be expected with hydrocephalus. c. Wearing head protection is essential until the child reaches adulthood. d. Shunt malfunction or infection requires immediate treatment.

ANS: A Moro, tonic neck, and withdrawal reflexes are three reflexes that are present in a healthy 2-month-old infant and are expected in this age group.

The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings? a. Neurologic health b. Severe brain damage c. Decorticate posturing d. Decerebrate posturing

Answer: 1, 2, 3, 4 Explanation: 1. Signs of shunt malfunction in infants are nonspecific and include irritability, vomiting, poor appetite, disordered sleep, and fever. Older children with shunt malfunction may have a headache, nausea, vomiting, and decreased level of consciousness.

The nurse is performing an admission assessment on an infant diagnosed with hydrocephalus and a malfunctioning shunt. Which assessment findings should the nurse expect? Select all that apply. 1. Vomiting 2. Fever 3. Irritability 4. Poor appetite 5. Decreased level of consciousness

ANS: A, B, C, E Clinical manifestations of bacterial meningitis in an adolescent include, fever, chills, headache, and drowsiness. Hyperactivity is present, not poor tone.

The nurse is preparing to admit an adolescent with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Fever b. Chills c. Headache d. Poor tone e. Drowsiness

ANS: B A compound fracture has the bone exposed through the skin. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. Diastatic skull fractures are traumatic separations of the cranial sutures. A depressed fracture has the bone pushed inward, causing pressure on the brain.

The nurse is teaching nursing students about childhood fractures. Which describes a compound skull fracture? a. Involves the basilar portion of the occipital bone b. Bone is exposed through the skin c. Traumatic separations of the cranial sutures d. Bone is pushed inward, causing pressure on the brain

Answer: 1 Explanation: 1. Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture. 2. Subdural hematoma might be seen with a linear fracture. 3. Protruding bone might be seen with a compound fracture. 4. Epidural hematoma is seen with linear fracture.

Which clinical manifestation should the nurse monitor for when assessing a pediatric client who is diagnosed with a basilar skull fracture? 1. Periorbital ecchymosis 2. Subdural hematoma 3. Protruding bone 4. Epidural hematoma

ANS: C, D, E Cushing triad (systemic hypertension, bradycardia, and respiratory depression) is a late sign of impending brainstem herniation. Fever or flushing does not occur with Cushing triad.

The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.) a. Fever b. Flushing c. Bradycardia d. Systemic hypertension e. Respiratory depression

ANS: B Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantula spiders, carnivorous wild animals, and domestic and wild animals are not reservoirs for the agents that cause viral encephalitis.

The vector reservoir for agents causing viral encephalitis in the United States is: a. tarantula spiders .b. mosquitoes. c. carnivorous wild animals. d. domestic and wild animals.

ANS: D Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so use of aspirin is avoided. No immunization currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or bacterial meningitis.

Which is beneficial in reducing the risk of Reye syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin to treat fever associated with influenza

Answer: 18.75 or 18.8 mL/hr

A 5-year-old child is admitted to the hospital with increased intracranial pressure after a motor vehicle struck the child. The child weighs 15 kg. The neurosurgeon orders: Mannitol 0.5 g/kg/10 minutes IV first, followed by Mannitol 0.25 g/kg IV every 4 hours. Medication on hand: Mannitol 100 g/500mL D5W. Calculate how many mL/hr to set the IV pump to infuse the Mannitol ordered every 4 hours.

ANS: A B C Febrile episodes, hypoglycemia, and sodium imbalances (hypernatremia and hyponatremia) can cause seizure activity. D. HIGH blood levels are a risk factor for seizure activity

A nurse is teaching a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? SATA a. febrile episodes b. hypoglycemia c. sodium imbalances d. low blood lead levels e. presence of diphtheria

ANS: C In the postictal phase, after a tonic-clonic seizure, the child may remain semiconscious and difficult to arouse. The average duration of the postictal phase is usually 30 minutes. The child may remain confused or sleep for several hours. He or she may have mild impairment of fine motor movements. The child may have visual and speech difficulties and may vomit or complain of headache.

After a tonic-clonic seizure, what symptoms should the nurse expect the child to experience? a. Diarrhea and abdominal discomfort b. Irritability and hunger c. Lethargy and confusion d. Nervousness and excitability

ANS: D H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.

The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the childs younger brother had when he was an infant. The nurse should base a response on which information? a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.

Answer: 1, 2, 5 Explanation: 1. There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10. Myelination is incomplete at birth.

The nurse educator is describing the pediatric differences associated with the anatomy and physiology of the neurologic system to a group of nursing students. Which statements made by the class indicate appropriate understanding of this topic after the teaching session? Select all that apply. 1. The bones of the cranium are connected by connective tissue to allow for brain growth. 2. The spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies. 3. Maturation of the nerves continues until age 10. 4. Myelination is complete at birth, 5. Myelination proceeds in a cephalocaudal direction.

ANS: 2 The nurse should assess the child with a head injury and decreasing level of consciousness first (LOC). Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his surroundings would be of least worry to the nurse.

The nurse has received report on four children. Which child should the nurse assess first?\ 1. A school-age child in a coma with stable vital signs 2. preschool child with a head injury and decreasing level of consciousness 3. An adolescent admitted after a motor vehicle accident is oriented to person and place 4.. A toddler in a persistent vegetative state with a low-grade fever

ANS: D The most important nursing observation is assessment of the childs level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage.

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. Which is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

Answer: a. "Has the child been huffing (ingesting) any household products?"; b. "Has the child had recent head trauma?"; c. "Has the child ever had a brain tumor or shunt?"; e. "Has the child been sick?" Feedback: A complete history is very important when assessing a child for altered levels of consciousness. Head trauma, illness, drug use, and medical history are a few of the valid points when assessing levels of consciousness. Recent animal exposure usually is not related to altered levels of consciousness.

The nurse is assessing the level of consciousness of a 10-year-old client in the emergency department. What would be important questions for the nurse to ask the child or the parent? (Select all that apply.) a. "Has the child been huffing (ingesting) any household products?" b. "Has the child had recent head trauma?" c. "Has the child ever had a brain tumor or shunt?" d. "Does the child have animals at home?" e. "Has the child been sick?"

ANS: A Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, non-stimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP.

The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the childs care plan? a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline. b. Maintain an active, stimulating environment. c. Perform chest percussion and suctioning every 1 to 2 hours. d. Perform active range of motion and nontherapeutic touch every 8 hours.

Answer: 3 Explanation: 1. Frequent vital signs and neurologic checks are needed postoperatively. 2. Small, frequent feedings are appropriate to decrease the chance of vomiting. 3. The 9-month-old should be placed in a flat position so that cerebrospinal fluid drainage is not too rapid. 4. Daily head circumferences are needed to help evaluate shunt functioning.

The nurse is caring for a 9-month-old infant who just returned from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question? 1. Vital signs and neurologic checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference

ANS: C, D, E Hemiparesis, hemiplegia, and anisocoria (unequal pupils) are signs of brainstem compression and require emergency treatment targeted at decreasing increased intracranial pressure. Coma and lethargy are seen with a subdural hematoma but do not indicate a brainstem compression.

The nurse is caring for a child with a subdural hematoma. The nurse should assess for what signs that can indicate brainstem compression? (Select all that apply.) a. Coma b. Lethargy c. Hemiplegia d. Hemiparesis e. Unequal pupils

ANS: A, D, E Other measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit environment; limiting visitors; preventing any sudden, jarring movement, such as banging into the bed; and preventing an increase in ICP. The latter is most effectively achieved by proper positioning and prevention of straining, such as during coughing, vomiting, or defecating. An antiemetic should be administered to prevent vomiting, and stool softeners should be prescribed to prevent straining with bowel movements. The head of the bed should be elevated 15 to 30 degrees.

