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

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? "She typically breastfeeds, but lately we have had to supplement with some oat cereal." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." "She has been irritable for the last hour....seems like she is just upset for some reason." "She always cries when the person holding her has on glasses...I guess glasses scare her."

"She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "Use this information to teach family and friends." "If he is out of bed, the helmet's on the head." "Bike riding and swimming are just too dangerous." "You'll always need a monitor in his room."

"Use this information to teach family and friends." Explanation: Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions.

What information is most correct regarding the nervous system of the child? The child has underdeveloped fine motor skills and well-developed gross motor skills. The child has underdeveloped gross motor skills and well-developed fine motor skills. The child's nervous system is fully developed at birth. As the child grows, the gross and fine motor skills increase.

As the child grows, the gross and fine motor skills increase. Explanation: As the child grows, the quality of the nerve impulses sent through the nervous system develops and matures. As these nerve impulses become more mature, the child's gross and fine motor skills increase in complexity. The child becomes more coordinated and able to develop motor skills.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: Battle sign. rhinorrhea. otorrhea. raccoon eyes.

Battle sign. Explanation: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)? Elevated sugar Decreased leukocytes Cloudy appearance Decreased pressure

Cloudy appearance Explanation: In the CSF of clients diagnosed with bacterial meningitis, the pressure is elevated, the appearance is cloudy, and the leukocytes are elevated. A decreased sugar content is noted.

The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? Decorticate posturing and fixed and dilated pupils Dizziness and irritability Decreased pupil reaction and decreased respiration. Headache and sunset eyes

Decorticate posturing and fixed and dilated pupils Explanation: Decerebrate or decorticate posturing and fixed and dilated pupils are late signs of increased intracranial pressure. Decreased pupil reaction, decreased respirations, headache, sunset eyes, dizziness, and irritability are early signs of increased intracranial pressure.

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question? Initiate an IV of 0.9% NS to run at 250 ml/hr. Administer mannitol IV, dosage determined by the pharmacist. Place in an indwelling urinary catheter. Administer dexamethasone, dosage determined by the pharmacist.

Initiate an IV of 0.9% NS to run at 250 ml/hr. Explanation: Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? Institute droplet precautions in addition to standard precautions. Encourage the mother to hold and comfort the infant. Educate the family about preventing bacterial meningitis. Palpate the child's fontanels (fontanelles).

Institute droplet precautions in addition to standard precautions. Explanation: Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Encouraging the mother to hold and comfort the child is an intervention but not the priority one; the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread. Educating the family about preventing bacterial meningitis would be appropriate later once the initial infection has been controlled. Palpating the fontanels (fontanelles) is used to assess for hydrocephalus.

Absence seizures are marked by what clinical manifestation? Loss of muscle tone and loss of consciousness Sudden, brief jerks of a muscle group Brief, sudden onset of increased tone of the extensor muscle Loss of motor activity accompanied by a blank stare

Loss of motor activity accompanied by a blank stare Explanation: An absence seizure consists of a sudden, brief arrest of the child's motor activity accompanied by a blank stare and loss of awareness. A tonic seizure consists of a brief onset of increased tone or muscle. A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. An atonic seizure involves a sudden loss of muscle tone and loss of consciousness.

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Muscle tone maintained and child frozen in position Brief, sudden contracture of a muscle or muscle group Sudden, momentary loss of muscle tone, with a brief loss of consciousness Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Explanation: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures? Understanding the side effects of medications Treating the child as though she did not have epilepsy Placing the child on her side on the floor Instructing her teacher how to respond to a seizure

Understanding the side effects of medications Explanation: The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control.

A 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication? Increase intake of citrus foods to promote absorption. Use a soft toothbrush. Take medication on an empty stomach. Avoid excessive sunlight.

Use a soft toothbrush. Explanation: Phenytoin is an anticonvulsant medication. It can be used in the management of seizure disorders. This medication is associated with gingival hyperplasia. This may result in tender and bleeding gums. The use of a soft toothbrush will reduce pain, bleeding and discomfort. There is no need to take this medication on an empty stomach or with citrus foods and beverages. The medication does not make an individual photosensitive.

