Nursing Care of the Child with a Neurologic Disorder
A 6-year-old has had a viral infection for the past 5 days and is now having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which of the following questions? a) "How high did his temperature rise when he was ill?" b) "Did you use any medications like aspirin for the fever?" c) "Did you give your child any acetaminophen, such as Tylenol?" d) "What type of fluids did your child take when he had a fever?"
"Did you use any medications like aspirin for the fever?" Correct 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 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.
An otherwise healthy 18-month-old child with a history of febrile seizures is in the wellchild clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? a) "I have ibuprofen available in case it's needed." b) "The most likely time for a seizure is when the fever is rising." c) "My child will likely outgrow these seizures by age 5." d) "I always keep phenobarbital with me in case of a fever."
"I always keep phenobarbital with me in case of a fever." Correct Explanation: Antiepileptics, such as phenobarbital (Luminal), 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 mother of a 12-year-old with Reye syndrome approaches the nurse wanting to know how this happened to her child, saying, "I never give my kids aspirin!" What could the nurse say to begin educating the woman? a) "Sometimes it's hard to tell what products may contain aspirin." b) "Don't worry; you're in good hands. We have it under control now." c) "Aspirin in combination with the virus will make the brain swell and the liver fail." d) "Do you think that maybe your child took aspirin on his own?"
"Sometimes it's hard to tell what products may contain aspirin." Correct Explanation: Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. The parent needs to be receptive to further education, and raising the possibility the child was responsible does not accomplish that goal. Don't state the obvious, but also don't minimize the situation. Encouraging the mother to ask for information and offering explanations in terms she will understand are important, but this response does not address the mother's assertion.
The nurse is educating the family of a 7-year-old epilepsy patient about care and safety for this child. Which of the following comments will be most valuable in helping the parent and the child cope? a) "Use this information to teach family and friends." b) "If he is out of bed, the helmet's on the head." c) "You'll always need a monitor in his room." d) "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, childcare 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 boy may be able to bike ride and swim with proper precautions.
After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which of the following as a neural tube defect? a) Anencephaly b) Encephalocele c) Arnold-Chiari malformation d) Spina bifida occulta
Arnold-Chiari malformation Correct Explanation: Arnold-Chiari malformation is a deformity of the cerebellar tonsils being displaced into the upper cervical canal. Anencephaly is a neural tube defect. Encephalocele is a neural tube defect Spina bifida occulta is a neural tube defect.
The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which of the following interventions would be most important for the nurse to perform? a) Pull up the side rails on the bed. b) Monitor core body temperature. c) Assess the child's level of consciousness. d) Help the child cope with an altered appearance.
Assess the child's level of consciousness. Correct Explanation: Decreased level of consciousness is frequently the first sign of major neurologic problems after head trauma. While body temperature is an important indicator of infection, it is not a priority here. Preventing harm by setting the side rails is more important for a seizure patient. The child's eyes will correct themselves when ICP is reduced.
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the patient's ear. This would be documented as which of the following? a) Raccoon eyes b) Otorrhea c) Battle sign d) Rhinorrhea
Battle sign Correct 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.
To detect complications as early as possible in a child with meningitis who's receiving I.V. fluids, monitoring for which condition should be the nurse's priority? a) Cerebral edema b) Renal failure c) Left-sided heart failure d) Cardiogenic shock
Cerebral edema Correct Explanation: The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Renal failure and cardiogenic shock aren't complications of I.V. therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent which of the following with regards to seizures? a) The EEG is normal. b) Cyanosis occurs at the onset of the seizure. c) The patient is bradycardiac. d) Convulsive activity occurs.
Convulsive activity occurs. Explanation: During seizures convulsive activity is typically noted. During a breath-holding spell, the child is bradycardiac, cyanosis occurs at the onset, and the EEG is normal.
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? a) Take vital signs every 4 hours b) Encourage the parents to hold the child c) Monitor temperature every 4 hours d) Decrease environmental stimulation
Decrease environmental stimulation Correct Explanation: 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. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.