The nurse is caring for a child with increased intracranial pressure (ICP). What interventions should the nurse plan for this child? (Select all that apply.) a. Avoid jarring the bed. b. Keep the room brightly lit. c. Keep the bed in a flat position. d. Administer prescribed stool softeners. e. Administer a prescribed antiemetic for nausea.

ANS: A, C, E Acute complications of meningitis include syndrome of inappropriate antidiuretic hormone (SIADH), subdural effusions, seizures, cerebral edema and herniation, and hydrocephalus. Long-term complications include cerebral palsy, cognitive impairments, learning disorder, attention deficit hyperactivity disorder, and seizures.

The nurse is caring for a child with meningitis. What acute complications of meningitis should the nurse continuously assess the child for? (Select all that apply.) a. Seizures b. Cerebral palsy c. Cerebral edema d. Hydrocephalus e. Cognitive impairments

ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Delirium is a state of mental confusion and excitement marked by disorientation for time and place. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Flexion posturing is seen with severe dysfunction of the cerebral cortex or of the corticospinal tracts above the brainstem.

The nurse is caring for a child with severe head trauma after a car accident. What is an ominous sign that often precedes death? a. Delirium b. Papilledema c. Flexion posturing d. Periodic or irregular breathing

ANS: D The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. One fixed and dilated pupil is not suggestive of brain death. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain.

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this? a. Eye trauma b. Brain death c. Severe brainstem damage d. Neurosurgical emergency

Answer: 1, 2, 3, 4 Explanation: 1. Lesions are a cause of simple partial seizures. 2. Cysts are a cause of simple partial seizures. 3. Tumors are a cause of simple partial seizures. 4. Brain abscesses are a cause of simple partial seizures. 5. Brain trauma a cause of complex partial seizures.

The nurse is planning a teaching session for the parents of a child who is diagnosed with simple partial seizures. Which causes should the nurse include when teaching the parents? Select all that apply. 1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses 5. Brain trauma

Answer: 1 Explanation: 1. A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.

The nurse is planning care for a school-age child diagnosed with bacterial meningitis. Which intervention is most appropriate? 1. Keeping environmental stimuli at a minimum 2. Avoiding giving pain medications that could dull sensorium 3. Measuring head circumference to assess developing complications 4. Having the child move the head from side to side at least every two hours

ANS: A The room is kept as quiet as possible and environmental stimuli are kept to a minimum. Most children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nuchal rigidity associated with meningitis would make moving the head from side to side a painful intervention. If pain is present, the child should be treated appropriately. Failure to treat can cause increased intracranial pressure. In this age group, the head circumference does not change. Signs of increased intracranial pressure would need to be assessed.

The nurse is planning care for a school-age child with bacterial meningitis. What intervention should be included? a. Keep environmental stimuli to a minimum. b. Have the child move her head from side to side at least every 2 hours. c. Avoid giving pain medications that could dull sensorium. d. Measure head circumference to assess developing complications.

ANS: A For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. The child will not be allowed to move and will be immobilized. Someone is able to remain with the child during the procedure.

The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral function. The nurse should include what statement in preparing the child? a. The scan will not hurt. b. Pain medication will be given. c. You will be able to move once the equipment is in place. d. Unfortunately no one can remain in the room with you during the test.

ANS: A, B, C The classic clinical picture of an epidural hemorrhage is a lucid interval (momentary unconsciousness) followed by a normal period for several hours, and then lethargy or coma due to blood accumulation in the epidural space and compression of the brain. The child may be seen with varying degrees of impaired consciousness depending on the severity of the traumatic injury. Common symptoms in a child with no neurologic deficit are irritability, headache, and vomiting. In infants younger than 1 year of age, the most common symptoms are irritability, pallor with anemia, and cephalhematoma.

The nurse is preparing to admit a 5-year-old with an epidural hemorrhage. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Headache b. Vomiting c. Irritability d. Cephalhematoma e. Pallor with anemia

ANS: A, B, C, E Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and an increased head circumference.

The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.) a. High-pitched cry b. Poor feeding c. Setting-sun sign d. Sunken fontanel e. Distended scalp veins f. Decreased head circumference

ANS: C, D, E Clinical features of complex partial seizures include the following: it is common to have mental disorientation, there is frequently a postictal state, and there is usually an impaired consciousness. These seizures last longer than 10 seconds (usually longer than 60 seconds), and there is usually an aura.

The nurse is preparing to admit a 7-year-old child with complex partial seizures. What clinical features of complex partial seizures should the nurse recognize? (Select all that apply.) a. They last less than 10 seconds. b. There is usually no aura. c. Mental disorientation is common. d. There is frequently a postictal state. e. There is usually an impaired consciousness.

ANS: A, B, C, E Clinical manifestations of bacterial meningitis in a neonate include jaundice, cyanosis, poor tone, and poor sucking ability. The neck is usually supple in neonates with meningitis, and there is no nuchal rigidity.

The nurse is preparing to admit a neonate with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Jaundice b. Cyanosis c. Poor tone d. Nuchal rigidity e. Poor sucking ability

ANS: A, B, D The clinical manifestations of encephalitis include malaise, apathy, and lethargy. There is hyperactivity, not hypoactivity, and hyperthermia, not hypothermia.

The nurse is preparing to admit an adolescent with encephalitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Malaise b. Apathy c. Lethargy d. Hypoactivity e. Hypothermia

Answer: 1 Explanation: 1. Range-of-motion exercises, especially hip flexion, would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible. 2. Oxygen should be ordered to keep the child's O2saturation above 95%. 3. Hourly vital signs and neurologic checks are appropriate to watch for changes in this child's condition. 4. The head is elevated 30 degrees to help decrease increased intracranial pressure.

The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question? 1. Passive range-of-motion exercises to promote hip flexion 2. Oxygen at 2 L nasal cannula to keep saturation above 95% 3. Hourly vital signs and neurologic checks 4. Elevate head of bed 30 degrees

Answer: 2 Explanation: 1. Carbonated beverages should never be used to dilute valproic acid. 2. Valproic acid (Depakote) should be given with foods to decrease gastrointestinal irritation. 3. This child should not be allowed to chew a valproic acid tablet. 4. It is appropriate to have periodic blood studies to check bleeding times and platelet count.

The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education? 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician's office for regular blood work to check bleeding times."

ANS: C Parents should try to place a pillow or folded blanket under the childs head for protection. The parent should not try to restrain the child during the seizure. The child does not need to go to the ED with each seizures; the nurse can teach parents certain criteria for when their child would need to be seen. Discussing what will happen in adulthood is not appropriate at this time.

The nurse is teaching the parents of a 3-year-old child who has been diagnosed with tonic-clonic seizures. What statement by the parent should indicate a correct understanding of the teaching? a. I should attempt to restrain my child during a seizure. b. My child will need to avoid contact sports until adulthood. c. I should place a pillow under my childs head during a seizure. d. My child will need to be taken to the emergency department [ED] after each seizure.

ANS: C, D, E The most common factors that may trigger seizures in children include emotional stress, sleep deprivation, fatigue, fever, and physical exercise. Other precipitating factors include sleep, flickering lights, menstrual cycle, alcohol, heat, hyperventilation, and fasting. Cold and sugared drinks are not triggers for seizures.

The nurse is teaching the parents of a child with a seizure disorder about the triggers that can cause a seizure. What should the nurse include in the teaching session? (Select all that apply.) a. Cold b. Sugared drinks c. Emotional stress d. Flickering lights e. Hyperventilation

ANS: D Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred vision, or has an unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated. THIS IS AN ALTERED MENTAL STATUS -> THINK GCS CHANGES

The nurse should recommend medical attention if a child with a slight head injury experiences: a. sleepiness. b. vomiting, even once. c. headache, even if slight. d. confusion or abnormal behavior.