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which as a risk factor for hemorrhagic stroke? arteriovenous malformations (AVMs) congenital heart defect meningitis sickle cell disease

arteriovenous malformations (AVMs) Explanation: Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke. Sickle cell disease is a risk factor for ischemic stroke. Congenital heart defects are risk factors for ischemic stroke. Meningitis or other infection is a risk factor for ischemic stroke.

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger? swimming twice a week 11 p.m. bedtime; 6:30 a.m. wake-up use of non-accented soap drinking three cans of diet cola

drinking three cans of diet cola Explanation: Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is: maintaining effective cerebral perfusion. establishing seizure precautions for the child. ensuring the parents know how to properly give antibiotics. encouraging development of motor skills.

ensuring the parents know how to properly give antibiotics. Explanation: Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected. Maintaining cerebral perfusion is important for a child with hydrocephalus, but the priority intervention for the parents at this time concerns the infection. Establishing seizure precautions is an intervention for a child with a seizure disorder. Encouraging development of motor skills would be appropriate for a microcephalic child.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. verbal response fontanels (fontanelles) eye opening motor response posture

eye opening verbal response motor response Explanation: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? intracranial hemorrhaging moderate closed-head injury congenital hydrocephalus early closure of the fontanels (fontanelles)

intracranial hemorrhaging Explanation: Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels (fontanelles) has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity, which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection.

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply. smelling salts suction at bedside padding for side rails oxygen gauge and tubing tongue blade

oxygen gauge and tubing suction at bedside padding for side rails Explanation: When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.

A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure? semi-Fowler position with a parent at the bedside prone on the bed with a parent or caregiver on either side of the bed high-Fowler position while sitting on the parent's lap supine on a parent's lap

semi-Fowler position with a parent at the bedside Explanation: Proper positioning for an infant after a ventricular tap is to place the child in a semi-Fowler position to prevent additional drainage from the puncture site. Allow the parents or caregivers to comfort the child. Placing the child in the prone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure.

Which of these age groups has the highest actual rate of death from drowning? infants school-aged children preschool children toddlers

toddlers Explanation: Toddlers and older adolescents have the highest actual rate of death from drowning.

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? vagus nerve stimulation ketogenic diet frequent temperature assessment use of anticonvulsant medications

use of anticonvulsant medications Explanation: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain? computed tomography lumbar puncture video electroencephalogram cerebral angiography

video electroencephalogram Explanation: A video electroencephalogram can determine the precise localization of the seizure area in the brain. Cerebral angiography is used to diagnose vessel defects or space-occupying lesions. Lumbar puncture is used to diagnose hemorrhage, infection, or obstruction in the spinal canal. Computed tomography is used to diagnose congenital abnormalities such as neural tube defects.

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? "My child will likely outgrow these seizures by age 5." "The most likely time for a seizure is when the fever is rising." "I have ibuprofen available in case it's needed." "I always keep phenobarbital with me in case of a fever."

"I always keep phenobarbital with me in case of a fever." Explanation: Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature because seizures occur as the temperature rises.

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "I need to set an alarm to wake up and check his temperature during the night when he is sick."

"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Explanation: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

The nurse is educating a child and his family about what to expect during the child's electroencephalogram (EEG) exam. Which statement by a parent suggests a need for further education? "The procedure will determine the electrical patterns of his brain." "I will make sure my child goes to bed early the night before the exam." "The room will be dark during the procedure." "If my child can't stay still during the procedure, they may have to give him medication to help him be still."

"I will make sure my child goes to bed early the night before the exam." Explanation: During an EEG, the client needs to be cooperative and quiet. Typically, parents are asked to keep their child up later the night before so that the child will fall asleep during the procedure. The room is also darkened to help them rest. If the child is unable to remain still, sedation may be used. The EEG reflects the electrical patterns of the brain.

The nurse has performed discharge teaching for parents of a child diagnosed with epilepsy. The child has been prescribed Zonegran (zonisamide). Which comments by the parents indicate the need for further discharge teaching regarding this medication? Select all that apply. "I hope this medicine doesn't upset our child's stomach when taking it since the medication should be given on an empty stomach." "This medication can make our child very sedated so we need to monitor for this side effect." "Since our child also takes Dilantin (phenytoin), the dosages will likely be adjusted since it increases the metabolism of the Zonegran (zonisamide)." "We need to watch our child's gums for swelling since this commonly happens with this medicine." "We may need to add B-complex vitamin supplementation to our child's medications because this can help mange side effects."