The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. Which of the following would the nurse identify as a possible trigger? a) Swimming twice a week b) 11 p.m. bedtime; 6:30 a.m. wake-up c) Use of nonscented soap d) Drinking three cans of diet cola
Drinking three cans of diet cola Correct 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.
A 9-year-old girl who is suspected of having an infection of the central nervous system is undergoing a lumbar puncture to withdraw cerebrospinal fluid for analysis. The nurse knows that the needle will be introduced into the subarachnoid space at the level of which of the following vertebrae? a) L1 or L2 b) L4 or L5 c) T3 or T4 d) C1 or C2
L4 or L5 Correct Explanation: Lumbar puncture, the introduction of a needle into the subarachnoid space (under the arachnoid membrane) at the level of L4 or L5 to withdraw CSF for analysis, is used most frequently with children to diagnose hemorrhage or infection in the CNS or to diagnose an obstruction of CSF flow.
The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position? a) Lying prone, with the neck flexed b) Sitting up, with the back straight c) Lying on one side, with the back curved d) Lying prone, with the feet higher than the head
Lying on one side, with the back curved Correct Explanation: Lumbar puncture involves placing a needle between the lumbar vertebrae into the subarachnoid space. For this procedure, the nurse should position the client on one side with the back curved because curving the back maximizes the space between the lumbar vertebrae, facilitating needle insertion. Prone and seated positions don't achieve maximum separation of the vertebrae.
While observing a child, the nurse notes that the child's arms and legs are extended and pronated. The nurse interprets this as indicating damage to which of the following? a) Midbrain b) Meninges c) Cerebral cortex d) Cranial nerves
Midbrain Correct Explanation: The observations indicate decerebrate posturing, which occurs with damage to the midbrain. Decorticate posturing as evidenced by arm adduction, elbow flexion with arms over the chest, and wrist flexion with fisted hands indicates damage to the cerebral cortex. Damage to the cranial nerves would be manifested by defects in motor and/or sensory function depending on the cranial nerves affected. Meningeal irritation as with bacterial meningitis is manifested by opisthotonus in an infant. With this position, the head and neck are hyperextended to relieve discomfort.
A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the following in the order that reflects this progression. Coma Disorientation Oriented to person, place, and time Obtundation Stupor
Oriented to person, place, and time Disorientation Obtundation Stupor Coma Explanation: Levels of consciousness in order from most alert to least alert are orientated to person, place, and time (full consciousness); confusion (disorientation); obtundation; stupor; and finally coma.
A nurse is caring for a 3-year-old girl with microcephaly. Which of the following actions is appropriate for the nurse to take? a) Playfully ask the child to touch her nose. b) Teach the parents about ventriculoperitoneal (VP) shunts. c) Administer antipyretics as ordered. d) Prepare the child for the experience of cranial surgery.
Playfully ask the child to touch her nose. Correct Explanation: Having the child touch her nose will assist the nurse in assessing probable neurologic and cognitive deficits. A VP shunt may be necessary for hydrocephaly, not this disorder. Surgery is often an intervention for craniosynostosis but cannot correct microcephaly. Hyperthermia is not a complication with microcephaly.
A nurse is assessing a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition? a) Positive Homans' sign b) Positive Kernig's sign c) Negative Kernig's sign d) Negative Brudzinski's sign
Positive Kernig's sign Correct Explanation: A positive Kernig's sign indicates nuchal rigidity, caused by an irritative lesion of the subarachnoid space. A positive Brudzinski's sign also is indicative of the condition. A positive Homans' sign may indicate venous inflammation of the lower leg.
Put the following events of a generalized epileptic seizure in correct order: Tonic stage Prodromal period Clonic stage Postictal period
Prodromal period Tonic stage Clonic stage Postictal period Correct Explanation: A tonic-clonic seizure is characterized by the following events: 1) prodromal period, 2) tonic stage, 3) clonic stage, and 4) postictal period.
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? a) Occurrence of urine and fecal contamination b) Degree and extent of nuchal rigidity c) Onset and character of fever d) Signs of increased intracranial pressure (ICP)
Signs of increased intracranial pressure (ICP) Correct 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 providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which of the following statements is the best to use for a teaching session? a) Tell me your concerns about your child's shunt. b) Always keep her head raised 30º. c) Her autoregulation mechanism to absorb spinal fluid has failed. d) Call the doctor if she gets a persistent headache.
