Child Care With Alteration in Intracranial Regulation/Neurologic Disorder

Nuchal rigidity is a sign of what

(stiffness in cervical neck area) meningitis

The young child has been diagnosed with bacterial meningitis. Which nursing interventions are appropriate? Select all that apply. 1 Initiate droplet isolation. 2 Identify close contacts of the child who will require post-exposure prophylactic medication. 3 Administer antibiotics as ordered. 4 Monitor the child for signs and symptoms associated with decreased intracranial pressure. 5 Initiate seizure precautions.

1.3. The child with bacterial meningitis should be placed in droplet isolation until 24 hours following the administration of antibiotics. 2 Close contacts of the child should receive antibiotics to prevent them from developing the infection. 5 The nurse should administer antibiotics and initiate seizure precautions. NOT 4 Children with bacterial meningitis have an increased (not DECREASED) risk of developing problems associated with increased intracranial pressure

The nurse is teaching new parents about cephalohematoma. Which statement by the parents suggests the need for further teaching? 1 "We should expect to see swelling on one side of our infant's scalp in a couple days." 2 "We should expect to see some discoloration on our child's scalp." 3 "A delivery assisted with forceps contributed to the cephalohematoma." 4 "Most cases of cephalohematoma resolve and only require observation."

2 Characteristics of cephalohematoma includes swelling that does not cross the midline and typically no discoloration. Causes of cephalohematoma include pressure against the mother's pelvis and commonly a forceps-assisted delivery. In most cases of cephalohematoma, only observation is necessary and resolution occurs within 2 to 9 weeks

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? 1 frequent temperature assessment 2 use of anticonvulsant medications 3 ketogenic diet 4 vagus nerve stimulation

2 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. NOT 1 Frequent temperature assessment would only be useful in febrile seizures. 3 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. 4 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

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: 1 raccoon eyes. 2 Battle sign. 3 rhinorrhea. 4 otorrhea.

2 Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and (1) "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). NOT 3 Rhinorrhea is CSF leakage from the nose. 4 Otorrhea is CSF leaking from the ear

The nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client? 1 The caregivers will be prepared to care for the child at home. 2 The child will have an understanding of the disorder. 3 The family will understand seizure precautions. 4 The child will remain free from injury during a seizure

4 Keeping the child free from injury is the priority goal. NOT 1.2.3. The other choices are important, but keeping the child safe is higher than preparing for home care or knowledge deficit concerns. The physical concerns are always priority over the psychological concerns when caring for clients.

A 4-year-old child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child, which will be the first change noted in the presence of increasing intercranial pressure?

A change in the level of consciousness is the initial finding in the client who is experiencing an increase in intracranial pressure.

A 12-year-old child has suffered a concussion after being in an automobile accident. What will be included in the plan of care/treatment? Select all that apply. 1 observation of level of consciousness 2 administration of intravenous fluids rest 3 strict monitoring of intake and output 4 assessment of serum electrolyte levels

A concussion is a common head injury. The injury is caused by a bump, blow, jolt, jarring, or shaking and results in disruption or malfunction of the electrical activities of the brain. 1.2. Treatment includes rest and monitoring for neurologic changes that could indicate a more severe injury

Contusion

A contusion is a bruise to the brain itself. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck. Contusions may occur along with a fracture or other blood clots.

Caput succedaneum vs Cephalohematoma

Caput Succedaneum- soft tissue swelling, that can cross suture lines Cephalohematoma- subperiosteal hemorrhage that does NOT cross suture lines.

Encephalocele

Encephalocele is a protrusion of the brain and meninges through a skull defect. It results from failure of the anterior portion of the neural tube to close. The prognosis, including the extent of complications and cognitive deficits, will depend on the size and location of the encephalocele and involvement of other brain structures.

Positional plagiocephaly

Flattening of the occiput and prominence of ipsilateral frontal area

Congenital hydrocephalus

Hydrocephalus is not a specific illness, but results from underlying brain disorders. It is a frequently seen disorder of the nervous system It 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 to occur.

Salicylates

Salicylates (Aspirin) are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. Two common medications containing salicylates are bismuth subsalicylate and effervescent heartburn relief antiacid

Periventricular

Situated or occurring around a ventricle especially of the brain periventricular white matter.

