Wong, Chapter 27: Altered LOC in peds/Neuro Assessment, submersion injury, meningitis.

3. The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3- year-old child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.) a. Elevated white blood cell (WBC) count b. Decreased glucose c. Normal protein d. Elevated red blood cell (RBC) count

...ANS: A, B The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased glucose, and increased protein content. There should not be RBCs evident in the CSF fluid. DIF: Cognitive Level: Analyze REF: p. 890 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

What is the purpose of a lumbar puncture (LP)? 1To analyze cerebrospinal fluid 2To rule out subdural effusions 3To detect electrical activity 4To relieve intracranial pressure

1 An LP is done to obtain cerebrospinal fluid (CSF) for laboratory analysis. A subdural tap is performed to rule out subdural effusions. It is also done to remove CSF to relieve pressure. Electrical activity or spikes are detected by an electroencephalogram (EEG). This test indicates the potential for seizures. LP is contraindicated in patients with increased intracranial pressure. A subdural tap or ventricular puncture may be done to remove CSF to relieve pressure.

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is the priority of nursing care? 1Administering antibiotic therapy as soon as it is ordered 2Initiating isolation precautions as soon as the diagnosis is confirmed 3Initiating isolation precautions as soon as the causative agent is identified 4Administering sedatives and analgesics on a preventive schedule to manage pain

1 Initiation of antibiotic therapy is the priority action. Antibiotics are begun as soon as possible to prevent death and avoid disabilities. Isolation should be instituted as soon as a diagnosis is anticipated, not as soon as the diagnosis is confirmed or the causative agent is identified, and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, isolation precautions may be discontinued. Pain should be managed on an as-needed basis.

You are working with a pediatric nurse who has just transferred to the pediatric clinic. You are role-playing phone triage related to a child with a head injury. You ascertain that the nurse needs more teaching based on what response? A. "After initial physical exam, if there was no loss of consciousness with the head injury, the child can be observed at home." B. "If there is a language barrier, written instructions can be given, followed by discharge." C. "Another physical exam should take place in 1 or 2 days." D. "Parens should call the doctor their child hasty of these signs: blurred vision, walking unsteady, or is hard to awaken."

ANS: B

As the nurse assigned to a child diagnosed with bacterial meningitis, you know that: A. The child will not need to be placed in isolation because antibiotics have been started B. Enteric precautions will remain in place for up to 48 hours C. Respiratory isolation will remain in place for 24 hours after antibiotics are started D. Due to headache, the child will want the head of the bed elevated with two pillows

ANS: C

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

ANS: C Initiation of antibiotic therapy is the priority action. Antibiotics are begun as soon as possible to prevent death and to avoid resultant disabilities. Isolation should be instituted as soon as a diagnosis is anticipated and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, then isolation precautions can be discontinued. Isolation should be instituted as soon as a diagnosis is anticipated and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, then isolation precautions can be discontinued. Initiation of antibiotics is the priority nursing intervention. Pain should be managed on an as-needed basis.

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

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.

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

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.

A nurse caring for a child with brain dysfunction notes that the child is exhibiting rigid flexion with the arms held tightly to the body and the legs extended and internally rotated. What posturing is this child demonstrating? 1Normal 2Rotating 3Decorticate 4Decerebrate

3 Decorticate posturing includes rigid flexion with the arms held tightly to the body; flexed elbows, wrists, and fingers; plantarflexed feet; legs extended and internally rotated; and sometimes a fine tremor. These findings are not normal; they indicate decorticate posturing. Rotating posturing is not a medical term. Decerebrate posturing is characterized by rigid extension and pronation of the arms and legs, flexed wrists and fingers, a clenched jaw, an extended neck, and possibly an arched back.

