Chapter 30 : The child with cerebral Dysfunction

Question 1

1. An injury to which part of the brain will cause a coma?
   a. Brainstem
   b. Cerebrum
   c. Cerebellum
   d. Occipital lobe

Answer 1

ANS: A-Brainstem

Injury to the brainstem results in stupor and coma. Signs of damage to the cerebrum are specific to the
involved area. Individuals with frontal lobe injury may have impaired memory, personality changes, or altered
intellectual functioning. Individuals with damage to the cerebellum have difficulties with coordination of
muscle movements, including ataxia and nystagmus. Impaired vision and functional blindness result from
injury to the occipital lobe.

Question 2

2. What finding is a clinical manifestation of increased intracranial pressure (ICP) in children?
   a. Low-pitched cry
   b. Sunken fontanel
   c. Diplopia, blurred vision
   d. Increased blood pressure

Answer 2

ANS: C-Diplopia, blurred vision

Diplopia and blurred vision are signs of increased ICP in children. A high-pitched cry and a tense or bulging
fontanel are characteristic of increased ICP. Increased blood pressure, common in adults, is rarely seen in
children

Question 3

3. What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called?
   a. Twitching
   b. Spasticity
   c. Choreiform movements
   d. Associated movements

Answer 3

ANS: C-Choreiform movements

Quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation are called
choreiform movements. Twitching is defined as spasmodic movements of short duration. Spasticity is the
prolonged and steady contraction of a muscle characterized by clonus (alternating relaxation and contraction of
the muscle) and exaggerated reflexes. Associated movements are the voluntary movement of one muscle
accompanied by the involuntary movement of another muscle.

Question 4

4. What term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated
   stimulation?

a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative stat

Answer 4

ANS: B- Stupor

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation
describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state
describes the permanent loss of function of the cerebral cortex.

Question 5

5. What term is used to describe a childs level of consciousness when the child is arousable with stimulation?
   a. Stupor
   b. Confusion
   c. Obtundation
   d. Disorientation

Answer 5

ANS: C-Obtundation

Obtundation describes a level of consciousness in which the child is arousable with stimulation. Stupor is a
state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion re

Question 6

6. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly
   has a fixed and dilated pupil. How should the nurse interpret this?

a. Eye trauma
b. Brain death
c. Severe brainstem damage
d. Neurosurgical emergency

Answer 6

ANS: D-Neurosurgical emergency

The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should
immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has
experienced a neurologic insult. One fixed and dilated pupil is not suggestive of brain death. Pinpoint pupils or
fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and
dilated pupil is suggestive of damage on the same side of the brain.

Question 7

7. The nurse is caring for a child with severe head trauma after a car accident. What is an ominous sign that
   often precedes death?

a. Delirium
b. Papilledema
c. Flexion posturing
d. Periodic or irregular breathing

Answer 7

ANS: D-Periodic or irregular breathing

Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often
precedes complete apnea. Delirium is a state of mental confusion and excitement marked by disorientation for
time and place. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased
intracranial pressure. Flexion posturing is seen with severe dysfunction of the cerebral cortex or of the
corticospinal tracts above the brainstem.

Question 8

8. What test is never performed on a child who is awake?
   a. Dolls head maneuver
   b. Oculovestibular response

c. Assessment of pyramidal
tract lesions

d. Funduscopic examination for papilledema

Answer 8

ANS: B-Oculovestibular response

The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose
child. The caloric test is painful and is never performed on an awake child or one who has a ruptured tympanic
membrane. The dolls head maneuver, assessment of pyramidal tract lesions, and funduscopic examination for
papilledema are not considered painful and can be performed on awake children.

Question 9

9. The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings?
   a. Neurologic health
   b. Severe brain damage
   c. Decorticate posturing
   d. Decerebrate posturing

Answer 9

ANS: A-Neurologic health

Moro, tonic neck, and withdrawal reflexes are three reflexes that are present in a healthy 2-month-old infant
and are expected in this age group

Question 10

10. The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral function. The nurse should include what statement in preparing the child?
    a. The scan will not hurt.
    b. Pain medication will be given.
    c. You will be able to move once the equipment is in place.
    d. Unfortunately no one can remain in the room with you during the test.

Answer 10

ANS: A-The scan will not hurt.

For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the
procedure painful. Pain medication is not required; however, sedation is sometimes necessary. The child will
not be allowed to move and will be immobilized. Someone is able to remain with the child during the
procedure.

Question 11

11. What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious
    child?

a. Suction the child frequently.
b. Turn the childs head side to side every hour.
c. Provide environmental stimulation.
d. Avoid activities that cause pain or crying.

Answer 11

ANS: D-Avoid activities that cause pain or crying.

Unrelieved pain, crying, and emotional stress all contribute to increasing the ICP. Disturbing procedures
should be carried out at the same time as therapies that reduce ICP, such as sedation. Suctioning is poorly
tolerated by children. When necessary, it is preceded by hyperventilation with 100% oxygen. Turning the head
side to side is contraindicated for fear of compressing the jugular vein. This would block the flow of blood
from the brain, raising ICP. Nontherapeutic touch and environmental stimulation increase ICP. Minimizing
both touch and environmental stimuli noise reduces ICP.

Question 12

12. What nursing intervention is appropriate when caring for an unconscious child?
    a. Avoid using narcotics or sedatives to provide comfort and pain relief.

b. Change the childs position infrequently to minimize the chance of increased intracranial pressure
(ICP).

c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.

d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are
contraindicated.

Answer 12

ANS: C-Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.

Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration
must be avoided to prevent fatal cerebral edema. Narcotics and sedatives should be used as necessary to reduce
pain and anxiety, which can increase ICP. The childs position should be changed frequently to avoid
complications such as pneumonia and skin breakdown. Antipyretics are the method of choice for fever
reduction.

Question 13

13. What statement is descriptive of a concussion?
    a. Petechial hemorrhages cause amnesia.
    b. Visible bruising and tearing of cerebral tissue occur.
    c. It is a transient and reversible neuronal dysfunction.
    d. It is a slight lesion that develops remote from the site of trauma.

Answer 13

ANS: C-It is a transient and reversible neuronal dysfunction.

A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and
responsiveness resulting from trauma to the head. Petechial hemorrhages on the superficial aspects of the brain
along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion
is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of
trauma as a result of an accelerationdeceleration injury

Question 14

14. What statement best describes a subdural hematoma?
    a. Bleeding occurs between the dura and the skull.
    b. Bleeding occurs between the dura and the cerebrum.
    c. Bleeding is generally arterial, and brain compression occurs rapidly.
    d. The hematoma commonly occurs in the parietotemporal region

Answer 14

ANS: B-Bleeding occurs between the dura and the cerebrum.

A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of
cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, i usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

Question 15

15. A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse immediately
    assesses airway, breathing, and circulation. What should be the next nursing action?

a. Place the child on his side.
b. Take the childs blood pressure.
c. Stabilize the childs neck and spine.
d. Check the childs scalp and back for bleeding.

Answer 15

ANS: C-Stabilize the childs neck and spine.

After determining that the child is breathing and has adequate circulation, the next action is to stabilize the
neck and spine to prevent any additional trauma. The childs position should not be changed until the neck and
spine are stabilized. Blood pressure is a later assessment. A less urgent but important assessment is inspection
of the scalp for bleeding.

Question 16

16. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The
    childs level of consciousness is variable. The parents tell the nurse that they think their child is in pain because
    of periodic crying and restlessness. What is the most appropriate nursing action?

a. Explain that analgesia is contraindicated with a head injury.
b. Have the parents describe the childs previous experiences with pain.
c. Consult with a practitioner about what analgesia can be safely administered.
d. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert.

Answer 16

ANS: C-Consult with a practitioner about what analgesia can be safely administered.

A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate
practitioner is necessary to avoid conflict between the necessity to monitor the childs neurologic status and to
promote comfort and relieve anxiety. Analgesia can be safely used in individuals who have sustained head
injuries. The childs previous experiences with pain should be obtained as part of the assessment, but because of
the severity of the injury, analgesia should be provided as soon as possible. Analgesia can decrease anxiety and
resultant increased intracranial pressure.

Question 17

17. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a
    worsening condition?

a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness

Answer 17

ANS: D-Level of consciousness

The most important nursing observation is assessment of the childs level of consciousness. Alterations in
consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal
neurologic signs. Neurologic posturing is indicative of neurologic damage.

