NUR 234 Ch 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder Exam 2
The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate? "You'll see a big difference after the surgery." "You won't need to change diapers often." "Take your time feeding your baby." "Lay him down after feeding."
"Take your time feeding your baby." Explanation: One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations.
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? "You'll always need a monitor in his room." "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."
"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.
Absence seizures are marked by what clinical manifestation? Sudden, brief jerks of a muscle group Loss of motor activity accompanied by a blank stare Loss of muscle tone and loss of consciousness Brief, sudden onset of increased tone of the extensor muscle
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.
A child was just brought into the emergency department after falling off a skateboard. The parents report that their child lost consciousness briefly and they noticed watery drainage coming from the nose. What action should the nurse take first? Notify the emergency department health care provider of the information the parents reported. Perform a thorough physical assessment. Perform a complete neurological assessment. Collect a sample of the nasal drainage and send the specimen to the laboratory.
Notify the emergency department health care provider of the information the parents reported. Explanation: The health care provider should be notified immediately if clear liquid fluid is noted draining from the ears or nose following a traumatic accident. Nasal drainage can be tested for glucose at the bedside. If the fluid tests positive for glucose, this is indicative of leakage of cerebrospinal fluid. The other assessments can continue after notifying the health care provider of these findings.
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? Refer the client to a neurologist. Administer lorazepam rectally to the client. Discuss dietary therapy with the client's caregivers. Protect the child from hitting the arms against the bed.
Protect the child from hitting the arms against the bed. Explanation: Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care; however, this is not a priority. Dietary therapy is considered for clients with chronic seizure disorders who do not respond to medication therapy.
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Degree and extent of nuchal rigidity Signs of increased intracranial pressure (ICP) Occurrence of urine and fecal contamination Onset and character of fever
Signs of increased intracranial pressure (ICP) Explanation: 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 discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client? The child will remain free from injury during a seizure. The caregivers will be prepared to care for the child at home. The child will have an understanding of the disorder. The family will understand seizure precautions.
The child will remain free from injury during a seizure. Keeping the child free from injury is the priority goal. 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.
tonic-clonic movements
The tonic phase: All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. The clonic phase: The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. Full cycle lasts between 1 to 3 minutes
Absence seizures (petit mal)
➢Occurs during childhood ➢10 to 30 sec loss of consciousness with eyelid fluttering, ➢abruptly stops activity ➢stares off ➢little to no tonic-clonic movement ➢w/out muscle involvement.
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. eye opening fontanels (fontanelles) motor response posture verbal response
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? moderate closed-head injury congenital hydrocephalus early closure of the fontanels (fontanelles) 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.
myoclonic seizure
sudden, brief jerks of muscle groups
Which of these age groups has the highest actual rate of death from drowning? preschool children toddlers infants school-aged children
toddlers Explanation: Toddlers and older adolescents have the highest actual rate of death from drowning.
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 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.
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. oxygen gauge and tubing suction at bedside smelling salts tongue blade padding for side rails
"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 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? "The VP shunt will help drain fluid from my baby's brain." "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."
"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.
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? Encourage the mother to hold and comfort the infant. Educate the family about preventing bacterial meningitis. Institute droplet precautions in addition to standard precautions. 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.
A child is hospitalized and diagnosed with bacterial meningitis. What can the nurse anticipate will be included in the plan of care and treatment? Select all that apply. antiviral medications acetaminophen ice packs to reduce body temperature antibiotic therapy tepid baths as needed
acetaminophen antibiotic therapy tepid baths as needed Explanation: Bacterial meningitis involves a multifaceted plan of care and treatment. Ice packs will sharply reduce temperature and should not be used. Measures that promote shivering should be avoided as they will increase the metabolic rate. Acetaminophen will be prescribed in an effort to reduce body temperature. Tepid baths can be instituted as needed to reduce body temperature. Antibiotic therapy will be initiated to eradicate the pathogens. Antiviral medications are not indicated as this is not a viral infection.
A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents? "The surgery was successful. Do you have any questions?" "I told you yesterday there would be facial swelling." "I will be watching hemoglobin and hematocrit closely." "This only happens in 1 out of 2,000 births."
"The surgery was successful. Do you have any questions?" Explanation: Often what parents need most is someone to listen to their concerns. Although this is a good time for education, the parents are more concerned about the success of the surgery than their infant's appearance. Watching the hemoglobin, hematocrit and swelling are important nursing functions but they do not address the parents' psychosocial needs. The parents do not need to be taught statistics about their infant's condition. They more than likely know this from health care provider visits, the Internet, and parent support groups. Following surgery, this knowledge is not what parents are concerned about. Parents want to know their infant is safe and well.
The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with? "Was the child unconscious?" "What happened just before the seizures?" "How did you treat the child afterwards?" "Were there any jerky movements?"
"What happened just before the seizures?" Asking what happened just before the seizure will suggest whether the episode was a seizure or a breath-holding event, which is frequently precipitated by an expression of anger or frustration. Cyanotic breath holding can be accompanied by clinical movements, as can seizures. Both types of events render the child unconscious. One would expect concerned, caring treatment from the parents regardless of the cause.