Which finding does the nurse note that is seen with severe dysfunction of the cerebral cortex or lesions to cortiocospinal tracts above the brainstem? 1Primitive posturing 2Extension posturing 3Decorticate posturing 4Unilateral decerebrate posturing

3 Flexion or decorticate posturing is seen with severe dysfunction of the cerebral cortex or with lesions to cortiocospinal tracts above the brainstem. Primitive posturing is the term used to describe how brain dysfunction results in the loss of primitive postural reflexes. Extension posturing is a sign of dysfunction at the level of the midbrain or lesions to the brainstem. Unilateral decerebrate posturing is caused by tentorial herniation.

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

ANS: A Children with meningitis are sensitive to noise, bright lights, and other external stimuli because of the irritation on the meningeal nerves. The nurse should keep the room as quiet as possible with a minimum of external stimuli, including lighting. After consultation with the practitioner, pain medications can be used on an as-needed basis. A school-age child will have closed sutures; therefore, the head circumference cannot change. The head circumference is not relevant to a child of this age. The child is placed in a side-lying position, with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that increase discomfort and put tension on the neck.

In assessing neurological integrity of the eyes, if the medical record stated that the Doll's reflex was present. The nurse would interpret this as A. a neurological deficit is present. B. the patient's eye movement is paired going in the direction to which the head is moved. C. no oscillations of eye movements are noted. D. cranial nerve III is intact.

ANS: A With regard to a Doll's reflex, a normal response is seen with paired eye movement is in the opposite direction to which the head is moved. Normal functioning of this reflex would indicate that cranial nerve III and brain stem are intact. Oscillation of eye movements indicate nystagmus.

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

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

An 18-month-old child is brought to the emergency department after being found unconscious in the family pool. What does the nurse identify as the primary problem in drowning incidents? a. Hypoxia b. Aspiration c. Hypothermia d. Electrolyte imbalance

ANS: A Hypoxia is the primary problem because it results in global cell damage, with different cells tolerating variable lengths of anoxia. Neurons sustain irreversible damage after 4 to 6 minutes of submersion. Severe neurologic damage occurs from hypoxia in 3 to 6 minutes. Aspiration of fluid does occur, resulting in pulmonary edema, atelectasis, airway spasm, and pneumonitis, which complicate the anoxia. Hypothermia occurs rapidly, except in hot tubs. Electrolyte imbalances do result, but they are not a major cause of morbidity and mortality.

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

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

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

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 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 child's 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.

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, nonstimulating 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 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 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

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

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 pediatric patient has fallen into a pool and paramedics have revived the child at the scene and brought him to the Emergency Room for follow up treatment. With regard to submersion injury, what critical assessments should be included in the plan of care? Select all that apply. A. Maintain airway and ventilator support B. Obtain arterial blood gases (ABGs) C. Find out what the temperature of the pool water D. Place the patient in reverse isolation E. Medicate patient for anxiety

ANS: A, B, C Priority interventions is to maintain airway and ventilator support as hypoxia is the primary concern with submersion injuries. Obtaining ABG will help to establish acid-base balance which will provide clinical response to treatment. It is important to find out what the temperature of the water was as this will affect the body's physiological responses. There is no need to place the patient in reverse isolation which would be indicated if the patient was immunosuppressed. Medicating the patient for anxiety is not a priority at this time as the focus is on preliminary survey and maintaining oxygenation and respiratory support.

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, 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 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: 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 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: 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 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: A, C, D 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: 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 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, 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.

A Glasgow Coma Scale (GCS) is being used to assess neurological status in a child who was in a car accident and sustained head trauma. Total score documented in the electronic health record is 12. Based on this finding, the nurse suspects that the child is A. unresponsive. B. aware of surroundings. C. unable to respond verbally. D. has substantial neurological deficits.

ANS: B The GCS is based on parameter measurements of eye opening, verbal response and motor response. Measurement metric goes from 0 to 15 with a higher score indicating neurological function is intact. Based on a total of 12, it is likely that the patient is aware of his/her surroundings. A score of 8 or below is suggestive of coma.

The Glasgow Coma Scale consists of an assessment of: a. pupil reactivity and motor response. b. eye opening and verbal and motor responses. c. level of consciousness and verbal response. d. ICP and level of consciousness.