Question 18

18. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse
    is discussing home care with her mother. What sign or symptom is considered a manifestation of
    postconcussion syndrome and does not necessitate medical attention?

a. Vomiting
b. Blurred vision
c. Behavioral changes
d. Temporary loss of consciousness

Answer 18

ANS: C-Behavioral changes

The parents are advised of probable posttraumatic symptoms that may be expected. These include behavioral
changes, sleep disturbances, emotional lability, and alterations in school performance. If the child is vomiting, has blurred vision, or has temporary loss of consciousness, she should be seen for evaluation.

Question 19

19. An 18-month-old child is brought to the emergency department after being found unconscious in the family
    pool. What does the nurse identify as the primary problem in drowning incidents?

a. Hypoxia
b. Aspiration
c. Hypothermia
d. Electrolyte imbalance

Answer 19

ANS: A-Hypoxia

Hypoxia is the primary problem because it results in global cell damage, with different cells tolerating variable
lengths of anoxia. Neurons sustain irreversible damage after 4 to 6 minutes of submersion. Severe neurologic
damage occurs from hypoxia in 3 to 6 minutes. Aspiration of fluid does occur, resulting in pulmonary edema, atelectasis, airway spasm, and pneumonitis, which complicate the anoxia. Hypothermia occurs rapidly, except
in hot tubs. Electrolyte imbalances do result, but they are not a major cause of morbidity and mortality.

Question 20

20. The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the
    childs younger brother had when he was an infant. The nurse should base a response on which information?

a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.

d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are
available.

Answer 20

ANS: D-Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are
available.

H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is
administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of
the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of
neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of
a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the
potential causative organisms.

Question 21

21. A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include
    isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will
    begin when?

a. After the diagnosis is confirmed
b. When the medication is received from the pharmacy
c. After the childs fluid and electrolyte balance is stabilized
d. As soon as the practitioner is notified of the culture results

Answer 21

ANS: B-When the medication is received from the pharmacy

Antimicrobial therapy is begun as soon as a presumptive diagnosis is made. The choice of drug is based on the
most likely infective agent. Drug choice may be adjusted when the culture results are obtained. Waiting for
culture results to begin therapy increases the risk of neurologic damage. Although fluid and electrolyte balance
is important, there is no indication that this child is unstable. Antibiotic therapy would be a priority
intervention.

Question 22

22. The nurse is planning care for a school-age child with bacterial meningitis. What intervention should be
    included?

a. Keep environmental stimuli to a minimum.
b. Have the child move her head from side to side at least every 2 hours.
c. Avoid giving pain medications that could dull sensorium.
d. Measure head circumference to assess developing complications.

Answer 22

ANS: A-Keep environmental stimuli to a minimum.

The room is kept as quiet as possible and environmental stimuli are kept to a minimum. Most children with
meningitis are sensitive to noise, bright lights, and other external stimuli. The nuchal rigidity associated with
meningitis would make moving the head from side to side a painful intervention. If pain is present, the child
should be treated appropriately. Failure to treat can cause increased intracranial pressure. In this age group, the
head circumference does not change. Signs of increased intracranial pressure would need to be assessed.

Question 23

23. A young childs parents call the nurse after their child is bitten by a raccoon in the woods. The nurses
    recommendation should be based on what knowledge?

a. Antirabies prophylaxis must be initiated immediately.
b. The child should be hospitalized for close observation.
c. No treatment is necessary if thorough wound cleaning is done.
d. Antirabies prophylaxis must be initiated as soon as clinical manifestations appear.

Answer 23

ANS: A- Antirabies prophylaxis must be initiated immediately.

Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive
immunization with human rabies immunoglobulin (HRIG) as soon as possible. Hospitalization is not
necessary. The wound cleansing, passive immunization, and immunoglobulin administration can be done as an
outpatient. The child needs to receive both HRIG and rabies vaccine.

Question 24

24. What intervention should be beneficial in reducing the risk of Reye syndrome?
    a. Immunization against the disease
    b. Medical attention for all head injuries
    c. Prompt treatment of bacterial meningitis
    d. Avoidance of aspirin for children with varicella or those suspected of having influenza

Answer 24

ANS: D-Avoidance of aspirin for children with varicella or those suspected of having influenza

Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, either varicella
or influenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so
use of aspirin is avoided. No immunization currently exists for Reye syndrome. Reye syndrome is not
correlated with head injuries or bacterial meningitis.