"This medication can make our child very sedated so we need to monitor for this side effect." "We need to watch our child's gums for swelling since this commonly happens with this medicine." "We may need to add B-complex vitamin supplementation to our child's medications because this can help mange side effects." Explanation: Presence of food will delay absorption of the medication so it should not be administered with food. Phenytoin, phenobarbital, and carbamazepine all increase the metabolism of this drug. A side effect of phenobarbital is excessive sedation and gingival hyperplasia. B-complex vitamin supplementation can help manage side effects of levetiracetam.

The nurse is caring for a child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What action(s) by the nurse should be performed now? Select all that apply. Ensure the drip chamber is below the child's clavicles. Ensure the tubing is not kinked. Check tubing clamps to ensure they are open. Encourage the child to cough and deep breathe to facilitate drainage. Check the child's temperature.

Check tubing clamps to ensure they are open. Ensure the tubing is not kinked. Explanation: Nursing care of an external ventricular drainage device requires the nurse to ensure all connections are secure and labeled. The amount of drainage requires close observation. If drainage is absent or minimal, the nurse must assess the tubing to make certain it is not clamped or kinked. The level of the drip chamber must be set at the height of the child (at the clavicle). Taking the temperature will be useful to assess for the presence of infection, but that is not currently a concern. Asking the child to cough and deep breathe should not be done. Deep breathing is beneficial for all postoperative clients, but coughing may increase pressures and should be avoided.

A child with a seizure disorder will be discharged home from the hospital on the drug levetiracetam. What discharge instruction is the most important for the nurse to provide the parent? Return to the clinic in 3 weeks for laboratory tests to determine the therapeutic level of the drug. Notify the health care provider if child experiences poor coordination. Notify the health care provider if the number of seizures increases after 4 weeks. Do not to take two doses together if one dose is missed.

Notify the health care provider if child experiences poor coordination. Explanation: Levetiracetam is used in children to help control seizures. One major side effect of the drug is that it can cause difficulty with gait or coordination. Another major side effect is the development of psychiatric symptoms. The parent should be instructed to call the health care provider immediately if either of these side effects occurs. This drug does not have a therapeutic level so there is no need for routine laboratory tests. The parent should be instructed not to give the child two doses together if one has been missed, but this is not the most important instruction. The drug takes about 4 weeks to stabilize in the bloodstream, so additional seizures may be seen during this time.

The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse? Apply ice packs to the child's axillary and groin area. Administer acetaminophen by mouth as prescribed. Place the child in a bathtub filled with cool water. Remove any blankets or heavy clothing and replace with a thin sheet

Remove any blankets or heavy clothing and replace with a thin sheet Explanation: The child should not have any blankets or clothing that would elevate the temperature further. Removing them is helpful in allowing the heat to dissipate. The child should not be placed in a bathtub because he or she may suffer another seizure and slip underwater. Using ice packs or alcohol can be a shock to an immature nervous system. Antipyretics should be administered as a suppository rather than PO to reduce the risk of aspiration while the child is in the postictal or drowsy state following the seizure.

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? "I will give the medication to him when I first wake him up in the morning." "I'm glad to know he will only need this medication for a short time to stop his seizures." "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I need to watch for any new bruises or bleeding and let my health care provider know about it."

"I need to watch for any new bruises or bleeding and let my health care provider know about it." Explanation: Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to watch for any signs of bruising, bleed, or infection and notify their health care provider if this happens. Administer this medication with food to minimize GI upset. This medication can cause drowsiness, so do not give any sleep-inducing or other sedative type medications. Antiseizure medication does not cure seizures; it only controls the seizures. Lifelong antiseizure medication may be needed.

The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction? "This shunt is the only surgery my baby will need." "My baby's cerebrospinal fluid is increasing intracranial pressure." "I will watch my baby for irritability and difficulty feeding." "The VP shunt will help drain fluid from my baby's brain."