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. 1 eye opening 2 verbal response 3 motor response 4 fontanels (fontanelles) 5 posture

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

Ventricles of the brain

The ventricles of the brain are a communicating network of cavities filled with cerebrospinal fluid (CSF) and located within the brain parenchyma. The ventricular system is composed of 2 lateral ventricles, the third ventricle, the cerebral aqueduct, and the fourth ventricle (see the images below).

Lumbar puncture

Used to sample spinal fluid or give medication Lying on one side, with the back curved maximizes the space between the lumbar vertebrae, facilitating needle insertion.

The nurse is caring for an 8-year-old girl who was in a car accident. What would lead the nurse to suspect a concussion? 1 The child is easily distracted and can't concentrate. 2 The child is weak and has blurry vision. 3 The child has vomited and has bruising behind her ear. 4 The child is bleeding from the ear and draining fluid from the nose

1 A child with a concussion will be distracted and unable to concentrate. NOT 2 Signs and symptoms of contusions include disturbances to vision, strength, and sensation. 3 Vomiting and bruising behind the ear are signs of a subdural hematoma. 4 Bleeding from the ear and otorrhea are signs of a basilar skull fracture

During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? 1 Dramatic increase in head circumference 2 Pupil of one eye dilated and reactive 3 Vertical nystagmus 4 Posterior fontanel (fontanelle) is closed

1 A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain. NOT 2 Only one pupil that is dilated and reactive is a sign of an intracranial mass. 3 Vertical nystagmus indicates brain stem dysfunction. 4 A closed posterior fontanel (fontanelle) would be frequently seen by this age

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? 1 Teach the child and his parents to keep a headache diary. 2 Review the signs of increased intracranial pressure with parents. 3 Have the child sleep without a pillow under his head. 4 Have the parents call the doctor if the child vomits more than twice.

1 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. NOT 2 Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. 3 Having the child sleep without a pillow is an intervention to reduce pain from meningitis. 4 Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? 1 head trauma 2 intracranial hemorrhaging 3 congenital hydrocephalus 4 positional plagiocephaly

1 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. NOT 2 Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. 3 Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. 4 Positional plagiocephaly is caused by an infant's head remaining in the same position for too long

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? 1 Tell me your concerns about your child's shunt. 2 Call the doctor if she gets a persistent headache. 3 Her autoregulation mechanism to absorb spinal fluid has failed. 4 Always keep her head raised 30º.

1 Always start by assessing the family's knowledge. Ask them what they feel they need to know. NOT 2.4. 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. 3 "Autoregulation" is too technical; base information on the parents' level of understanding

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? 1 "During delivery, your vaginal wall put pressure on the baby's head." 2 "The forceps used during delivery caused this to happen." 3 "Your baby's head became blocked inside your vagina while you were pushing." 4 "It's normal for this to happen, but they don't really know why."

1 Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. NOT 2 The use of forceps is associated with a cephalohematoma. 3 Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. 4 The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

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? 1 "Watch for changes in his behavior or eating patterns." 2 "Call the doctor if he gets a headache." 3 "Always keep his head raised 30 degrees." 4 "Limit the amount of television he watches."

1 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. NOT 2 Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. 3 It is not necessary to keep the child's head raised 30 degrees. 4 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? 1 Assess the LOC. 2 Notify the primary health care provider. 3 Place the child on fall precaution. 4 Place a patch over the client's affected eye.

1 Decreased LOC is frequently the first sign of a major neurologic problem after head trauma. NOT 2 The nurse would assess the client's LOC before notifying the health care provider. 3 The child may need to be placed on fall precaution, depending on the results of the assessment. 4 The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect? 1 hydrocephalus 2 anencephaly 3 encephalocele 4 spina bifida occulta

1 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 intracranial pressure. NOT 2.3.4. Anencephaly, encephalocele and spina bifida occulta are all neural tube defects

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? 1 moving the infant's head every 2 hours 2 measuring the intake and output every shift 3 massaging the scalp gently every 4 hours 4 giving the infant small feedings whenever he is fussy

1 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. NOT 3 Massaging the scalp will not affect the skull. 2 Measuring the intake and output is important but has no effect on the skull bones. 4 Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care

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? 1 "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." 2 "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." 3 "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." 4 "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine."

1 Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. NOT 2 Meningococcal conjugate vaccine protects against four types of meningitis. 3.4. 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

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? 1 Report the findings to the pediatric health care provider. 2 Reassess the head circumference in 24 hours. 3 Document that the infant has microcephaly. 4 Tell the parent the infant's brain is underdeveloped.