ANS: A Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Diplopia (double vision), not blurred vision, can be a presenting sign of brainstem glioma. Ataxia is a clinical manifestation of brain tumors, but headaches and vomiting are the most common. Hydrocephalus can be a presenting sign in infants when the sutures have not closed. Children at this age are usually not walking steadily. Poor fine motor coordination may be a presenting sign of astrocytoma, but headaches and vomiting are the most common presenting signs of brain tumors.

What are the most common clinical manifestations of brain tumors in children? a. Headaches and vomiting b. Blurred vision and ataxia c. Hydrocephalus and clumsy gait d. Fever and poor fine motor control

ANS: B, D, E The CSF analysis in viral meningitis shows a normal or slightly elevated protein count, negative Gram stain, and a slightly elevated WBC. The color is clear or slightly cloudy, and the glucose level is normal.

What cerebrospinal fluid (CSF) analysis should the nurse expect with viral meningitis? (Select all that apply.) a. Color is turbid. b. Protein count is normal. c. Glucose is decreased. d. Gram stain findings are negative. e. White blood cell (WBC) count is slightly elevated.

ANS: B Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. A closed fontanel, high-pitched cry, constant low-pitched cry, restlessness, a depressed fontanel, and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.

What clinical manifestations suggest hydrocephalus in an infant? a. Closed fontanel and high-pitched cry b. Bulging fontanel and dilated scalp veins c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure

ANS: B, C, D, E The serum sodium is decreased, urinary output is decreased, evidence of overhydration is present, and urine specific gravity is increased in SIADH. Hypertension, not hypotension, occurs.

What effects of an altered pituitary secretion in a child with meningitis indicates syndrome of inappropriate antidiuretic hormone (SIADH)? (Select all that apply.) a. Hypotension b. Serum sodium is decreased c. Urinary output is decreased d. Evidence of overhydration e. Urine specific gravity is increased

ANS: D Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so use of aspirin is avoided. No immunization currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or bacterial meningitis.

What intervention should be beneficial in reducing the risk of Reye syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin for children with varicella or those suspected of having influenza

ANS: D Unrelieved pain, crying, and emotional stress all contribute to increasing the ICP. Disturbing procedures should be carried out at the same time as therapies that reduce ICP, such as sedation. Suctioning is poorly tolerated by children. When necessary, it is preceded by hyperventilation with 100% oxygen. Turning the head side to side is contraindicated for fear of compressing the jugular vein. This would block the flow of blood from the brain, raising ICP. Nontherapeutic touch and environmental stimulation increase ICP. Minimizing both touch and environmental stimuli noise reduces ICP.

What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child? a. Suction the child frequently. b. Turn the childs head side to side every hour. c. Provide environmental stimulation. d. Avoid activities that cause pain or crying.

ANS: C The EVD is inserted into the childs ventricle. Frequent assessment is necessary to determine amount of drainage and whether an infection is present. The EVD is a closed system and is not opened for irrigation. Antibiotics may be administered through the drain, but this is usually done by the neuropractitioner. The dressing is not changed. If it becomes wet, then the practitioner should be notified that cerebrospinal fluid (CSF) may be leaking. Unless ordered, maintaining the EVD below the level of the childs head position will create too much pressure and potentially drain too much CSF.

What is a priority of care when a child has an external ventricular drain (EVD)? a. Irrigation of drain to maintain flow b. As-needed dressing changes if dressing becomes wet c. Frequent assessment of amount and color of drainage d. Maintaining the EVD below the level of the childs head

ANS: A When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child is not suctioned during the seizure. If possible, the child should be placed on the side, facilitating drainage to prevent aspiration.

What is important to incorporate in the plan of care for a child who is experiencing a seizure? a. Describe and record the seizure activity observed. b. Suction the child during a seizure to prevent aspiration. c. Place a tongue blade between the teeth if they become clenched d. Restrain the child when seizures occur to prevent bodily harm.

ANS: D Children taking phenobarbital or phenytoin should receive adequate vitamin D and folic acid because deficiencies of both have been associated with these drugs.

What is the antiepileptic medication that requires monitoring of vitamin D and folic acid? a. Topiramate (Topamax) b. Valproic acid (Depakene) c. Gabapentin (Neurontin) d. Phenobarbital (Luminal)

ANS: C Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.

What is the initial clinical manifestation of generalized seizures? a. Confusion b. Feeling frightened c. Loss of consciousness d. Seeing flashing lights

ANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. Narcotics and sedatives should be used as necessary to reduce pain and anxiety, which can increase ICP. The childs position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Antipyretics are the method of choice for fever reduction.

What nursing intervention is appropriate when caring for an unconscious child? a. Avoid using narcotics or sedatives to provide comfort and pain relief. b. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP). c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are contraindicated.

ANS: C Obtundation describes a level of consciousness in which the child is arousable with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.

What term is used to describe a childs level of consciousness when the child is arousable with stimulation? a. Stupor b. Confusion c. Obtundation d. Disorientation

ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

What term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

ANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Absence seizures have a sudden onset and are characterized by a brief loss of consciousness, a blank stare, and automatisms. Acquired seizure disorder is a result of a brain injury from a variety of factors; it is not a term that labels the type of seizure. Complex partial seizures are the most common seizures. They may begin with an aura and be manifested as repetitive involuntary activities without purpose, carried out in a dreamy state.

What term refers to seizures that involve both hemispheres of the brain? a. Absence b. Acquired c. Generalized d. Complex partial

ANS: B The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on an awake child or one who has a ruptured tympanic membrane. The dolls head maneuver, assessment of pyramidal tract lesions, and funduscopic examination for papilledema are not considered painful and can be performed on awake children.

What test is never performed on a child who is awake? a. Dolls head maneuver b. Oculovestibular response c. Assessment of pyramidal tract lesions d. Funduscopic examination for papilledema

ANS: A Absence seizures may go unrecognized because little change occurs in the childs behavior during the seizure. Generalized, simple partial, and complex partial all have clinical manifestations that are observable.

What type of seizure may be difficult to detect? a. Absence b. Generalized c. Simple partial d. Complex partial

Answer: d. Headaches associated with an aura prior to onset Feedback: Stress-related headaches are tension headaches. Using certain medications more than three times per week can trigger headaches. Sinus headaches do not have an aura, whereas migraine headaches often do.

When evaluating a child who complains of headaches, which description would lead the nurse to suspect migraine headaches? a. Headaches associated with stress only b. Headaches associated with frequent use of acetaminophen c. Headaches associated with sinus pressure and upper-respiratory symptoms d. Headaches associated with an aura prior to onset

ANS: B The etiology of Reye syndrome is not well understood, but most cases follow a common viral illness, typically influenza or varicella.

When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised if a week ago the child had recovered from what? a. Measles b. Influenza c. Meningitis d. Hepatitis

Answer: 1 Explanation: 1. The posterior fontanel closes between 2 and 3 months of age. 2. Good head control is expected at 4 months of age. 3. Rolling from abdomen to back is a skill the 4-month-old infant should be learning. 4. An open anterior fontanel, which is soft, is a normal finding at 4 months.

Which assessment finding for a 4-month-old infant would require further action by the nurse? 1. The posterior fontanel is open. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft.

Feedback: Neurofibromatosis is characterized by six or more café au lait spots, axillary and inguinal freckling, and small tumors on the body. Seizures, limping, and an increasing head circumference are not necessarily signs of neurofibromatosis.