Question 25

25. What term refers to seizures that involve both hemispheres of the brain?
    a. Absence
    b. Acquired
    c. Generalized
    d. Complex partial

Answer 25

ANS: C-Generalized

Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Absence seizures have a sudden onset and are characterized by a brief loss of consciousness, a blank stare, and
automatisms. Acquired seizure disorder is a result of a brain injury from a variety of factors; it is not a term
that labels the type of seizure. Complex partial seizures are the most common seizures. They may begin with
an aura and be manifested as repetitive involuntary activities without purpose, carried out in a dreamy state.

Question 26

26. What is the initial clinical manifestation of generalized seizures?
    a. Confusion
    b. Feeling frightened
    c. Loss of consciousness
    d. Seeing flashing lights

Answer 26

ANS: C-Loss of consciousness

Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial
seizure.

Question 27

27. What type of seizure may be difficult to detect?
    a. Absence
    b. Generalized
    c. Simple partial
    d. Complex partial

Answer 27

ANS: A-Absence

Absence seizures may go unrecognized because little change occurs in the childs behavior during the seizure. Generalized, simple partial, and complex partial all have clinical manifestations that are observable.

Question 28

28. What is important to incorporate in the plan of care for a child who is experiencing a seizure?
    a. Describe and record the seizure activity observed.
    b. Suction the child during a seizure to prevent aspiration.
    c. Place a tongue blade between the teeth if they become clenched.
    d. Restrain the child when seizures occur to prevent bodily harm.

Answer 28

ANS: A-Describe and record the seizure activity observed.

When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse
then describes and records the seizure activity. The child is not suctioned during the seizure. If possible, the
child should be placed on the side, facilitating drainage to prevent aspiration.

Question 29

29. A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school that
    lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion occurs. What is the most
    appropriate initial action by the school nurse?

a. Stay with child and have someone else call emergency medical services (EMS).
b. Notify the parent and regular practitioner.
c. Notify the parent that the child should go home.
d. Stay with the child, offering calm reassurance.

Answer 29

ANS: A-Stay with child and have someone else call emergency medical services (EMS).

Because this is the childs first seizure and it lasted more than 5 minutes, EMS should be called to transport the
child, and evaluation should be performed as soon as possible. The nurse should stay with the recovering child
while someone else notifies EMS.

Question 30

30. A child has been seizure free for 2 years. A father asks the nurse how much longer the child will need to
    take the antiseizure medications. How should the nurse respond?

a. Medications can be discontinued at this time.
b. The child will need to take the drugs for 5 years after the last seizure.
c. A step-wise approach will be used to reduce the dosage gradually.
d. Seizure disorders are a lifelong problem. Medications cannot be discontinued.

Answer 30

ANS: C-A step-wise approach will be used to reduce the dosage gradually.

A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is
seizure free for 2 years. Medications must be gradually reduced to minimize the recurrence of seizures. The
risk of recurrence is greatest within 6 months after discontinuation.

Question 31

31. A young adolescent experiences infrequent migraine episodes. What pharmacologic intervention is most
    likely to be prescribed?

a. Opioid
b. Lorazepam
c. Ergotamine
d. Sumatriptan

Answer 31

ANS: D-Sumatriptan

Sumatriptan is a serotonin agonist at specific vascular serotonin receptor sites and causes vasoconstriction in
large intracranial arteries. Opioids are used infrequently because they rarely work on the mechanism of pain. Lorazepam is a benzodiazepine that acts as an anxiolytic and sedative. It is not indicated for treatment of
migraine episodes. Ergotamine, an a-adrenergic blocker, is used for adult vascular headaches, but it is not used
in adolescents because of the side effects

Question 32

32. The nurse is teaching the parents of a 3-year-old child who has been diagnosed with tonic-clonic seizures. What statement by the parent should indicate a correct understanding of the teaching?
    a. I should attempt to restrain my child during a seizure.
    b. My child will need to avoid contact sports until adulthood.
    c. I should place a pillow under my childs head during a seizure.
    d. My child will need to be taken to the emergency department [ED] after each seizure

Answer 32

ANS: C-I should place a pillow under my childs head during a seizure.

