Ch 27 Neuro/Cerebral Dysfunction

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

The nurse is performing a neurologic assessment of a child whose level of consciousness has been variable since she sustained a cervical neck injury 12 hours ago. What is the appropriate assessment for this child? 1 Reactivity of pupils 2 Doll's head maneuver 3 Oculovestibular response 4 Funduscopic examination to identify papilledema

1 Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. The doll's head maneuver should not be performed if there is a cervical spine injury. Assessment for an oculovestibular response is a painful test that should not be done in a child who is displaying a variable level of consciousness. Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse, drawing on knowledge of seizures, recognizes this as which disorder? 1 Status epilepticus 2 An absence seizure 3 A generalized seizure 4 A simple partial seizure

1 Status epilepticus is a generalized seizure that lasts more than 30 minutes. This is considered a medical emergency and requires immediate treatment. Absence seizures are generalized seizures that are characterized by brief loss of consciousness, blank staring, and fluttering of the eyelids. Generalized seizures are the most common form of seizures. They include tonic-clonic (grand mal) seizures and absence (petit mal) seizures. Tonic-clonic seizures involve tonic-clonic activity and loss of consciousness and affect both hemispheres of the brain. Simple partial seizures are characterized by varying sensations and motor behaviors.

The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest what? 1 Neurologic health 2 Decorticate posturing 3 Severe brain damage 4 Decerebrate posturing

1 The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4 months of age. Therefore the presence of these reflexes indicates neurologic health. The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe brain damage. Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes. Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes.

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

1 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 may be used on an as-needed basis. A school-age child will have closed sutures; therefore the head circumference cannot change and is not relevant. 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.

A patient who has sustained a head injury exhibits rhinorrhea. What immediate nursing intervention is appropriate for the patient? 1 Reassure the patient, because it is an insignificant finding. 2 Test the discharge for presence of glucose. 3 Sedate the patient and administer antihistamine. 4 Ask the patient to report immediately if the nose bleeds.

2 (I guessed 4) Patients with head injury may have leakage of cerebrospinal fluids. The watery nasal discharge is tested for presence of glucose to rule out cerebrospinal fluid (CSF) leakage. Reassurance is given only after excluding CSF leakage. Sedating by administering an antihistamine is not appropriate in managing rhinorrhea of head injury. The patient is asked to report nasal bleeding, but priority is given to check for CSF leakage.

What is a clinical manifestation of increased intracranial pressure in infants? 1 Photophobia 2 Vomiting and diarrhea 3 Shrill, high-pitched cry 4 Pulsating anterior fontanel

3 A shrill, high-pitched cry is a common clinical manifestation of increased intracranial pressure (ICP) in infants. The characteristic cry occurs as a result of the pressure being placed on the meningeal nerves, which causes pain. Photophobia is not indicative of increased ICP in infants. A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a bulging anterior fontanel. Vomiting is one of the signs of increased ICP in children, but when present with diarrhea it is more indicative of a gastrointestinal disturbance.

Six months ago a 5-year-old child started having seizures that result in a brief loss of consciousness and slight alteration in muscle tone. They sometimes go unrecognized because of the minimal change in the child's behavior. How is this seizure classified? 1 Atonic 2 Partial 3 Absence 4 Complex partial

3 Absence seizures, which usually appear between 4 and 12 years of age, are characterized by a brief loss of consciousness and slight alternation in muscle tone; they sometimes go unrecognized because of the minimal change in the child's behavior. Atonic seizures are characterized by an onset between 2 and 5 years of age and sudden momentary loss of muscle tone and postural control. Partial seizures are characterized by localized motor symptoms, usually eye movements. Complex partial seizures are characterized by altered behavior, amnesia, inability to respond to the environment, and drowsiness or sleep after the event.

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? 1 Normal 2 Rotating 3 Decorticate 4 Decerebrate

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? 1 Primitive posturing 2 Extension posturing 3 Decorticate posturing 4 Unilateral 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 assessing the level of consciousness of a patient who has received a high dose of morphine. How can the nurse reverse the effects of morphine in this patient? 1 Administer fentanyl 2 Administer midazolam 3 Administer naloxone 4 Administer vecuronium

3 Naloxone is a morphine antagonist and is useful in reversing the effects of morphine. Fentanyl is another opioid drug and is not suitable for reversing the effect of morphine. Midazolam is a sedative and does not reverse the morphine effect. Vecuronium is a paralyzing agent.