"This shunt is the only surgery my baby will need." Explanation: Hydrocephalus results from an imbalance in the production and absorption of CSF. In hydrocephalus, CSF accumulates within the ventricular system and causes the ventricles to enlarge, and increases in ICP subsequently occur. A VP shunt can be used to drain excess CSF, but it will need to be replaced as the child grows, requiring shunt revision surgery at various times during the client's life. The parent should be taught to monitor for signs and symptoms of increased ICP, which include irritability and vomiting. Increased ICP indicates the shunt is not functioning properly.

The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Provide information regarding policies of the unit's playroom for the parents to review. Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized. Gather appropriate equipment and signage for respiratory isolation precautions. Place multiple pillows in the room to assist with propping the child's head up.

Gather appropriate equipment and signage for respiratory isolation precautions. Explanation: Children with meningitis are placed on respiratory precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the infection to other family members or health care providers. While a child is on respiratory isolation, they will typically not be allowed out of their rooms to play. Due to pain when their neck is flexed, most children are most comfortable without a pillow. Reducing stimulation can help to promote rest for the child.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? Delayed growth and development related to physical restrictions Risk for injury related to seizure activity Ineffective airway clearance related to history of seizures Risk for acute pain related to surgical procedure

Risk for injury related to seizure activity Explanation: The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? early closure of the fontanels (fontanelles) moderate closed-head injury congenital hydrocephalus intracranial hemorrhaging

intracranial hemorrhaging Explanation: Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels (fontanelles) has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity, which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? giving the infant small feedings whenever he is fussy moving the infant's head every 2 hours massaging the scalp gently every 4 hours measuring the intake and output every shift

moving the infant's head every 2 hours Explanation: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.

The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session? Call the doctor if she gets a persistent headache. Her autoregulation mechanism to absorb spinal fluid has failed. Always keep her head raised 30º. Tell me your concerns about your child's shunt.

Tell me your concerns about your child's shunt. Explanation: Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? head trauma intracranial hemorrhaging positional plagiocephaly congenital hydrocephalus

head trauma Explanation: A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Positional plagiocephaly is caused by an infant's head remaining in the same position for too long

The nurse is caring for a child admitted with focal onset motor seizures (simple partial motor seizures). Which clinical manifestation would likely have been noted in the child with this diagnosis? The child had jerking movements in the legs and facial muscles. The child was rubbing the hands and smacking the lips. The child was dizzy and had decreased coordination. The child had shaking movements on one side of the body.

The child had shaking movements on one side of the body. Explanation: Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part. A focal onset sensory seizure may include sensory symptoms called an aura, which signals an impending attack. Myoclonic seizures are characterized by a sudden jerking of a muscle or group of muscles, often in the arms or legs, without loss of consciousness. Complex partial seizures may cause nonpurposeful movements, such as hand rubbing and lip smacking. During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination.

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse pads the crib or side rails before a seizure. The nurse teaches the caregivers regarding seizure precautions. The nurse places a washcloth in the mouth to prevent injury during seizure. The nurse positions the child on the side during a seizure.

The nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions. Explanation: The nurse should pad the crib sides and keep sharp or hard items out of the crib. The nurse should also position the child to one side to prevent aspiration of saliva or vomitus and have oxygen and suction equipment readily available for emergency use. The nurse should teach family caregivers seizure precautions so they can handle a seizure that occurs at home. The nurse should not put anything in the child's mouth; doing so could cause injury to the child or to the nurse. It is important for the nurse to promptly inform other members of the care team when a child is experiencing seizure activity, but leaving the bedside to do so would be unsafe.

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? "I need to encourage my child to drink at least 1 glass of water after the procedure." "My child may have a headache after the procedure. If she does, she can have something for the pain." "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things." "I will cradle her in my arms after the procedure for at least 30 minutes."

"I will cradle her in my arms after the procedure for at least 30 minutes." Explanation: During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.

The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine."

"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." Explanation: Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Meningococcal conjugate vaccine protects against four types of meningitis. There is nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the infection, or that the adolescent's immune system is compromised.

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? "Limit the amount of television he watches." "Watch for changes in his behavior or eating patterns." "Always keep his head raised 30 degrees." "Call the doctor if he gets a headache."

"Watch for changes in his behavior or eating patterns." Explanation: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? Place a patch over the client's affected eye. Notify the primary health care provider. Place the child on fall precaution. Assess the level of consciousness (LOC).