Which assessment finding would the nurse not find in a 4-year-old child with neurofibromatosis? a. Walking with a limp b. Seizure activity c. Increased head circumference d. Café au lait spots

Answer: 1, 2, 3 Explanation: 1. Abrupt onset of fever is a clinical manifestation associated with viral meningitis. 2. Headache is a clinical manifestation associated with viral meningitis. 3. Myalgia is a clinical manifestation associated with viral meningitis. 4. Hemorrhagic rash is a clinical manifestation associated with bacterial, not viral, meningitis. 5. Purpura is a clinical manifestation associated with bacterial, not viral, meningitis.

Which clinical manifestations support the diagnosis of viral meningitis? Select all that apply. 1. Abrupt onset of fever 2. Headache 3. Myalgia 4. Hemorrhagic rash 5. Purpura

Answer: c. The infant is placed in a flat supine position immediately after surgery. Feedback: There are no surgical sites in the foot for ventriculoatrial shunt surgery. Volume expanders are not indicated and can increase risk of increased intracranial pressure (ICP). The child's pain always should be managed regardless of age. The infant never should have nuchal rigidity; it indicates meningeal irritation due to infection or increased ICP. The infant is placed in a flat position and the head of the bed is elevated gradually to prevent rapid cerebrospinal fluid drainage.

Which consideration would be important in planning nursing care for an infant following surgical insertion of a ventriculoperitoneal shunt? a. Pain relief interventions are not utilized routinely for infants. b. Some nuchal rigidity is expected after this procedure. c. The infant is placed in a flat supine position immediately after surgery. d. Administration of intravascular volume expanders is necessary to maintain shunt function.

ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.

Which drug should the nurse expect to administer to a preschool child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol (Osmitrol) b. Epinephrine hydrochloride (Adrenalin) c. Atropine sulfate (Atropine) d. Sodium bicarbonate (Sodium bicarbonate)

Answer: 1 Explanation: 1. Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange. 2. The child already has an infection. 3. The parents will be anxious about the outcome for their child, but this is not the priority diagnosis. 4. Pain management is important but is not the priority.

Which is the priority nursing diagnosis when planning care for a pediatric client who is diagnosed with bacterial meningitis? 1. Impaired Gas Exchange 2. Risk for Infection 3. Anxiety (parental) 4. Acute Pain

ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority. A neurologic assessment and determination of whether a neck injury is present will be performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

Which is the priority nursing intervention for an unconscious child after a fall? a. Establish adequate airway. b. Perform neurologic assessment. c. Monitor intracranial pressure. d. Determine whether a neck injury is present.

3. The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage? 1. Placing infant supine to decrease pressure on the sac 2. Appling a heat lamp to facilitate drying and toughening of the sac 3. Measuring head circumference every shift to identify developing hydrocephalus 4. Appling a diaper to prevent contamination of the sac

Answer: 1, 2, 3, 5 Explanation: 1. Many children with myelodysplasia have normal intellect. They should be treated according to their intellectual level rather than their motor development. 2. Children with myelodysplasia are at great risk for latex allergy. It is important to use latex-free products. 3. Self-catheterization fosters independence in this child. It is important to maintain the same schedule as much as possible when this child is hospitalized. 4. Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function. 5. Due to decreased sensation in the buttocks and lower extremities, it is very important for the child to shift positions while in the wheelchair, to prevent pressure sores.

Which should the nurse include in the plan of care for a hospitalized school-age child with myelodysplasia? Select all that apply. 1. Implementing interventions for a client of normal intelligence 2. Using latex precautions when providing client care 3. Allowing the client to self-catheterize 4. Ensuring that the client has a low-fiber diet 5. Encouraging the client to shift positions hourly when in the wheelchair

2. Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Which statement made by a parent during a well-child visit would cause the nurse to suspect the child has cerebral palsy? 1. "My 6-month-old baby is rolling from back to prone now." 2. "My 3-month-old seems to have floppy muscle tone." 3. "My 8-month-old can sit without support." 4. "My 10-month-old is not walking."

ANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

Which type of seizure involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

Explanation: 1. Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

With a group of new parents, the nurse is reviewing treatment for viral illnesses such as influenza. Which statement by the parents indicates appropriate understanding of the teaching session? 1. "Some over-the-counter medications contain aspirin." 2. "Acetaminophen is good for treatment of fevers in young children." 3. "I can use ibuprofen as needed when my child has aches and pains." 4. "Aspirin is acceptable if my child does not have a virus."

Answer: 2Vomiting is a symptom of increased intracranial pressure. Bulging fontanels would not be present in a school-age child. Drainage from the ear or nose might indicate a basilar skull fracture, not a brain tumor. Some brain tumors display the symptom of diabetes insipidus, not diabetes mellitus, thus the symptom would be dilute urine rather than elevated blood glucose.

1 A 6-year-old child is being admitted for surgical removal of a brain tumor. The nurse anticipates that which of the following nursing assessment data will be present during the preoperative period? 1. Bulging fontanels 2. Vomiting 3. Drainage from the ear or nose 4. Elevated blood glucose levels

2. Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drug's effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.

1) A child is diagnosed with epilepsy and is prescribed daily phenytoin (Dilantin). Which topic is most appropriate for the nurse to include in the discharge teaching? 1. Increasing fluid intake 2. Performing good dental hygiene 3. Decreasing intake of vitamin D 4. Taking the medication with milk

ANS: A Injury to the brainstem results in stupor and coma. Signs of damage to the cerebrum are specific to the involved area. Individuals with frontal lobe injury may have impaired memory, personality changes, or altered intellectual functioning. Individuals with damage to the cerebellum have difficulties with coordination of muscle movements, including ataxia and nystagmus. Impaired vision and functional blindness result from injury to the occipital lobe.

1. An injury to which part of the brain will cause a coma? a. Brainstem b. Cerebrum c. Cerebellum d. Occipital lobe

ANS: A, D, E Clinical features of absence seizures include no auras, a brief loss of consciousness, and an occasional clonic movement. There is no postictal state, and the seizures rarely last longer than 30 seconds.

13. The nurse is preparing to admit a 10-year-old child with absence seizures. What clinical features of absence seizures should the nurse recognize? (Select all that apply.) a. There is no aura. b. There is a postictal state. c. They usually last longer than 30 seconds. d. There is a brief loss of consciousness. e. There is an occasional clonic movement.

ANS: C A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages on the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an accelerationdeceleration injury.

13. What statement is descriptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient and reversible neuronal dysfunction. d. It is a slight lesion that develops remote from the site of trauma.

ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

14. What statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.

Answer: 4 Explanation: 1. There are no data to suspect a childhood crush is creating the situation. 2. There is no indication of increased intracranial pressure. 3. There is no indication of a head injury. 4. Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher.

15) A teacher states to the school nurse, "I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?" Which should the nurse include in the response to the teacher? 1. The child has a crush on the teacher. 2. The child has increased intracranial pressure. 3. The child may have had a head injury. 4. The child is experiencing absence seizures.

Answer: 1 Explanation: 1. These are the early symptoms of Reye syndrome. 2. These symptoms are associated with a malfunctioning shunt and not the early symptoms of Reye syndrome. 3. These symptoms are more likely to indicate pneumonia, not Reye syndrome. 4. These are not the early symptoms of Reye syndrome.

16) The nurse is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the nurse concern? 1. Nausea, vomiting, and confusion 2. Headache, vomiting, and seizures 3. Sore throat, moist respirations, and cough 4. Fever, rash, and photophobia

Answer: 1, 5 Explanation: 1. Fluid intake will help heat loss. 2. Aspirin should be avoided due to the risk for Reye syndrome. 3. Cold water may cause shivering, which will increase the body temperature. 4. Decreasing fluid intake would increase the retention of heat. 5. A tepid bath will bring down the temperature; patting, instead of rubbing, will help keep the child's temperature down.