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Brief, sudden contracture of a muscle or muscle group Sudden, momentary loss of muscle tone, with a brief loss of consciousness Muscle tone maintained and child frozen in position 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.
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? Reassess the head circumference in 24 hours. Tell the parent the infant's brain is underdeveloped. Document that the infant has microcephaly. Report the findings to the pediatric health care provider.
Report the findings to the pediatric health care provider. Explanation: These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain. Waiting 24 hours to reassess will delay treatment. In microcephaly, the head circumference is small, but the fontanels (fontanelles) and suture line are palpable.
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? Risk for delayed development Risk for injury Risk for self-care deficit: bathing and dressing Risk for ineffective tissue perfusion: cerebral
Risk for injury 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.
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. Review the signs of increased intracranial pressure with parents. Have the child sleep without a pillow under his head. 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.
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. Tell me your concerns about your child's shunt. Always keep her head raised 30º. Her autoregulation mechanism to absorb spinal fluid has failed.
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.
Atonic seizure (drop attack)
generalized seizure characterized by sudden loss of muscle tone and strength; may cause the head to drop suddenly, objects to fall from the hands, or the legs to lose strength, with falling and potential injury involves either a tonic epidsode or a paraoxysmal loss of muscle tone and begins suddenly with person falling to ground
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? massaging the scalp gently every 4 hours measuring the intake and output every shift moving the infant's head every 2 hours giving the infant small feedings whenever he is fussy
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 caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion? vomiting trouble focusing when reading difficulty concentrating bleeding from the ear
trouble focusing when reading Explanation: Signs and symptoms for cerebral contusions include disturbances to vision, strength, and sensation. A child suffering a concussion will be distracted and unable to concentrate. Vomiting is a sign of a subdural hematoma. Bleeding from the ear is a sign of a basilar skull fracture.
The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? frequent temperature assessment vagus nerve stimulation ketogenic diet use of anticonvulsant medications
use of anticonvulsant medications 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 knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? positional plagiocephaly congenital hydrocephalus head trauma intracranial hemorrhaging
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.
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? "Did you use any medications, like aspirin, for the fever?" "Did you give your child any acetaminophen, such as Tylenol?" "How high did his temperature rise when he was ill?"
"Did you use any medications, like aspirin, for the fever?" 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 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 helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? "The child will be held by the mother on her lap with his back toward the health care provider." "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." "The child will be placed in the prone position with the nurse holding the child still." "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."
"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." Explanation: 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. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.
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? "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine." "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."
"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 meningococcal vaccine should be offered to high-risk populations. If never vaccinated, who has an increased risk of becoming infected with meningococcal meningitis? Select all that apply. 9-year-old child who was diagnosed with diabetes when he was 7 years old 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates 8-year-old child who is in good health 12-year-old child with asthma
18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates 12-year-old child with asthma 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti 9-year-old child who was diagnosed with diabetes when he was 7 years old Explanation: The following people have an increased risk of becoming infected with meningococcal meningitis: college freshman living in dormitories, children 11 years old or older, children who travel to high risk areas, and children with chronic health conditions.
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: raccoon eyes. Battle sign. rhinorrhea. otorrhea.
Battle sign. 2 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 in the emergency department with a head injury obtained in a motor vehicle crash. The Glasgow Coma Scale assessment is rated at 10 (3 eye opening, 3 motor, 4 verbal). How should the nurse interpret these findings? The child's eyes open to speech; child is able to obey commands but is confused. The child's eyes open spontaneously; child is able to localize pain and uses inappropriate words. The child's eyes open to verbal stimuli; child is confused and flexes with painful stimuli. The child's eyes open to pain; child opens to extension and says incomprehensible words.
The child's eyes open to verbal stimuli; child is confused and flexes with painful stimuli. Explanation: The Glasgow Coma Scale is a widely-used tool for assessing the extent of brain injury and prognosis. The scores are based on eye opening, motor response, and verbal response. The perfect score is 15. The lower the score the more severe the injury and prognosis. severe head injury are 8 or less. moderate head injury scores between 9-12 points mild head injury scores between 13- 15. With a score of 10, this child would be classified as having a moderate head injury. Eyes open spontaneously (4), localizes pain (5), and uses incomprehensive words(2) makes for a total score of 11. Eyes open to speech (3), uses inappropriate words (2), and has flexion withdrawal (4) makes for a total score of 9. Eyes open to pain (2), extremities open to expansion (2), and uses incomprehensible words (2) makes for a total score of 6.
The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? Select all that apply. Number of seizures child has had in the last 48 hours Eye position and movement Time the seizure started Factors present before seizure started Persons in attendance during seizure Incontinence of urine or stool
Time the seizure started Factors present before seizure started Eye position and movement Incontinence of urine or stool Explanation: Following a seizure, the nurse documents the following: time the seizure started; what the child was doing when the seizure began; any factor present just before the seizure (bright light, noise); part of the body where seizure activity began; movement and parts of the body involved; any cyanosis; eye position and movement; incontinence of urine or stool; time seizure ended; and child's activity after the seizure. Who was with the child or the number of seizures the child has had are not relevant to document regarding observation of this seizure.