Assess the level of consciousness (LOC). Explanation: Decreased LOC is frequently the first sign of a major neurologic problem after head trauma. The nurse would assess the client's LOC before notifying the health care provider. The child may need to be placed on fall precaution, depending on the results of the assessment. The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary.

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? "What type of fluids did your child take when he had a fever?" "How high did his temperature rise when he was ill?" "Did you use any medications, like aspirin, for the fever?" "Did you give your child any acetaminophen, such as Tylenol?"

"Did you use any medications, like aspirin, for the fever?" Explanation: Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

The nurse is caring for a child admitted with focal onset impaired awareness seizure (complex partial seizure). Which clinical manifestation would likely have been noted in the child with this diagnosis? The child was rubbing the hands and smacking the lips. The child had jerking movements and then the extremities stiffened. The child had shaking movements on one side of the body. The child was dizzy and had decreased coordination.

The child was rubbing the hands and smacking the lips. Explanation: With the focal onset impaired awareness seizure, formerly called complex partial seizure, the child is confused or their awareness is affected during the seizure. The seizure begins in a small area of the brain and changes or alters consciousness. These seizures can have motor and non-motor symptoms. They cause memory loss and staring and nonpurposeful movements, such as hand rubbing, lip smacking, arm dropping, and swallowing. In the tonic phase of tonic-clonic seizures, the child's muscles contract, the child may fall, and the child's extremities may stiffen. During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination.Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate? "Your baby's head became blocked inside your vagina while you were pushing." "It's normal for this to happen, but they don't really know why." "The forceps used during delivery caused this to happen." "During delivery, your vaginal wall put pressure on the baby's head."

"During delivery, your vaginal wall put pressure on the baby's head." Explanation: Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? Teach the child and his parents to keep a headache diary. Have the child sleep without a pillow under his head. Review the signs of increased intracranial pressure with parents. Have the parents call the doctor if the child vomits more than twice.

Teach the child and his parents to keep a headache diary. Explanation: A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.

A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus."

"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Explanation: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.

A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement? "I am glad that my headache is getting better." "My stomach is upset. I feel like I might throw up." "You look funny. Well, both of you do. I see two of you." "It will be nice when you will let me take a long nap. I am sleepy."

"You look funny. Well, both of you do. I see two of you." Explanation: The caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider.

A client presents reporting headache that she describes as "throbbing pain on the left side of my head and sensitivity to light and motion." The nurse asks the client to describe the sequence of events before the onset of the headache. Which signs and symptoms described by the client are characteristic of the prodrome phase of a migraine headache? Select all that apply. Fatigue Neck stiffness Loss of appetite Frequent yawning Seeing flashing lights

Neck stiffness Frequent yawning Loss of appetite Explanation: The prodrome phase includes experiencing signs and symptoms that occur hours or days before the onset of the headache. Stiffness of the neck muscles, frequent yawning, or loss of appetite are common during the prodrome (or preheadache) phase. Seeing flashing lights is an aura, which is a warning sign of the impending onset of a migraine headache. Fatigue is common during the postdrome portion of a migraine.

The nurse is reinforcing teaching with the caregivers of a child being discharged from the urgent care setting following a mild head injury that occurred in a roller skating accident. What should the caregivers be instructed to do? Select all that apply. Observe for and report to provider any double or blurred vision. Administer acetaminophen for headache. Observe and report any vomiting that occurs within 6 hours. Wake the child every 1 to 2 hours to check level of consciousness. Check the pupil reaction to light every 15 minutes for 12 hours.

Wake the child every 1 to 2 hours to check level of consciousness. Observe and report any vomiting that occurs within 6 hours. Observe for and report to provider any double or blurred vision. Explanation: A child with a concussion should be observed for at least 24 hours and the caregiver should be prepared to bring the child to the hospital if symptoms worsen. The child should be awakened every 2 hours to assess that the child wakes easily and has not developed neurological symptoms. The child should be brought back to the hospital if the child vomits within 6 hours of the injury or more than two times. Other signs for parents to watch for are increased sleepiness, a worsening headache, confusion, or poor balance or walking. No analgesics or sedatives should be administered during this period of observation. In the home the parents would not be checking pupil reaction.