17) Which preventative strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures? Select all that apply. 1. Increasing oral intake of fluids 2. Administering dose-appropriate aspirin 3. Providing a sponge bath with cold water 4. Decreasing oral fluid intake 5. Patting the child dry after a tepid bath

Answer: 1 Explanation: 1. Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in head first. Because of mobility limitations, the child may not be able to get out of the bucket without help. 2. This is appropriate to reduce the risk of injury. 3. This allows the mother to adjust the temperature of the bath water and reduces the risk of burns. 4. This is the safest place for the child.

18) When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? 1. The mother leaves the filled mop bucket on the floor while in another room. 2. The mother turns all pan handles to the back of the stove. 3. The mother fills the bath tub before bringing the baby into the bathroom. 4. When riding in a car, the child is in a car seat in the middle of the back seat.

Answer: 1, 2, 3, 4 Explanation: 1. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 2. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 3. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 4. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 5. This nursing diagnosis is more appropriate for a client diagnosed with cerebral palsy, not a TBI.

19) Which nursing diagnoses should the nurse include in the plan of care for a pediatric client who experiences a traumatic brain injury (TBI)? Select all that apply. 1. Risk for Ineffective Tissue Perfusion: Cerebral 2. Risk for Aspiration 3. Risk for Imbalanced Fluid Volume 4. Compromised Family Coping 5. Chronic Pain

Answer: 2This tumor occurs in 1 in 10,000 live births. It arises out of embryonic neural crest cells and, therefore, is usually found in the adrenals or retroperitoneal sympathetic chain. Symptoms are vague and depend on location.

2 The parent of a child with neuroblastoma verbalizes regret at not coming in earlier for the child's complaints. An appropriate response is: 1. "This tumor may be diagnosed early because of obvious symptoms." 2. "This is a silent tumor, which is difficult to diagnose early." 3. "This is a very common brain tumor in children." 4. "I know you feel guilty about not being more observant, but you shouldn't blame yourself."

ANS: C Diplopia and blurred vision are signs of increased ICP in children. A high-pitched cry and a tense or bulging fontanel are characteristic of increased ICP. Increased blood pressure, common in adults, is rarely seen in children.

2. What finding is a clinical manifestation of increased intracranial pressure (ICP) in children? a. Low-pitched cry b. Sunken fontanel c. Diplopia, blurred vision d. Increased blood pressure

Answer: 1, 2, 3, 4 Explanation: 1. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 2. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 3. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 4. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 5. Risk for constipation is not an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus.

21) Which nursing diagnoses should the nurse include in the plan of care for a pediatric client diagnosed with hydrocephalus? Select all that apply. 1. Risk for Infection 2. Impaired Physical Mobility 3. Risk for Caregiver Role Strain 4. Risk for Injury 5. Risk for Constipation

ANS: C Quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation are called choreiform movements. Twitching is defined as spasmodic movements of short duration. Spasticity is the prolonged and steady contraction of a muscle characterized by clonus (alternating relaxation and contraction of the muscle) and exaggerated reflexes. Associated movements are the voluntary movement of one muscle accompanied by the involuntary movement of another muscle.

3. What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called? a. Twitching b. Spasticity c. Choreiform movements d. Associated movements

Answer: 1 Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

383. The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow

Answer: 4 Rationale: Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

384. A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

Answer: 4 Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

387. A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? 1. Assessing hearing loss 2. Monitoring urine output 3. Changing body position every 2 hours 4. Providing a quiet atmosphere with dimmed lighting

Answer: 4 Rationale: A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside but would be available in the treatment room or nearby on the nursing unit.

388. The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

Answer: 3 Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

389. A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

Answer: 4 Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the prescribed antibiotic as soon as a culture is obtained. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.

390. The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

Answer: 2 Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP). In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in ICP. It is not necessary to check the blood pressure every 15 minutes.

391. An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

Answer: 1, 3, 5 Rationale: A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on her or his side in a lateral position. Positioning on the side prevents aspiration, because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

392. The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

Answer: 3The most common reported symptoms of brain tumors in children are headache, especially upon awakening, and vomiting that is unrelated to eating. Both are related to increased intracranial pressure. Irritability and ataxia may also be present; however, presenting symptoms are often vague. Fever is not a symptom of a brain tumor. Papilledema may be noted, but red reflex is not indicative of brain tumors.

4 The school health nurse has seen a child several times with the same complaints. The school health nurse would suspect a brain tumor after noting the presence of which of the following symptoms that is compatible with this health problem? 1. Ataxia and irritability 2. Papilledema and positive red reflex 3. Early morning headache and vomiting 4. Fever and seizures

ANS: A For in-hospital management of status epilepticus, intravenous diazepam or lorazepam (Ativan) is the first-line drug of choice. Lorazepam is the preferred agent because of its rapid onset (25 minutes) and long half-life (1224 hours) with few side effects.

43. A child has been admitted with status epilepticus. An emergency medication has been ordered. What medication should the nurse expect to be prescribed? a. Lorazepam (Ativan) b. Phenytoin (Dilantin) c. Topiramate (Topamax) d. Ethosuximide (Zarontin)

ANS: A Because this is the childs first seizure and it lasted more than 5 minutes, EMS should be called to transport the child, and evaluation should be performed as soon as possible. The nurse should stay with the recovering child while someone else notifies EMS.

A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school that lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion occurs. What is the most appropriate initial action by the school nurse? a. Stay with child and have someone else call emergency medical services (EMS). b. Notify the parent and regular practitioner. c. Notify the parent that the child should go home. d. Stay with the child, offering calm reassurance.

ANS: B It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The nurse must remain calm, stay with the child, and prevent the child from sustaining any harm during the seizure. The nurse should not move or forcefully restrain the child during a tonic-clonic seizure and should not place a solid object between the teeth. Suctioning may be needed but not until the seizure has ended.

A 2-year-old child starts to have a tonic-clonic seizure. The childs jaws are clamped. What is the most important nursing action at this time? a. Place a padded tongue blade between the childs jaws. b. Stay with the child and observe his respiratory status. c. Prepare the suction equipment. d. Restrain the child to prevent injury.

ANS: D Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is carried out at frequent intervals on a child with meningitis. The nurse should avoid actions that cause pain or increase discomfort, such as lifting the childs head, so the Brudzinski reflex should not be checked hourly. Checking the Babinski reflex or childs voluntary movements will not help with assessing the childs status.

A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very irritable with a temperature of 102 F. What should the nurses care plan include? a. Observing the childs voluntary movement b. Checking the Babinski reflex every 4 hours c. Checking the Brudzinski reflex every 1 hour d. Assessing the level of consciousness (LOC) and vital signs every 2 hours

Answer: 4 Explanation: 1. Appendicitis does not occur as a result of the ketogenic diet. 2. The ketogenic diet does not cause a bowel obstruction. 3. Urinary tract infections are not a result of a ketogenic diet. 4. Kidney stones are seen in 5% of children on a ketogenic diet.

A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect? 1. Appendicitis 2. Bowel obstruction 3. Urinary tract infection 4. Kidney stones

ANS: C The parents are advised of probable posttraumatic symptoms that may be expected. These include behavioral changes, sleep disturbances, emotional lability, and alterations in school performance. If the child is vomiting, has blurred vision, or has temporary loss of consciousness, she should be seen for evaluation.