1 These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain. NOT 2 Waiting 24 hours to reassess will delay treatment. 3 In microcephaly, the head circumference is small, but the fontanels (fontanelles) and suture line are palpable

An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child? Select all that apply. 1 Request order for an antiemetic. 2 Assess intake and output every shift. 3 Assess child's skin for the development of distinctive rash every 4 hours. 4 Request order for anticonvulsant. 5 Monitor the child's laboratory values related to pancreatic function.

1 This child likely has Reye syndrome and may require an antiemetic for severe vomiting. 2 The nurse should monitor the child's intake and output every shift for the development of fluid imbalance. 4 The child may require an anticonvulsant due to an increased intracranial pressure that may induce seizures. NOT 3 A distinctive rash is associated with the development of meningococcal meningitis. 5 The nurse should monitor the laboratory values of the child with Reye syndrome for indications that the liver is not functioning well

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 what type of statements? Vomiting? Eyes? LOC? Mobility? Head?

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

The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority? 1 Risk for delayed development 2 Risk for injury 3 Risk for ineffective tissue perfusion: cerebral 4 Risk for self-care deficit: bathing and dressing

2 A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures are the most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to an inability to swallow. All of these symptoms would make Risk for injury the highest priority.

The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III? 1 The nurse allows the child to smell objects and describe them. 2 A bright-colored toy is moved in the child's visual fields. 3 The nurse observes facial features and expressions for symmetry. 4 The nurse talks softly to the child to note the ability to hear.

2 Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement. NOT 1 Cranial nerve I (olfactory nerve) controls the sense of smell. Asking the child to smell objects would be an assessment of this cranial nerve. 3 Cranial nerve VII (facial nerve) is assessed by monitoring symmetry of facial movements. 4 Cranial nerve VIII (acoustic nerve) is assessed by whispering

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: 1 maintaining effective cerebral perfusion. 2 ensuring the parents know how to properly give antibiotics. 3 establishing seizure precautions for the child. 4 encouraging development of motor skills

2 Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected. NOT 1 Maintaining cerebral perfusion is important for a child with hydrocephalus, but the priority intervention for the parents at this time concerns the infection. 3 Establishing seizure precautions is an intervention for a child with a seizure disorder. 4 Encouraging development of motor skills would be appropriate for a microcephalic child

Which of these age groups has the highest actual rate of death from drowning? 1 infants 2 toddlers 3 preschool children 4 school-aged children

2 Toddlers and older adolescents have the highest actual rate of death from drowning

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? 1 Take vital signs every 4 hours 2 Monitor temperature every 4 hours 3 Decrease environmental stimulation 4 Encourage the parents to hold the child

3 A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. NOT 1.2. Vital signs would be taken initially every hour and temperature monitored every 2 hours. 4 Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

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? 1 "I have ibuprofen available in case it's needed." 2 "My child will likely outgrow these seizures by age 5." 3 "I always keep phenobarbital with me in case of a fever." 4 "The most likely time for a seizure is when the fever is rising."

3 Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. NOT 1 Ibuprofen, not phenobarbital, is given for fever. 2 Febrile seizures usually occur after age 6 months and are unusual after age 5. 4 Treatment is to decrease the temperature because seizures occur as the temperature rises

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? 1 Onset and character of fever 2 Degree and extent of nuchal rigidity 3 Signs of increased intracranial pressure (ICP) 4 Occurrence of urine and fecal contamination

3 Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life

The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? 1 Place multiple pillows in the room to assist with propping the child's head up. 2 Provide information regarding policies of the unit's playroom for the parents to review. 3 Gather appropriate equipment and signage for respiratory isolation precautions. 4 Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized.

3 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. NOT 2 While a child is on respiratory isolation, they will typically not be allowed out of their rooms to play. 1 Due to pain when their neck is flexed, most children are most comfortable without a pillow. 4 Reducing stimulation can help to promote rest for the child

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? 1 "If he is out of bed, the helmet's on the head." 2 "Bike riding and swimming are just too dangerous." 3 "Use this information to teach family and friends." 4 "You'll always need a monitor in his room."

3 Families need and want information they can share with relatives, child care providers, and teachers. NOT 1.4. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. 2 The child may be able to bike ride and swim with proper precautions

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? 1 "She always cries when the person holding her has on glasses...I guess glasses scare her." 2 "She typically breastfeeds, but lately we have had to supplement with some rice cereal." 3 "She has been irritable for the last hour....seems like she is just upset for some reason." 4 "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper."

3 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. NOT 1.2.4. The other responses would be typical and normal for an infant

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? 1 The child had jerking movements and then the extremities stiffened. 2 The child had shaking movements on one side of the body. 3 The child was rubbing the hands and smacking the lips. 4 The child was dizzy and had decreased coordination.

3 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. NOT 1 In the tonic phase of tonic-clonic seizures, the child's muscles contract, the child may fall, and the child's extremities may stiffen. 4 During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination. 2 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 parents of a child with a history of seizures who has been taking phenytoin ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate? 1 "A drop in the plasma drug level will lead to a toxic state." 2 "The capacity to metabolize the drug becomes overwhelmed over time." 3 "Small increments in dosage lead to sharp increases in plasma drug levels." 4 "Large increments in dosage lead to a more rapid stabilizing therapeutic effect."

3 Within the therapeutic range for phenytoin, small increments in dosage produce sharp increases in plasma drug levels. NOT 2 The capacity of the liver to metabolize phenytoin is affected by slight changes in the dosage of the drug, not necessarily the length of time the client has been taking the drug. 4.1. Large increments in dosage will greatly increase plasma levels, leading to drug toxicity

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? 1 Sudden, momentary loss of muscle tone, with a brief loss of consciousness 2 Muscle tone maintained and child frozen in position 3 Brief, sudden contracture of a muscle or muscle group 4 Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

4 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. NOT 1 A sudden loss of muscle tone describes atonic seizures. 2 A frozen position describes the appearance of someone having akinetic seizures. 3 A brief, sudden contraction of muscles describes a myoclonic seizure

The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? 1 "The child will be held by the mother on her lap with his back toward the health care provider." 2 "When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible." 3 "The child will be placed in the prone position with the nurse holding the child still." 4 "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back."

4 Correct positioning for a lumbar puncture is to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. NOT 1 Newborns may be seated upright with their head bent forward. 3 The child is not placed prone; this does not allow the back to be arched.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? 1 moderate closed-head injury 2 early closure of the fontanels (fontanelles) 3 congenital hydrocephalus 4 intracranial hemorrhaging

4 Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. NOT 2 Closure of the fontanels (fontanelles) has nothing to do with fragile capillaries within the brain. 1 Larger head size gives children a higher center of gravity, which causes them to hit their head more readily. 3 Congenital hydrocephalus may be caused by abnormal intrauterine development or infection

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? 1 tachypnea 2 hyperthermia 3 poor handwriting 4 hypertension

4 Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? 1 While turning the child's head to the left, the eyes turn to the right. 2 While stimulating the child's foot, the big toe points upward and other toes fan outward. 3 While calling the child's name, the child stares straight ahead and does not turn to the sound. 4 While assessing the child's pupils, there is no change in diameter in response to a light.

4 To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate ICP. NOT 1 To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. 2.3. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination

Anencephaly

Anencephaly is a defect in brain development resulting in small or missing brain hemispheres, skull, and scalp. It occurs when the cephalic or upper end of the neural tube fails to close during the third to fourth week of gestation. These infants are born without both a forebrain and a cerebrum and the remaining brain tissue may be exposed. The condition is incompatible with life. Nursing management is supportive in nature and focuses on comfort measures for the dying infant.

Glasgow Coma Scale

Glascow Coma Scale was designed and should be used to assess the depth and duration coma and impaired consciousness. This scale helps to gauge the impact of a wide variety of conditions such as acute brain damage due to traumatic and/or vascular injuries or infections, metabolic disorders (e.g., hepatic or renal failure, hypoglycemia, diabetic ketosis), etc. Head Injury Classification: Severe Head Injury - GCS score of 8 or less Moderate Head Injury - GCS score of 9 to 12 Mild Head Injury - GCS score of 13 to 15

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? 1 "I will watch my baby for irritability and difficulty feeding." 2 "My baby's cerebrospinal fluid (CSF) is increasing intracranial pressure (ICP)." 3 "The VP shunt will help drain fluid from my baby's brain." 4 "This shunt is the only surgery my baby will need."

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 to 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 sign and symptoms of increased ICP, which include irritability and vomiting. Increased ICP indicates the shunt is not functioning properly

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): 1 diuretic. 2 antihistamine. 3 anticonvulsant. 4 steroid.

ICP may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. NOT 1 The diuretic mannitol may be used to decrease edema. 3 An anticonvulsant is used with increased ICP to prevent seizures. 2 An antihistamine would not be warranted for the treatment of a head injury