Tell me your concerns about your child's shunt. Correct 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 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 which of the following? a) The child may begin to have absence seizures every day. b) The child is having generalized seizures. c) The child is in status epilepticus. d) The child's history indicates she has infantile seizures.
The child is in status epilepticus. Correct Explanation: Status epilepticus is the term used to describe a seizure that lasts longer than 30 minutes or a series of seizures in which the child does not return to his or her previous normal level of consciousness. The child likely is having generalized seizures, but the most accurate description of what is happening is status epilepticus. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes. With absence seizures the child loses awareness and stares straight ahead but does not fall.
The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which of the following interventions is most effective for eliminating breakthrough seizures? a) Instructing her teacher how to respond to a seizure b) Understanding the side effects of medications c) Placing the child on her side on the floor d) Treating the child as though she did not have epilepsy
Understanding the side effects of medications Correct 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.
The nurse determines that a child is experiencing late signs of increased intracranial pressure based on assessment of which of the following? Select all that apply. a) Bradycardia b) Fixed dilated pupils c) Increased blood pressure d) Irregular respirations e) Sunset eyes
• Bradycardia • Fixed dilated pupils • Irregular respirations Explanation: Late signs of increased intracranial pressure include bradycardia, fixed and dilated pupils, and irregular respirations. Increased blood pressure and sunset eyes are early signs of increased intracranial pressure.
A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate to give in this situation? Select all that apply. a) Lorazepam b) Diazepam c) Fosphenytoin d) Gabapentin e) Carbamazepine
• Lorazepam • Diazepam • Fosphenytoin Correct Explanation: Commonly used medications for treating status epilepticus include lorazepam, diazepam, and fosphenytoin. Gabapentin and carbamazepine are anticonvulsants used to treat and prevent seizures in general.
When assessing a neonate for seizures, which of the following would the nurse expect to find? Select all that apply. a) Tonic-clonic contractions b) Tachycardia c) Ocular deviation d) Elevated blood pressure e) Jitteriness
• Tachycardia • Ocular deviation • Elevated blood pressure • Jitteriness Correct Explanation: Neonatal seizures may be difficult to recognize but may be manifested by tremors, jitteriness, tachycardia and elevated blood pressure, and ocular deviation. Tonic-clonic contractions typically are more common in older children.
The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. Which of the following would the nurse assess? Select all that apply. a) Verbal response b) Motor response c) Posture d) Eye opening e) Fontanels
• Verbal response • Motor response • Eye opening Correct Explanation: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.
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 an in-line skating accident. The caregiver should be instructed to do which of the following? Select all that apply. a) Administer acetaminophen for headache. b) Observe for and report to provider any double or blurred vision. c) Check the pupil reaction to light every 15 minutes for two hours. d) Wake the child every one to two hours to check level of consciousness. e) Observe and report any vomiting that occurs within six hours.
• Wake the child every one to two hours to check level of consciousness. • Observe and report any vomiting that occurs within six hours. • Observe for and report to provider any double or blurred vision. Explanation: The caregiver should observe the child for at least six hours for vomiting or a change in the child's level of consciousness. If the child falls asleep, he or she should be awakened every one to two hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The child's pupils are checked for reaction to light every four hours for 48 hours.
A nurse is providing information to the parents of a child diagnosed with absence seizures. Which of the following would the nurse expect to include when describing this type of seizure? Select all that apply. a) You might have mistaken this type of seizure for lack of attention. b) This type of seizure is more common in girls than it is in boys. c) This type of seizure is usually short, lasting usually for no more than 30 seconds. d) Your child will probably sleep deeply for ½ to 2 hours after the seizure. e) You might see a blank facial expression after a sudden stoppage of speech. f) The child will commonly report a strange odor or sensation before the seizure.