The nurse is preparing a care plan for a patient who has developed diabetes insipidus (DI) following a head trauma. What treatment is included in the care plan? 1 Fluid restriction 2 Diuretics 3 Vasopressin 4 Corticosteroids

3 Patients with diabetes insipidus lack vasopressin, resulting in increased urine output and decreased intravascular volume. Therefore the condition can be managed by administering vasopressin. The increased urine output results in dehydration, which can be aggravated by fluid restriction. Diuretics add to the patient's dehydration. Corticosteroids are not usually administered for managing diabetes insipidus.

The nurse is examining a child who had a head injury. What assessment finding does the nurse recognize as a comminuted fracture? 1 Presence of irregular fragments of broken bones 2 Presence of single fracture line and soft-tissue swelling 3 Presence of multiple associated linear fractures 4 Presence of bleeding around the eyes (raccoon eyes)

3 (I guessed 1) Comminuted fractures consist of multiple associated linear fractures as a result of intense impact from repeated blows against an object. In a depressed fracture, the bone is locally broken, usually into several irregular fragments that are pushed inward, causing pressure on the brain. The child's head appears misshapen. Linear fractures are a single fracture line that starts at the point of maximum impact but does not cross suture lines. Most linear skull fractures are associated with an overlying hematoma or soft-tissue swelling. Basilar fractures involve the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bones. Clinical features may include bleeding around the eyes.

A mother calls the clinic to tell the nurse that her young child hit her head when she tripped and fell down three stairs. What sign of head injury, requiring immediate medical attention, is of greatest concern to the nurse? 1 The child refuses to eat. 2 The child becomes sleepy. 3 The child becomes confused. 4 The child has a mild headache.

3 (I put 2) Altered mental status is a clinical manifestation that indicates that the damage from the head injury is progressing. Medical evaluation is necessary. Refusal to eat has many causes and is not a specific sign of head injury. Observation is required for changes in behavior or other signs that indicate progression. Sleepiness may occur after a minor head injury. Observation is required to ensure that the child is arousable. Headache is a common occurrence after a head injury and does not require medical evaluation unless it is accompanied by other signs of progression.

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 of which developmental issue? 1 Anterior fontanel is not yet closed 2 Nervous tissue is not well developed 3 Infant's scalp has extensive vascularity 4 Musculoskeletal support of the head is insufficient

4 A 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, lack of well-developed nervous tissue, and vascularity of the scalp are not relevant to the risk of acceleration-deceleration injuries in infants.

What should the nurse include in the plan of care for a patient when administering intravenous phenytoin? 1 Administering phenytoin with glucose solution 2 Administering phenytoin at a rate of 70 mg/min 3 Administering phenytoin at a rate of 150 mg/min 4 Administering phenytoin with normal saline solution

4 Normal saline solution does not react with phenytoin so it is appropriate to administer phenytoin intravenously with normal saline solution. Phenytoin precipitates when mixed with glucose, so it is not appropriate to administer phenytoin with glucose. The appropriate IV push rate for phenytoin is 50 mg/min. Therefore, administering phenytoin at 70 mg/min or 150 mg/min may cause severe complications for the patient.

What nursing intervention is used to prevent increased intracranial pressure in an unconscious child? 1 Frequent suctioning 2 Providing environmental stimulation 3 Turning the head from side to side every hour 4 Avoiding activities that result in pain or crying

4 Nursing interventions should be focused on assessment and interventions to minimize pain. These activities can cause the intracranial pressure (ICP) to increase. Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase ICP. Environmental stimulation should be minimized because it can increase ICP. The child's head should not be turned from side to side. If the jugular vein is compressed, the ICP may increase.

The nurse is caring for a young child who has sustained a head injury. During assessment the nurse notes that the child is arousable with stimulation. What level of consciousness does this finding suggest? 1 Stupor 2 Lethargy 3 Confusion 4 Obtundation

4 Obtundation is a level of consciousness described as arousable with stimulation. Stupor is marked by continued deep sleep, slow response to vigorous and repeated stimulation, and moaning responses to stimuli. Lethargy is marked by limited spontaneous movement, sluggish speech, drowsiness, and falling asleep quickly. Confusion is indicated by impaired decision-making.

The parent of a 4-year-old child who experienced a single seizure at home asks the nurse what caused the seizure. What is the best response by the nurse? 1 Seizures are caused by fever. 2 The child probably has epilepsy. 3 Seizures are caused by meningitis. 4 Seizures are a symptom of an underlying disorder.

4 Seizures are a symptom of an underlying disorder. Seizures may be caused by infection; neurologic, metabolic, or traumatic causes; or the ingestion of toxins. Epilepsy is a condition characterized by two or more unprovoked seizures.

What is the most common type of head injury in children? 1 Deceleration injuries 2 Deformation injuries 3 Acceleration injuries 4 Acceleration-deceleration injuries

4 The most common type of head injury in infants is the acceleration-deceleration injury, not deceleration injury, deformation injury, or acceleration injury.

What is the priority nursing action when a nurse caring for a young child with a head injury notes that the pupils have suddenly become fixed and dilated? 1 Reorientation of the patient 2 Glasgow Coma Scale assessment 3 Institution of seizure precautions 4 Preparations for dealing with a neurologic emergency

4 (I guessed 3) A neurologic emergency may be occurring in a child who exhibits suddenly fixed and dilated pupils. During a neurologic emergency the child may not be able to be reoriented; the priority is preparing for the possible consequences of a neurologic emergency. When the pupils suddenly become fixed and dilated the priority nursing action is not a Glasgow Coma Scale assessment or institution of seizure precautions but instead preparations for dealing with a neurologic emergency.

The nurse is caring for a comatose child with multiple injuries. The nurse should recognize which fact about pain? 1 Cannot occur if the child is comatose 2 May occur if the child regains consciousness 3 Requires astute nursing assessment and management 4 Is best assessed by family members who are familiar with the child

3 Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain. Pain can occur in the comatose child. The child can be in pain while comatose. The family can provide insight into the child's different responses, but the nurse should be monitoring physiologic and behavioral manifestations.

The temperature of an unconscious adolescent is 105º F (40.5º C). What is the priority nursing intervention? 1 Administer aspirin stat 2 Initiate a pain assessment 3 Apply a hypothermia blanket 4 Continue to monitor temperature

3 Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely important to institute temperature-lowering interventions such as hypothermia blankets and tepid water baths immediately. The temperature needs to be monitored, but lowering the temperature is the priority. Pain assessments should be performed, but this is not the priority at this time. Lowering the body temperature is the priority. Aspirin should never be administered to a child, because of the risk of Reye syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not effective against temperatures as high as 105º F (40. 5ºC).

What is the purpose of a lumbar puncture (LP)? 1 To analyze cerebrospinal fluid 2 To rule out subdural effusions 3 To detect electrical activity 4 To 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 assesses a child for the doll's-head maneuver. What does the absence of the doll's-head maneuver indicate? 1 Dysfunction of the brainstem 2 Dysfunction of the parietal lobe 3 Dysfunction of the frontal cortex 4 Dysfunction of the temporal lobe

1 Absence of the doll's head maneuver suggests dysfunction of the brainstem or oculomotor nerve (cranial nerve III). Its absence does not suggest dysfunction of the parietal lobe, frontal cortex, or temporal lobe.

The nurse is caring for a 2-year-old child who is unconscious but in stable condition after a car accident. The child's parents are staying at the bedside most of the time. What is an appropriate nursing intervention? 1 Encouraging the parents to hold, talk to, and sing to the child as they usually would 2 Using ointment on the lips but not attempting to cleanse the teeth until swallowing returns 3 Suggesting that the parents go home until the child is alert enough to know that they are present 4 Positioning the child with proper body alignment and the head of the bed lowered to 15 degrees

1 The parents should be encouraged to interact with the child. The senses of hearing and tactile perception may be intact, and stimulation is important in the child's recovery. Suggesting that the parents go home until the child is awake is not recommended. The child may be able to hear that they are present, and this stimulation may assist in recovery. Oral care is essential in the unconscious child. Mouth care should be performed at least twice daily to prevent oral infections. The head of the bed should be elevated, not lowered, in a child with neurologic involvement.

What is the most appropriate nursing intervention in the care of a child experiencing a seizure? 1 Describing and documenting the seizure activity observed 2 Suctioning the child during the seizure to prevent aspiration 3 Restraining the child when a seizure occurs to prevent bodily harm 4 Placing a padded tongue blade between the teeth if they become clenched

1 The priority nursing intervention is to observe the child and document the seizure activity. To prevent aspiration, the child should be placed on the side if possible to facilitate drainage. The child should not be restrained, because this could cause an injury. Nothing should be placed in the child's mouth, because this could cause injury not only to the child but to the nurse as well.