A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. What sign or symptom is considered a manifestation of postconcussion syndrome and does not necessitate medical attention? a. Vomiting b. Blurred vision c. Behavioral changes d. Temporary loss of consciousness

Answer: b. Dim the lights and quiet room as needed. Feedback: Due to the neurologic sequela of this disease, reducing external stimuli is extremely important. Lights should be dim and the room quiet. Food usually is held initially and IV fluids initiated. Head circumference usually is only performed for children under 2 years old.

A 5-year-old is admitted to the hospital with suspected meningitis. Which nursing intervention would be included in the child's plan of care? a. Measure the head circumference. b. Dim the lights and quiet room as needed. c. Play music that the child enjoys. d. Provide a high-calorie diet.

ANS: D In older children, who are usually admitted to the hospital for elective or emergency shunt revision, the most valuable indicators of increasing intracranial pressure are an alteration in the childs level of consciousness, complaint of headache, and changes in interaction with the environment.

A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary? a. Tachycardia b. Gastrointestinal upset c. Hypotension d. Alteration in level of consciousness

ANS: A The treatment of SIADH consists of fluid restriction until serum electrolytes and osmolality return to normal levels. SIADH often occurs in children who have meningitis. Monitoring weights, keeping I and O and specific gravity of urine, and observing for signs of increasing cerebral edema are all part of the nursing care for a child with SIADH.

A child develops syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a complication to meningitis. What action should be verified before implementing? a. Forcing fluids b. Daily weights with strict input and output (I and O) c. Strict monitoring of urine volume and specific gravity d. Close observation for signs of increasing cerebral edema

Answer: 1, 2 Explanation: 1. When a child is sedated, respiratory status should be monitored with a pulseoximetry machine. The child should be close to the nurse's station so that frequent monitoring can be done. Several visitors at the bedside would increase the child's anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

A child diagnosed with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized. Which nursing interventions are appropriate for this child? Select all that apply. 1. Place a continuous-pulse oximetry monitor on the child. 2. Place the child in a room near the nurse's station. 3. Allow for several visitors to remain at the child's bedside. 4. Use soft restraints if the child becomes confused. 5. Use sedation around the clock to decrease agitation.

ANS: D An EEG is obtained for all children with seizures and is the most useful tool for evaluating a seizure disorder. The EEG confirms the presence of abnormal electrical discharges and provides information on the seizure type and the focus. The EEG is carried out under varying conditionswith the child asleep, awake, awake with provocative stimulation (flashing lights, noise), and hyperventilating. Stimulation may elicit abnormal electrical activity, which is recorded on the EEG. Various seizure types produce characteristic EEG patterns: high-voltage spike discharges are seen in tonic-clonic seizures, with abnormal patterns in the intervals between seizures; a three-per-second spike and wave pattern is observed in an absence seizure; and absence of electrical activity in an area suggests a large lesion, such as an abscess or subdural collection of fluid

A child has a seizure disorder. What test should be done to gather the most specific information about the type of seizure the child is having? a. Sleep study b. Skull radiography c. Serum electrolytes d. Electroencephalogram (EEG)

ANS: C A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure free for 2 years. Medications must be gradually reduced to minimize the recurrence of seizures. The risk of recurrence is greatest within 6 months after discontinuation.

A child has been seizure free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. How should the nurse respond? a. Medications can be discontinued at this time. b. The child will need to take the drugs for 5 years after the last seizure. c. A step-wise approach will be used to reduce the dosage gradually. d. Seizure disorders are a lifelong problem. Medications cannot be discontinued.

ANS: D An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the childs growth. Meningitis would require an emergent replacement or revision of the shunt. Gastrointestinal upset alone would not indicate the need for shunt revision. Noncommunicating hydrocephalus will not resolve without surgical intervention.

A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What is a common reason for elective revision of this shunt? a. Meningitis b. Gastrointestinal upset c. Hydrocephalus resolution d. Growth of the child since the initial shunting

ANS: B Chronic treatment with phenytoin may cause gum hypertrophy. Children taking phenobarbital or phenytoin should receive adequate vitamin D and folic acid because deficiencies of both have been associated with these drugs. The medication should not be taken with milk, and fluids should be encouraged, not restricted.

A child is on phenytoin (Dilantin). What should the nurse encourage? a. Fluid restriction b. Good dental hygiene c. A decrease in vitamin D intake d. Taking the medication with milk

2. To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 3 to 4 hours.

A child is ready for discharge after surgery for a myelomeningocele repair. Before discharge, the nurse works with the parents to establish a catheterization schedule to prevent urinary tract infection. With what frequency should the nurse instruct the parents to catheterize the child? 1. Every 1 to 2 hours 2. Every 3 to 4 hours 3. Every 6 to 8 hours 4. Every 10 to 12 hours

ANS: D Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved.

A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests: a. diabetic coma. b. brainstem injury. c. upper respiratory tract infection. d. leaking of cerebrospinal fluid (CSF).

Answer: 1, 2, 3 Explanation: 1. The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

A child sustains a traumatic brain injury and is monitored in the pediatric intensive-care unit (PICU). The nurse is using the Glasgow Coma Scale to assess the child. Which items will the nurse assess when using this tool? Select all that apply. 1. Eye opening 2. Verbal response 3. Motor response 4. Head circumference 5. Pulse oximetry

Answer: 4 Explanation: 1. Taking vital signs is important, but airway always comes first. 2. Once the airway is secure, securing an IV is vital. 3. A rapid neurologic assessment is appropriate once the airway is secure. 4. Airway is always the priority of care.

A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurologic assessment. 4. Maintain patent airway.

3. A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

A child with myelomeningocele, corrected at birth, is now 5 years old. Which is the priority nursing diagnosis for a child with corrected spina bifida at this age? 1. Risk for Altered Nutrition 2. Risk for Impaired Tissue Perfusion-Cranial 3. Risk for Altered Urinary Elimination 4. Risk for Altered Comfort

ANS: B Chemotherapy is the mainstay of therapy for extensive local or disseminated neuroblastoma. The drugs of choice are vincristine, doxorubicin, cyclophosphamide, cisplatin, etoposide, ifosfamide, and carboplatin. These cause immunosuppression, so the laboratory values will indicate a low white blood cell count and hemoglobin.

A child, age 10 years, has a neuroblastoma and is in the hospital for additional chemotherapy treatments. What laboratory values are most likely this childs? a. White blood cell count, 17,000/mm 3 ; hemoglobin, 15 g/dl b. White blood cell count, 3,000/mm 3 ; hemoglobin, 11.5 g/dl c. Platelets, 450,000/mm 3 ; hemoglobin, 12 g/dl d. White blood cell count, 10,000/mm 3 ; platelets, 175,000/mm 3

ANS: A A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured and samples are obtained for culture, Gram stain, blood cell count, and determination of glucose and protein content. The findings are usually diagnostic. The patient generally has an elevated white blood cell count, often predominantly polymorphonuclear leukocytes. The glucose level is reduced, generally in proportion to the duration and severity of the infection.

A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse expects which results for the cerebrospinal fluid that can confirm the diagnosis of meningitis? a. WBCs; glucose b. RBCs; normal WBCs c. glucose; normal RBCs d. Normal RBCs; normal glucose

Answer: 1 Explanation: 1. The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated WBC count is seen with bacterial meningitis. The RBC count is not elevated, and the glucose is decreased in meningitis.

A lumbar puncture is performed on an infant suspected of having meningitis. Which finding does the nurse expect in the cerebral spinal fluid if the infant has meningitis? 1. Elevated WBC count 2. Elevated RBC count 3. Normal glucose 4. Decreased WBC count

Answer: 4 Explanation: 1. A diaper is not used because it also puts pressure on the sac. 2. A side-lying position would be contraindicated because it would place pressure on the sac. 3. The mother should not hold the baby because that would put too much pressure on the sac. 4. The newborn should be placed in a prone position to keep pressure off the sac.