ANS: B The Glasgow Coma Scale assesses eye opening and verbal and motor responses.

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 child's fluid and electrolyte balance is stabilized d. As soon as the practitioner is notified of the culture results

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

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

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 doll's head maneuver, assessment of pyramidal tract lesions, and funduscopic examination for papilledema are not considered painful and can be performed on awake children.

When assessing a child for bacterial meningitis, which diagnostic tests should be included? Select all that apply. A. Romberg test B. Kernig's sign C. Brudzinki sign D. Tactile fremitus E. Ortolani Maneuver

ANS: B, C Positive Kernig's and Brudzinki sign demonstrate evidence of bacterial meningitis. Romberg test indicates whether there is intact cerebellar function. Tactile fremitus determines whether there is any fluid or consolidation in the lungs that would affect vibratory response. Ortolani maneuver is done to asses for congenital hip fracture.

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.

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: 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.

5. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant? (Select all that apply.) a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations

ANS: B, D, E Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations. DIF: Cognitive Level: Analyze REF: p. 872 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

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

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.

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

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.

4. The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed? (Select all that apply.) a. Headache b. Photophobia c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone

ANS: C, D, E Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child. DIF: Cognitive Level: Understand REF: p. 890 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

You are the nurse assigned to care for a child with a basilar skull fracture. Your most important nursing observation is change in level of consciousness (LOC). You will be highly alert for: A. Alterations in vital signs that often appear before alterations in consciousness or focal neurologic signs B. Bleeding from the ear, which is indicative of an anterior basal skull fracture C. Seizures, which are relatively uncommon in children at the time of head injury D. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement

ANS: D

A child is admitted to the pediatric intensive care unit for a submersion injury. The child's parents express guilt over the submersion injury to the nurse. The most appropriate response by the nurse is A. "You will need to watch your child more closely in the future." B. "Why did you let your child almost drown?" C. "Your child will be fine, so don't worry." D. "Tell me more about your feelings."

ANS: D The nurse needs to be nonjudgmental and provide the parents an opportunity to express their feelings. You will need to watch your child more closely in the future is a judgmental statement. Why did you let your child almost drown? is a judgmental question. Saying the child will be fine may not be true.

The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration-deceleration head injuries because the A. anterior fontanel is not yet closed. B. nervous tissue is not well developed. C. scalp of head has extensive vascularity. D. musculoskeletal support of head is insufficient.

ANS: D The relatively large head size coupled with insufficient musculoskeletal support increases the risk to infants of acceleration-deceleration head injuries. The lack of closure of the anterior fontanel is not relevant to the development of acceleration-deceleration head injuries in infants. The lack of well-developed nervous tissue is not relevant to the development of acceleration-deceleration head injuries in infants. The vascularity of the scalp is not relevant to the development of acceleration-deceleration injuries in infants.

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 nurse's care plan include? a. Observing the child's 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

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 child's head, so the Brudzinski reflex should not be checked hourly. Checking the Babinski reflex or child's voluntary movements will not help with assessing the child's status

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.

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

a. Bulging fontanel and dilated scalp veins ANS: A Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation. DIF: Cognitive Level: Analyze REF: p. 906 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

9. 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.

a. Establish adequate airway. 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. DIF: Cognitive Level: Apply REF: p. 879 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

14. Which 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.

b. Bleeding occurs between the dura and the cerebrum. 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. DIF: Cognitive Level: Understand REF: p. 883 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

4. 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 these findings? a. Eye trauma b. Neurosurgical emergency c. Severe brainstem damage d. Indication of brain death

b. Neurosurgical emergency ANS: B 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. Pinpoint pupils or bilateral fixed 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. One fixed and dilated pupil is not suggestive of brain death. DIF: Cognitive Level: Analyze REF: p. 875 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