The nurse is caring for a toddler who has undergone surgery for a brain tumor. During an assessment the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. What is the most appropriate nursing action? 1 Notifying the practitioner immediately 2 Assessing the child for level of consciousness 3 Administering pain medication and assessing the response 4 Observing the child closely for signs of increased intracranial pressure

1 The worsening of symptoms may indicate that the intracranial pressure (ICP) is increasing. The practitioner should be notified immediately because this is considered a medical emergency. Determination of the level of consciousness should be done as part of the assessment. The nurse is noting signs of increased ICP; therefore this assessment has already been completed. Pain medication should not be given because it can often mask the signs of increasing ICP.

What is a sign of increased intracranial pressure in infants? 1 Irritability 2 Photophobia 3 Vomiting and diarrhea 4 Pulsating anterior fontanel

1 (I guessed 4) Irritability is one of the changes that may indicate increased intracranial pressure. Photophobia is not indicative of increased intracranial pressure. Vomiting and diarrhea suggest a gastrointestinal problem rather than increased intracranial pressure. A pulsating anterior fontanel is a normal variation observed in infants and is not a common sign of increased intracranial pressure.

What is a priority nursing consideration for the parents of a child with simple febrile seizures? 1 To notify the child's pediatrician as soon as possible 2 To seek medication attention if the seizure lasts more than 5 minutes 3 To seek medication attention if the seizure lasts more than 10 minutes 4 To place the child who is actively having a seizure in the car and driving to the nearest emergency department

2 A priority nursing consideration for the parents of a child with simple febrile seizures is to seek medical attention if the seizure lasts more than 5 minutes, not 10 minutes. The priority is to seek medical attention if the seizure lasts more than 5 minutes, not to place the child in an active seizure in the car and driving to the nearest emergency department. The pediatrician should be notified after emergency treatment is sought by contacting 911.

The nurse is providing postoperative care for a child with hydrocephalus. Which assessment does the nurse recognize as a sign of infection of the cerebrospinal fluid? 1 Increased intracranial pressure 2 Elevated temperature 3 Dilation of the pupils 4 Improved feeding

2 Infection is the greatest hazard in the postoperative period. Manifestations of infection include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. An obstruction of the shunt can lead to increased intracranial pressure (ICP). This causes pupillary dilation on the side of the pressure. In case of increased ICP, the surgeon may prescribe elevation of the head of the bed and allowing the child to sit up. This enhances gravity flow through the shunt and helps to reduce ICP. The child has improved feeding in the absence of infection.

What is the most serious complication of placement of a ventriculoperitoneal shunt used to correct hydrocephalus? 1 Leakage 2 Infection 3 Malfunction 4 Brain damage

2 Infection is the most serious complication of placement of a ventriculoperitoneal (VP) shunt to correct hydrocephalus. Leakage and malfunction are common complications after VP shunt insertion but not the most common. Brain damage is not a common complication of VP shunt insertion.

What would the nurse expect to find when assessing a child with cerebral dysfunction related to barbiturate poisoning? 1 Dilated pupils 2 Pinpoint pupils 3 Unilateral fixed pupil 4 Widely dilated pupils

2 Pinpoint pupils are commonly observed in patients with a medical history of poisoning from opiates or barbiturates. This also occurs in brainstem dysfunction. Dilated pupils are observed in an infant with a medical history of poisoning with atropine-like substances. A unilateral fixed pupil usually indicates the presence of a brain lesion on the same side. Widely dilated pupils indicate paralysis of cranial nerve III secondary to pressure from herniation of the brain through the tentorium.

The nurse is assessing the cerebrospinal fluid (CSF) analysis for a child. Which laboratory finding helps the nurse to distinguish bacterial meningitis from viral meningitis? 1 Clear cerebrospinal fluid 2 Positive Gram stain 3 Normal glucose content 4 Normal protein content

2 The CSF of a child with bacterial meningitis is positive for Gram stain, whereas viral meningitis is negative. The CSF is cloudy, with decreased glucose content and elevated protein content. The CSF in viral meningitis is clear, with normal glucose content, and normal or slightly increased protein content.