• You might have mistaken this type of seizure for lack of attention. • This type of seizure is more common in girls than it is in boys. • This type of seizure is usually short, lasting usually for no more than 30 seconds. • You might see a blank facial expression after a sudden stoppage of speech. Correct Explanation: Absence seizures are more common in girls than boys and are characterized by a sudden cessation of motor activity or speech with a blank facial expression or rhythmic twitching of the mouth or blinking of the eyelids. This type of seizure lasts less than 30 seconds and may have been mistaken for inattentiveness because of the subtle changes. Absence seizures are not associated with a postictal state.
The nurse is reinforcing teaching with the caregivers of a child who has had a head injury and is being discharged. Which of the following statements made by the caregiver indicate an accurate understanding of the follow-up care for their child? a) "We can give him Tylenol for a headache, but no aspirin." b) "Even if the flashlight bothers him, we will check his eyes." c) "If he vomits again, we will bring him back immediately." d) "If he falls asleep, we will wake him up every 15 minutes."
"Even if the flashlight bothers him, we will check his eyes." Explanation: The child's pupils are checked for reaction to light every four hours for 48 hours. If the child falls asleep, he or she should be awakened every one to two hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The caregiver should observe the child for at least six hours for vomiting or a change in the child's level of consciousness. The caregiver should notify the health-care provider immediately if the child vomits more than three times, but if the child vomits once, returning to the care provider immediately is not needed.
The nurse is collecting data from the caregivers of a child admitted with seizures. Which of the following statements indicates the child most likely had an absence seizure? a) "He kept smacking his lips and rubbing his hands." b) "His arms had jerking movements in his legs and face." c) "He was just staring into space and was totally unaware." d) "He usually is very coordinated, but he couldn't even walk without falling."
"He was just staring into space and was totally unaware." Correct Explanation: Absence seizures rarely last longer than 20 seconds. The child loses awareness and stares straight ahead but does not fall. Absence seizures rarely last longer than 20 seconds. The child loses awareness and stares straight ahead but does not fall. 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 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.
Seven-year old Isabelle 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 Isabelle first complained of 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 of the following statements would be best for the nurse to say to this mother? a) "This might or might not be a problem. Watch Isabelle 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." b) "This might or might not be a problem. Watch Isabelle 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." c) "This is a serious problem. Aspirin is likely to cause Reye syndrome, and Isabelle should be admitted to the hospital for observation as a precaution." d) "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 Isabelle 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." Correct 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 three to five 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 doctor orders the placement of an ICP monitor in a patient with cerebral edema. The nurse is aware that this surgery will take place in the infratentorial region of the brain. a) True b) False
False Explanation: Surgical procedures in the infratentorial region are usually indicated for tumor or cyst resection. Most surgical procedures in the supratentorial region of the brain are indicated for resection of epileptogenic cortex (seizure foci), placement of ventricular catheters to drain CSF, draining collected blood following head injury, placement of ICP monitors, and also resection or biopsy of tumors or cysts
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 of the following inquiries would suggest what has happened? a) "Was the child unconscious?" b) "Were there any jerky movements?" c) "What happened just before the seizures?" d) "How did you treat the child afterwards?"
"What happened just before the seizures?" Explanation: 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 clinic 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.
A child is home with the caregivers following a treatment for a head injury. If the child makes which of the following statements, the caregiver should contact the care provider. a) "It will be nice when you will let me take a long nap. I am sleepy." b) "I am glad that my headache is getting better." c) "My stomach is upset. I feel like I might throw up." d) "You look funny. Well, both of you do. I see two of you."
"You look funny. Well, both of you do. I see two of you." Correct 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 naueauted is not a reason to notify the provider.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room? a) A room with an 8-month-old infant with failure to thrive b) A private room near the nurses' station c) A room with a 12-month-old infant with a urinary tract infection d) A two-bed room in the middle of the hall
A private room near the nurses' station Correct Explanation: A child who has the diagnosis of bacterial meningitis will need to be placed in a private room until that child has received I.V. antibiotics for 24 hours because the child is considered contagious. Additionally, bacterial meningitis can be quite serious; therefore, the child should be placed near the nurses' station for close monitoring and easier access in case of a crisis.