22. 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. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

c. "I should expect my child to have some behavioral changes after the accident." ANS: C The parents are advised of probable posttraumatic symptoms that may be expected. These include behavioral changes and sleep disturbances. If the child has these clinical signs, they should be immediately reported for evaluation. Sleep disturbances are to be expected. DIF: Cognitive Level: Apply REF: p. 883 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

23. A 3-year-old child is hospitalized after a submersion injury. The child's mother complains to the nurse, "Being at the hospital seems unnecessary when he is perfectly fine." What is the nurse's best reply? a. "He still needs a little extra oxygen." b. "I'm sure he is fine, but the doctor wants to make sure." c. "The reason for this is that complications could still occur." d. "It is important to observe for possible central nervous system problems."

c. "The reason for this is that complications could still occur." ANS: C All children who have a submersion injury should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur 24 hours after the incident. The mother would not think the child is fine if oxygen were still required. The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary. DIF: Cognitive Level: Apply REF: p. 888 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

29. A young child's parents call the nurse after their child was bitten by a raccoon in the woods. The nurse's recommendation should be based on which statement? a. The child should be hospitalized for close observation. b. No treatment is necessary if thorough wound cleaning is done. c. Antirabies prophylaxis must be initiated. d. Antirabies prophylaxis must be initiated if clinical manifestations appear.

c. Antirabies prophylaxis must be initiated. ANS: C Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible. Hospitalization is not necessary. The wound cleansing, passive immunization, and immune globulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine. DIF: Cognitive Level: Apply REF: p. 895 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

12. The nurse is planning care for an 8-year-old child with a concussion. Which 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. A slight lesion develops remotely from the site of trauma.

c. It is a transient and reversible neuronal dysfunction. 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 along 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 acceleration-deceleration injury. DIF: Cognitive Level: Understand REF: p. 883 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

16. A 10-year-old boy on a bicycle has been hit by a car in front of the school. The school nurse immediately assesses airway, breathing, and circulation. What is the next nursing action? a. Place on side b. Take blood pressure c. Stabilize neck and spine d. Check scalp and back for bleeding

c. Stabilize neck and spine ANS: C After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The child's position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding. DIF: Cognitive Level: Apply REF: p. 886 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 b. 11 c. 13 d. 15

d. 15 ANS: D The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient's level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15. DIF: Cognitive Level: Understand REF: p. 873 TOP: Integrated Process: Nursing Process: Assessment

26. What 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

d. Avoidance of aspirin to treat fever associated with influenza 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. DIF: Cognitive Level: Understand REF: p. 895 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

1. Which are clinical manifestations of increased intracranial pressure (ICP) in infants? (Select all that apply.) a. Low-pitched cry b. Sunken fontanel c. Diplopia and blurred vision d. Irritability e. Distended scalp veins f. Increased blood pressure

d. Irritability e. Distended scalp veins ANS: D, E Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Diplopia and blurred vision are indicative of elevated ICP in children. A high-pitched cry and a tense or bulging fontanel are characteristics of increased ICP. Increased blood pressure, common in adults, is rarely seen in children. DIF: Cognitive Level: Understand REF: p. 872 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

15. When should the nurse recommend medical attention for a child with a slight head injury? a. Experiences sleepiness b. Vomits c. Has a headache d. Is confused or has abnormal behavior

d. Is confused or has abnormal behavior 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. DIF: Cognitive Level: Apply REF: p. 883 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

20. 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

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. DIF: Cognitive Level: Analyze REF: p. 886 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

5. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema b. Delirium c. Doll's head maneuver d. Periodic and irregular breathing

d. Periodic and irregular breathing ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of optic nerve. It is commonly a sign of increased intracranial pressure Delirium is a state of mental confusion and excitement marked by disorientation for time and place. The doll's head maneuver is a test for brainstem or oculomotor nerve dysfunction. DIF: Cognitive Level: Understand REF: p. 880 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

24. The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on which statement? 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. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.

d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children. 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. DIF: Cognitive Level: Apply REF: p. 890 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential