Chapter 16: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder
The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure?
"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."
An infant with a ventriculoperitoneal (VP) shunt in place is brought to the clinic because of being drowsy and less responsive. Which question in the health history would provide information to the nurse indicating that the VP shunt is perhaps infected?
"Has your child been eating well the last few days?"
A child with a seizure disorder has been prescribed phenytoin to control the seizures. While providing teaching about the medication, what dietary instructions should the nurse provide the parent?
"Increase your child's intake of whole milk and orange juice."
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.
- Time the seizure started - Factors present before seizure started - Eye position and movement - Incontinence of urine or stool
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.
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?
Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?
Positive Kernig sign
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?
Protect the child from hitting the arms against the bed.
Which of these age groups has the highest actual rate of death from drowning?
toddlers
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?
"Watch for changes in his behavior or eating patterns."
The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III?
A bright-colored toy is moved in the child's visual fields.
The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse?
Administer lorazepam IV as prescribed.
What information is most correct regarding the nervous system of the child?
As the child grows, the gross and fine motor skills increase.
The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority?
Assess the client's respiratory status.
A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use?
Place a cap or similar covering on the newborn's head.
The nurse is assessing a toddler for motor function. Which activity will be the most valuable?
Watch the child reach for a toy.
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)?
While assessing the child's pupils, there is no change in diameter in response to a light.
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)
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:
ensuring the parents know how to properly give antibiotics.
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 verbal response 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
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?
moving the infant's head every 2 hours
The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant?
placing the infant in an infant car seat after feeding the infant
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?
video electroencephalogram
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 will cradle her in my arms after the procedure for at least 30 minutes."
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 has been irritable for the last hour....seems like she is just upset for some reason."
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?
"Small increments in dosage lead to sharp increases in plasma drug levels."
The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my children aspirin!" What could the nurse say to begin educating the parent?
"Sometimes it is hard to tell what products may contain aspirin."
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session?
"What questions or concerns do you have about this device?"
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?
Assess the level of consciousness (LOC).
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
The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns?
IX
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.
What is a true statement regarding status epilepticus?
It is a common neurologic emergency in children.
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.
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?
Tell me your concerns about your child's shunt.
During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents?
The child shouldn't participate in activities that could be hazardous if a seizure occurs
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
A 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication?
Use a soft toothbrush.
The nurse is completing a nursing history on a female client who has just found out she is 6 weeks' pregnant. She reports that over the last 2 months she has been drinking excessive amounts of alcohol every weekend and smokes a half-pack of cigarettes per day. What is the nurse concerned with given this information? Select all that apply.
brain development in the fetus spinal cord development in the fetus
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
The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the child questions. How should the nurse document the child's level of consciousness?
obtunded
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
The nurse is preparing an in-service for the staff about abusive head trauma (shaken baby syndrome). When planning to review risk factors, what should be included? Select all that apply.
teen parents infant with colic premature infants financial concerns in the family.
While observing a child, the nurse notes that the child's arms and legs are extended and pronated. During shift hand-off, the nurse reports potential damage to:
the midbrain.
The nurse is talking with a teen and her parents about triggers for her frequent headaches. Which statements indicate an understanding? Select all that apply.
- "I may experience headaches during certain periods in my menstrual cycle." - "Change in weather can trigger my headaches." - "Giving up cola may be beneficial to helping me avoid headaches." - "Chocolate may trigger my headaches."
Antibiotic therapy to treat meningitis should be instituted immediately after which event?
Collection of cerebrospinal fluid (CSF) and blood for culture
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?
Decrease environmental stimulation
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."
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 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."
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."
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?
"What happened just before the seizures?"
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?
Risk for injury related to seizure activity
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?
"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."
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?"
The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse?
"Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns."
An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent indicates to the nurse that additional teaching is needed?
"I always keep phenobarbital with me in case of a fever."
Gabapentin has been prescribed for a pediatric client. Which statement by the client indicates an understanding of teaching related to the medication?
"I can't take this medication within 2 hours of taking my antacid medication."
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 need to watch for any new bruises or bleeding and let my health care provider know about it."
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.
- 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."
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.
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 Injury
The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be:
The child is in status epilepticus.
The young boy was involved in a motor vehicle accident and was admitted to the pediatric intensive care unit with changes in level of consciousness and a high-pitched cry. Which are late signs of increased intracranial pressure? Select all that apply.
The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. The child's heart rate is 56 beats per minute. The child's pupils are fixed and dilated.