A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 1. Applying a diaper to prevent contamination of sac 2. Positioning the newborn in a side-lying position 3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery 4. Positioning the newborn in a prone position

ANS: C The greatest risk to a child following an MVA is CERVICAL INJURY. Therefore, keeping the next stabilized until cervical injury can be ruled out is the priority action.

A nurse in the emergency department is assessing a child following an MVA. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take FIRST? a. stabilize the child's neck b. clean the child's laceration with soap and water c. implement seizure precautions for the child d. initiate IV access for the child

ANS: D Identify a high-pitched cry as a finding associated with meningitis between ages 3mo - 2 yr A. Expect a BULGING anterior fontanel B. VOMITING is an expected finding C. Rooting reflex is an expected finding up to 12mo

A nurse is assessing a 4 month old infant who has meningitis. Which of the following manifestations should the nurse expect? A. Depressed anterior fontanel B. Constipation C. Presence of rooting reflex D. High-pitched cry

ANS: A E Amnesia and confusion are manifestations of a concussion B,C: Systemic hypertension and bradycardia are manifestations of Cushing's triad. D: Respiratory depression is a late manifestation of epidural hematoma and requires emergency intervention.

A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? SATA a. amnesia b. systemic hypertension c. bradycardia d. respiratory depression e. confusion

Answer: b. The indentation from the Frisbee Feedback: Injuries to the scalp, which can be caused by falls, blunt trauma, or penetration of a foreign body, are usually benign. Bleeding may be extensive, but hypovolemia or shock is uncommon unless the client is an infant. Bony fragments, depressions, CSF leakage, or debris is a cause for concern.

A nurse is assessing the wound of an 8-year-old female who suffered a scalp laceration while playing Frisbee. Which observation by the nurse is the most concerning? a. The extensive bleeding b. The indentation from the Frisbee c. The length of the laceration d. The hypovolemia from the bleeding

Answer: a. The client can experience personality changes within the next 6 months. Feedback: Young athletes should avoid sports for anywhere from 7 days to the entire season after a concussion to avoid getting a second concussion. Several symptoms can occur as a postconcussive syndrome for up to 6 months after a concussion, such as headache, personality changes, poor memory, and vertigo. Multiple concussions can have a significantly longer recovery time. Concussions happen most of the time without any evidence of a skull fracture.

A nurse is caring for a 15-year-old male who is recovering from a concussion after hitting his head during a fall while playing basketball. Which educational statement would be important for the nurse to present to this family? a. The client can experience personality changes within the next 6 months. b. Concussions usually are associated with skull fractures. c. If the client has another concussion in the near future, recovery time should remain the same. d. The client should not play sports for 1 year after the concussion.

ANS: B D E Stimulation, increased pressure in the abdomen, and flexion/extension of the neck can INCREASE ICP, so a quiet environment, stool softener, and a maintained body alignment will help maintain ICP. A: Trach suctioning is contraindicated b/c there is a risk of the catheter entering the brain through a skull fracture C: Pillows under the head cause flexion which INCREASES ICP

A nurse is caring for a child who has ICP. Which of the following actions should the nurse take? SATA a. suction the endotracheal tube every 2hr b. maintain a quiet environment c. use two pillows to elevate the head d. administer a stool softener e. maintain body alignment

ANS: A B C LOC for 5-10 sec, daydreaming, and dropping a held object are manifestations of an absence seizure. D, E: falling to the floor and a piercing cry are manifestations of a TONIC CLONIC seizure.

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? SATA a. LOC b. Appearance of daydreaming c. Dropping held objects d. falling to the floor e. having a piercing cry

4. Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

A nurse is caring for a child who is diagnosed with cerebral palsy. Which goal of therapy is most appropriate for the nurse to include in the plan of care? 1. Reversing the degenerative processes that have occurred 2. Curing the underlying defect causing the disorder 3. Preventing the spread to individuals in close contact with the child 4. Promoting optimum development

ANS: A Following a seizure, children often experience vomiting. Using ABC priority-setting framework, the first action to take is placing the child side-lying to maintain a patent airway and prevent aspiration of secretions.

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? a. position the child in a side-lying position b. try to determine the seizure trigger c. reorient the child to the environment d. note the time of the postictal period

ANS: A Place the client on NPO status due to the client's decreased level of consciousness to prevent aspiration B. Expect a pt who has Reye syndrome to require a liver biopsy C. Position the pt w/o a pillow and slightly elevate the HOB to prevent increasing intracranial pressure D. Pts who are immunocompromised require a protective environment. Place a pt who has suspected meningitis on droplet precautions at least 24hr after the initiation of antibiotic therapy

A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A. Place the client on NPO status. B. Prepare the client for a liver biopsy C. Position the client dorsal recumbent. D. Put the client in a protective environment.

ANS: A B D Headache, alterations in pupillary response, and increased sleeping are indications of ICP. C, E: DECREASED motor/sensory response are indications of ICP

A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? SATA a. report of headache b. alteration in pupillary response c. increased motor response d. increased sleeping e. increased sensory response

Answer: d. Assess the surgical site for cerebrospinal fluid leakage and symptoms of infection. Feedback: Covering the defect with sterile, saline-soaked gauze is a preoperative intervention. After surgery, the site should be checked for cerebrospinal fluid leakage and infection. Head circumference should be measured daily for signs of increased developing hydrocephalus. The child should never be placed supine, due to the location of the lesion.

A nurse is caring for an infant with myelomeningocele following surgical postoperative repair. What would be an important nursing intervention for this client? a. Place the infant in a supine position with the head elevated. b. Cover the surgical site with sterile, saline-soaked gauze. c. Measure the head circumference every other day. d. Assess the surgical site for cerebrospinal fluid leakage and symptoms of infection.

4. A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt? 1. Incisional pain 2. Movement of all extremities 3. Negative Brudzinski sign 4. Bulging fontanel

ANS: B, D The introduction of the PCV decreased the incidence of bacterial meningitis in children as it provides immunity against bacteria that causes the illness. The introduction of the Hib vaccine decreases incidence/provides immunity against bacteria that cause the illness. A, C, E IPV, DTaP, and TIV do not decrease the incidence of bacterial meningitis in children.

A nurse is developing an educational program about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? SATA A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)

Answer: b. "We should let our doctor know if the child complains of double vision." Feedback: The parents should be taught that there is a risk of the child developing seizures, even if the shunt is functioning properly. All children with this condition should be referred to early-intervention programs for tracking developmental milestones and appropriate therapy. Diplopia (double vision) should be reported to the physician immediately because this could be a sign of a shunt problem. A shunt malfunction can occur at any time.

A nurse is providing discharge teaching to the family of a child that just had a ventriculoperitoneal shunt placed. Which statements would indicate that the parents understand the teaching? a. "There is no chance that my child will have a seizure as long as the shunt is functioning correctly." b. "We should let our doctor know if the child complains of double vision." c. "Our child does not need to be followed by any early-intervention programs unless a problem develops." d. "We will observe for symptoms of shunt malfunction until our child has had the shunt for 6 months."

ANS: A The child should remain still and quiet, as excessive movements can cause false-positives. B. The child's hair SHOULD be washed to remove oils, permitting adherence of the EEG electrodes.

A nurse is providing teaching to the guardians of a child who is to have an EEG. Which of the following statements by a guardian indicated teaching was effective? a. "My child should remain quiet and still during this procedure" b. "I cannot wash my child's hair prior to the procedure." c. "I should not give my child anything to eat prior to the surgery." d. " This procedure will be very painful for my child."