A 6-year-old child with hydrocephalus had a ventriculoperitoneal (VP) shunt placed 6 weeks ago and now has experienced a seizure, vomiting, and loss of appetite. Which of the following interventions will target the child's most pressing need? a) Prepare a menu with the child's favorite foods. b) Pad and raise the rails on the child's bed. c) Administer intravenous antibiotics as ordered. d) Educate the parents about seizure precautions.
Administer intravenous antibiotics as ordered. Explanation: It is likely the child's VP shunt has become infected. Intravenous antibiotics are required. The symptoms of seizures and vomiting should diminish once the infection is brought under control. Eradicating the likely central nervous system infection takes precedence over poor appetite.
A nurse is performing a complete neurological examination of a 7-year-old boy. She will now test his cerebellar function. Which of the following tests would be appropriate for this purpose? a) Ask the boy to close his eyes and then touch his skin with a cotton wisp; ask him to point to where he was touched b) Ask the boy who he is, where he is, and what day it is c) Measure the circumference of the calves and thighs with a tape measure d) Ask the boy to touch each finger on one hand with the thumb that hand in rapid succession
Ask the boy to touch each finger on one hand with the thumb that hand in rapid succession Correct Explanation: Tests for cerebellar function are tests for balance and coordination, such as asking the child to touch each finger on one hand with the thumb of that hand in rapid succession. Motor function is measured by evaluating muscle size, strength, and tone. Begin by comparing the size and symmetry of extremities. If in doubt about either of these, measure the circumference of the calves and thighs or upper and lower arms with a tape measure. If children's sensory systems are intact, they should be able to distinguish light touch, pain, vibration, hot, and cold. Have a child close his eyes and then ask him to point to the spot where you touch him with an object. Orientation, which is one measure of cerebral function, refers to whether children are aware of who they are, where they are, and what day it is (person, place, and time).
Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis? a) Avoid making noise when in the child's room b) Keep the lights on brightly so that he can see his mother c) Rock the child frequently d) Have the child's 2-year-old brother stay in the room
Avoid making noise when in the child's room Correct Explanation: Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation.
Which of the following is consistent with increased ICP in the child? a) Increased appetite b) Emotional lability c) Bulging fontanel d) Narcolepsy
Bulging fontanel Correct Explanation: Children with increased ICP exhibit bulging fontanels. They typically have a decreased appetite, are restless, and have trouble sleeping.
The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for which of the following? a) Intracranial hemorrhaging b) Congenital hydrocephalus c) Positional plagiocephaly d) Closed head injury
Closed head injury Correct 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 closed head injury. 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 child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)? a) Cloudy appearance b) Elevated sugar c) Decreased leukocytes d) Decreased pressure
Cloudy appearance Correct 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.
Antibiotic therapy to treat meningitis should be instituted immediately after which event? a) Identification of the causative organism b) Collection of cerebrospinal fluid (CSF) and blood for culture c) Initiation of I.V. therapy d) Admission to the nursing unit
Collection of cerebrospinal fluid (CSF) and blood for culture Explanation: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of I.V. therapy aren't, by themselves, appropriate times to begin antibiotic therapy.
A child is diagnosed with aseptic meningitis. The child's mother states, "I don't know where she would have picked this up." The nurse prepares to respond to the mother, based on the understanding that this disorder is most likely caused by which of the following? a) Haemophilus influenza type B b) Escherichia coli c) Streptococcus group B d) Enterovirus
Enterovirus Correct Explanation: Aseptic meningitis is the most common type of meningitis, and if a causative organism can be identified, it is usually a virus such as enterovirus. E. coli is a cause of bacterial meningitis. H. influenza type B is a cause of bacterial meningitis. Streptococcus group B is a cause of bacterial meningitis.
In caring for the child with meningitis, the nurse recognizes that which of the following nursing diagnoses would be the most important to include in this child's plan of care? a) Risk for injury related to seizure activity b) Risk for acute pain related to surgical procedure c) Delayed growth and development related to physical restrictions d) Ineffective airway clearance related to history of seizures
In caring for the child with meningitis, the nurse recognizes that which of the following nursing diagnoses would be the most important to include in this child's plan of care? You selected: Risk for injury related to seizure activity Correct Explanation: Keeping the child free of injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and the history of seizures does not impact the airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.
