Chapter 27: The Child With Cerebral Dysfunction

17. Which is the initial clinical manifestation of generalized seizures? a. Being confused b. Feeling frightened c. Losing consciousness d. Seeing flashing lights

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.

1. The nurse has documented that a child's level of consciousness is obtunded. Which describes this level of consciousness? a. Slow response to vigorous and repeated stimulation b. Impaired decision making c. Arousable with stimulation d. Confusion regarding time and place

ANS: C Obtunded 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.

1. A. Place in order the interventions the nurse would implement starting with the highest-priority intervention sequencing to the lowest-priority intervention for a child experiencing a generalized seizure. Provide the answer using lowercase letters separated by commas (e.g., A, B, C, D, E). a. Monitor vital signs. b. Ease child to the floor. c. Evaluate postictal symptoms. d. Turn child to the side. e. Note onset of seizure.

ANS: E, B, D, A, C The nurse would note the onset of the seizure and ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs would be taken next and the child would be allowed to rest. Evaluate postictal symptoms such as confusion and return of speech.

4. 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 e. Positive Gram stain

ANS: A, B, E 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.

8. Which drug would 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)

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.

7. 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.

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.

11. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping, with extreme fluctuations in blood pressure, and pupils are dilated and fixed. The nurse would suspect which type of head injury? a. Brainstem b. Skull fracture c. Subdural hemorrhage d. Epidural hemorrhage

ANS: A Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture, subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries.

6. The nurse is taking care of a child who is alert but showing signs of increased intracranial pressure. Which test is contraindicated in this case? a. Oculovestibular response b. Doll's head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions

ANS: A 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 a child who is awake or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination for papilledema, and assessment of pyramidal tract lesions can be performed on children who are awake.

5. Which clinical manifestations would the nurse prepare to assess if bacterial meningitis is confirmed? (Select all that apply.) a. Headache b. Photophobia c. Bulging anterior fontanel d. Seizures e. Poor muscle tone

ANS: A, B, D The onset of illness may be abrupt and rapid, or develop progressively over one or several days, and may be preceded by a febrile illness. Most children with meningitis are seen with fever, chills, headache, and vomiting that are associated with or quickly followed by alterations in sensorium; however, some may present only with lethargy and irritability (Weinberg & Thompson-Stone, 2018). The child is extremely irritable and agitated and may develop seizures, photophobia, confusion, hallucinations, aggressive behavior, drowsiness, stupor, or coma.

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

ANS: A, 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.

3. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions would be included in the child's postoperative care? (Select all that apply.) a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Observe for signs of increased intracranial pressure. f. Monitor for abdominal distention.

ANS: A, E, F Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping of the shunt may cause obstruction or other problems and should not be performed unless indicated by the neurosurgeon. Pain management rather than sedation should be the goal of therapy. The child is kept flat to avoid too rapid a reduction of intracranial fluid.

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

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.

16. When taking the history of a child hospitalized with Reye syndrome, the nurse would not be surprised that a week ago the child had recovered from a. measles. b. varicella. c. meningitis. d. hepatitis.

ANS: B Most cases of Reye syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye syndrome.

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

ANS: B 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.

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 would the nurse interpret these findings? a. Eye trauma b. Neurosurgical emergency c. Severe brainstem damage d. Indication of brain death

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.

15. Which are the vector reservoirs for agents causing viral encephalitis in the United States? a. Tarantula spiders b. Mosquitoes c. Carnivorous wild animals d. Domestic and wild animals

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.

1. 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? (Select all that apply.) a. "I should expect my child to have a few episodes of vomiting." b. "My child may have changes in her normal sleep patterns." c. "My child may have some behavioral changes after the accident." d. "My child may experience headaches after the fall." e. "I will limit my child's physical activity for a minimum of one month."

ANS: B, C, D 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.

6. 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.

9. Which is an appropriate nursing intervention when caring for an unconscious child? 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: 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.

18. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin (Dilantin) may experience a deficiency of a. calcium. b. vitamin C. c. fat-soluble vitamins. d. vitamin D and folic acid.

ANS: D Deficiencies of vitamin D and folic acid have been reported in children taking phenobarbital and phenytoin. Calcium, vitamin C, and fat-soluble vitamin deficiencies are not associated with phenobarbital or phenytoin.

14. 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 would 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.

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.

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

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.

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 would record? a. 8 b. 11 c. 13 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.

13. 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

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.

12. A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. Which does this finding suggest? a. Diabetic coma b. Brainstem injury c. Upper respiratory tract infection d. Leaking of cerebrospinal fluid (CSF)

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.