ANS: A, B, E A. Expect a pt who has viral meningitis to have a negative Gram stain B. Expect a glucose level within the expected reference range E. Expect a protein level within the expected range C. Expect a CLEAR color D. Expect a slightly ELEVATED WBC count

A nurse is reviewing cerebrospinal fluid analysis for a pt who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? SATA A. Negative Gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC count E. Normal protein content

ANS: C Id the gastroenteritis as a viral illness, which is a risk factor for developing Reye syndrome A. Candida is a fungus, not a RF B. Bacterial infection not a RF D. Bacteria is not a RF

A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye Syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis

ANS: A B C D Vagal nerve stimulators, additional antiepileptic medications, corpus callosotomy, and focal resection can all provide seizure control. E. Radiation therapy is used for cancer treatment.

A nurse is reviewing treatment options with the guardian of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? SATA a. vagal nerve stimulator b. additional antiepileptic medications c. corpus callosotomy d. focal resection e. radiation therapy

answer 2 1. If the child suffered a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. 2. These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. 3. Normal sleeping pulse at this age is 60 to 90 bpm. 4. Without previous vital signs, there is no way to determine if the current changes in the vital signs indicate improvement.

A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. Which does the nurse suspect based on these data? 1. Spinal cord injury 2. Increased intracranial pressure. 3. Typical for sleep 4. Improvement

ANS: C Hydrocephalus can be diagnosed by fetal ultrasonography as early as 14 weeks of gestation. Most incidents of hydrocephalus are not chromosomal in origin. The lecithin-to-sphingomyelin ratio can be used to determine fetal lung maturity.

A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurses response should be based on which knowledge? a. It can be diagnosed only after birth b. It can be diagnosed by chromosome studies. c. It can be diagnosed with fetal ultrasonography. d. It can be diagnosed by measuring the lecithin-to-sphingomyelin ratio.

2. In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.

A school-age client experiences a near-drowning episode and is admitted to the pediatric intensive-care unit (PICU). The parents express guilt over the near drowning of their child. Which response by the nurse is most appropriate? 1. "You will need to watch the child more closely." 2. "Tell me more about your feelings related to the accident." 3. "The child will be fine, so don't worry." 4. "Why did you let the child almost drown?"

4. Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

A school-age client is transported to the emergency department by ambulance from the scene of a car accident. The client is alert and oriented × 3; pulse, respirations, and blood pressure are stable; and the neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The client states, "I can't feel or move my legs." Which injury does the nurse suspect? 1. Traumatic brain injury 2. Ruptured spleen 3. Traumatic shock 4. Spinal cord injury

Answer: 1 Explanation: 1. Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.

A school-age client sustains a basilar skull fracture. Which symptom is a priority for this nurse to assess for when providing care to this client? 1. Cerebral spinal fluid leakage from the nose or ears 2. Headache 3. Transient confusion 4. Periorbital ecchymosis

ANS: B Antimicrobial therapy is begun as soon as a presumptive diagnosis is made. The choice of drug is based on the most likely infective agent. Drug choice may be adjusted when the culture results are obtained. Waiting for culture results to begin therapy increases the risk of neurologic damage. Although fluid and electrolyte balance is important, there is no indication that this child is unstable. Antibiotic therapy would be a priority intervention.

A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will begin when? a. After the diagnosis is confirmed b. When the medication is received from the pharmacy c. After the childs fluid and electrolyte balance is stabilized d. As soon as the practitioner is notified of the culture results

2. During a seizure, the nurse remains with the child, watching for complications. The child's respiratory rate should be monitored. Be sure nothing is placed in the child's mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

A toddler-age client has a tonic-clonic seizure while in a crib in the hospital. The client's jaw is clamped. Which nursing action is the priority? 1. Place a padded tongue blade between the child's jaws. 2. Stay with the child and observe the respiratory status. 3. Prepare the suction equipment. 4. Restrain the child to prevent injury.

ANS: D Sumatriptan is a serotonin agonist at specific vascular serotonin receptor sites and causes vasoconstriction in large intracranial arteries. Opioids are used infrequently because they rarely work on the mechanism of pain. Lorazepam is a benzodiazepine that acts as an anxiolytic and sedative. It is not indicated for treatment of migraine episodes. Ergotamine, an a-adrenergic blocker, is used for adult vascular headaches, but it is not used in adolescents because of the side effects.

A young adolescent experiences infrequent migraine episodes. What pharmacologic intervention is most likely to be prescribed? a. Opioid b. Lorazepam c. Ergotamine d. Sumatriptan

Answer: 4 Explanation: 1. Bacterial meningitis causes CSF protein levels to be elevated due to swelling and obstruction of CSF flow. 2. In bacterial meningitis, the fluid is often cloudy with white blood cells (WBCs). 3. The nurse would expect WBCs to be elevated due to the infection. The RBCs may indicate a bloody tap. 4. Glucose levels are low in CSF when a child has bacterial meningitis.

A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data? 1. Decreased protein count 2. Clear, straw-colored fluid 3. Positive for red blood cells (RBCs) 4. Decreased glucose level

ANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.

An appropriate nursing intervention when caring for an unconscious child should be to: a. change the child's position infrequently to minimize the chance of increased ICP .b. avoid using narcotics or sedatives to provide comfort and pain relief. c. monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. give tepid sponge baths to reduce fever because antipyretics are contraindicated.

ANS: A When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in the child's mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on the side, facilitating drainage.

An important nursing intervention when caring for a child who is experiencing a seizure would be to: a. describe and record the seizure activity observed. b. restrain the child when seizure occurs to prevent bodily harm. c. place a tongue blade between the teeth if they become clenched. d. suction the child during a seizure to prevent aspiration.

ANS: B After brain surgery, cerebral edema is a risk. Careful monitoring is essential. All fluids, including intravenous antibiotics, are included in the intake. Turning and positioning depend on the surgical procedure. When large tumors are removed, the child is usually not positioned on the operative side. The dressing is not changed. It is reinforced with gauze after the amount of drainage is marked and estimated. A quiet, dimly lit environment is optimum to decrease stimulation and relieve discomfort such as headaches.

Essential postoperative nursing management of a child after removal of a brain tumor includes which nursing care? a. Turning and positioning every 2 hours b. Measuring all fluid intake and output c. Changing the dressing when it becomes soiled d. Using maximum lighting to ensure accurate observations

ANS: A The nurse should watch for bleeding from the site. Because of related liver dysfunction with Reye syndrome, laboratory studies, such as prolonged bleeding time, should be monitored to determine impaired coagulation.

If an intramuscular (IM) injection is administered to a child who has Reye syndrome, the nurse should monitor for what? a. Bleeding b. Infection c. Poor absorption d. Itching at the injection site

Answer: c. Febrile Feedback: Febrile seizures usually are associated with fevers. A generalized or partial seizure also has the jerking movements but is not necessarily associated with a fever. Status epilepticus is when the seizure lasts longer than 30 minutes.

Parents bring a 3-year-old to the emergency department stating that the child has just had her first seizure. The seizure lasted less than 5 minutes and involved jerking movements over the entire body. Prior to the seizure, the child had been sick and started running a fever. Based on the description, the nurse suspects that the child experienced which type of seizure? a. Partial b. Status epilepticus c. Febrile d. Generalized

ANS: D The child with an infratentorial procedure is usually positioned flat and on either side. Pillows should be placed against the childs back, not head, to maintain the desired position. The Trendelenburg position is contraindicated in both infratentorial and supratentorial surgeries because it increases intracranial pressure and the risk of hemorrhage.

Postoperative positioning for a child who has had a medulloblastoma brain tumor (infratentorial) removed should be which? a. Trendelenburg b. Head of bed elevated above heart level c. Flat on operative side with pillows behind the head d. Flat, on either side with pillows behind the back