A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which of the following interventions should the nurse take initially? a) Institute droplet precautions in addition to standard precautions. b) Palpate the child's fontanels. c) Encourage the mother to hold and comfort the infant. d) Educate the family about preventing bacterial meningitis.
Institute droplet precautions in addition to standard precautions. Correct 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 on once the initial infection has been controlled. Palpating the fontanels is used to assess for hydrocephalus.
Absence seizures are marked by which of the following clinical manifestations? a) Loss of muscle tone and loss of consciousness b) Brief, sudden onset of increased tone of the extensor muscle c) Sudden, brief jerks of a muscle group d) Loss of motor activity accompanied by a blank stare
Loss of motor activity accompanied by a blank stare Correct 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 of the following is a description of an absence seizure? a) Sudden, momentary loss of muscle tone, with a brief loss of consciousness b) Muscle tone maintained and child frozen in position c) Brief, sudden contracture of a muscle or muscle group d) Minimal or no alteration in muscle tone, with a brief loss of consciousness
Minimal or no alteration in muscle tone, with a brief loss of consciousness 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.
A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which of the following interventions would be most appropriate? a) Have the child sleep without a pillow under his head. b) Have the parents call the doctor if the child vomits more than twice. c) Teach the child and his parents to keep a headache diary. d) Review the signs of increased intracranial pressure with parents.
Teach the child and his parents to keep a headache diary. Correct 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 mother has brought her 5-month-old son to the clinic because he has been drowsy and unresponsive. The child has hydrocephalus and had a shunt placed about a month previously. Which of the following symptoms indicate that the shunt is infected? a) The fontanels are bulging or tense. b) The child is not responding or eating well. c) The child's pupil reaction time is rapid and uneven. d) The child has a high-pitched cry.
The child is not responding or eating well. Correct Explanation: Poor feeding and decreased responsiveness are signs of an infection. The nurse might also observe localized inflammation along the shunt tract. Bulging or tense fontanels suggest a shunt malfunction that is causing increased intracranial pressure. A high-pitched cry suggests increased intracranial pressure due to a shunt malfunction. Decreased and uneven pupil reaction times are symptoms of a shunt malfunction that is causing increased intracranial pressure.
Which of the following age groups of children have the highest actual rate of death from drowning? a) School-age children b) Infants c) Preschool children d) Toddlers
Toddlers Correct Explanation: Toddlers and older adolescents have the highest actual rate of death from drowning.
The best way to evaluate a child's level of consciousness is through conversation. a) True b) False
True Correct Explanation: The best way to evaluate a child's level of consciousness is through conversation. Note any drowsiness or lethargy. Allow the child to answer questions without prompting, and listen carefully to be certain the answer is appropriate to the question.
The treatment for children with seizures disorders is most often which of the following? a) Use of anticonvulsant medications b) Surgical intervention c) Strict exercise regimen d) Restricted fat diet
Use of anticonvulsant medications Correct Explanation: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. A few children may be candidates for surgical intervention but, in most cases, surgery is not the treatment. Ketogenic diets (high in fat and low in carbohydrates and protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Exercise is not a treatment for seizure disorders.
A nurse is performing a neurological examination of a preschool girl. She is testing her remote memory. Which of the following would be an appropriate type of memory to ask the girl to recall? a) Where the girl and her family went on vacation last year b) What the girl had for dinner last night c) A string of three digits that the nurse has just spoken to her d) The name of an object that the nurse showed her 5 minutes ago
What the girl had for dinner last night Explanation: Immediate recall is the ability to retain a concept for a short time such as being able to remember a series of numbers and repeat them (a child of 4 years can usually repeat three digits; a child older than 6 years can repeat five digits). Recent memory covers a slightly longer period of time. To measure this, show the preschool child an object such as a key and ask him to remember it, because later you will ask him to tell you what it was. After about 5 minutes, ask whether he remembers what object you showed him. Ask older children what they ate for breakfast to test recent memory. Remote memory is long-term recall. Ask preschoolers what they ate for breakfast that morning, or dinner the night before as, for them, that was a long time ago; ask older children what was the name of their first-grade teacher as most people remember that their whole life.