Parents should try to place a pillow or folded blanket under the childs head for protection. The parent should
not try to restrain the child during the seizure. The child does not need to go to the ED with each seizures; the
nurse can teach parents certain criteria for when their child would need to be seen. Discussing what will
happen in adulthood is not appropriate at this time.

Question 33

33. The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma
    Scale score of 9, and is unconscious. What intervention should the nurse include in the childs care plan?

a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.
b. Maintain an active, stimulating environment.
c. Perform chest percussion and suctioning every 1 to 2 hours.
d. Perform active range of motion and nontherapeutic touch every 8 hours.

Answer 33

ANS: A-Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.

Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the
head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to
maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning
should be performed judiciously because they can elevate ICP. Range of motion should be passive and
nontherapeutic touch should be avoided because both of these activities can increase ICP.

Question 34

34. What clinical manifestations suggest hydrocephalus in an infant?
    a. Closed fontanel and high-pitched cry
    b. Bulging fontanel and dilated scalp veins
    c. Constant low-pitched cry and restlessness
    d. Depressed fontanel and decreased blood pressure

Answer 34

ANS: B-Bulging fontanel and dilated scalp veins

Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in
neonates. A closed fontanel, high-pitched cry, constant low-pitched cry, restlessness, a depressed fontanel, and
decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for
evaluation.

Question 35

35. A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurses response should be based
    on which knowledge?

a. It can be diagnosed only after birth
b. It can be diagnosed by chromosome studies.
c. It can be diagnosed with fetal ultrasonography.
d. It can be diagnosed by measuring the lecithin-to-sphingomyelin ratio.

Answer 35

ANS: C-It can be diagnosed with fetal ultrasonography.

Hydrocephalus can be diagnosed by fetal ultrasonography as early as 14 weeks of gestation. Most incidents of
hydrocephalus are not chromosomal in origin. The lecithin-to-sphingomyelin ratio can be used to determine
fetal lung maturity.

Question 36

36. A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What is a common reason for elective revision of this shunt?
    a. Meningitis
    b. Gastrointestinal upset
    c. Hydrocephalus resolution
    d. Growth of the child since the initial shunting

Answer 36

ANS: D-Growth of the child since the initial shunting

An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the childs
growth. Meningitis would require an emergent replacement or revision of the shunt. Gastrointestinal upset
alone would not indicate the need for shunt revision. Noncommunicating hydrocephalus will not resolve
without surgical intervention

Question 37

37. What is a priority of care when a child has an external ventricular drain (EVD)?
    a. Irrigation of drain to maintain flow
    b. As-needed dressing changes if dressing becomes wet
    c. Frequent assessment of amount and color of drainage
    d. Maintaining the EVD below the level of the childs head

Answer 37

ANS: C-Frequent assessment of amount and color of drainage

The EVD is inserted into the childs ventricle. Frequent assessment is necessary to determine amount of
drainage and whether an infection is present. The EVD is a closed system and is not opened for irrigation. Antibiotics may be administered through the drain, but this is usually done by the neuropractitioner. The
dressing is not changed. If it becomes wet, then the practitioner should be notified that cerebrospinal fluid
(CSF) may be leaking. Unless ordered, maintaining the EVD below the level of the childs head position will
create too much pressure and potentially drain too much CSF.

Question 38

38. The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. What issues should be addressed?
    a. Most childhood activities must be restricted.
    b. Cognitive impairment is to be expected with hydrocephalus.
    c. Wearing head protection is essential until the child reaches adulthood.
    d. Shunt malfunction or infection requires immediate treatment.

Answer 38

ANS: D-Shunt malfunction or infection requires immediate treatment.

Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and
treated immediately. Limits should be appropriate to the childs developmental age. Except for contact sports,
the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt
was placed.

Question 39

39. A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating
    hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary?

a. Tachycardia
b. Gastrointestinal upset
c. Hypotension
d. Alteration in level of consciousness

Answer 39

ANS: D-Alteration in level of consciousness

In older children, who are usually admitted to the hospital for elective or emergency shunt revision, the most ndicators of increasing intracranial pressure are an alteration in the childs level of consciousness, complaint of headache, and changes in interaction with the environment.

Question 40

40. After a tonic-clonic seizure, what symptoms should the nurse expect the child to experience?
    a. Diarrhea and abdominal discomfort
    b. Irritability and hunger
    c. Lethargy and confusion
    d. Nervousness and excitability

Answer 40

ANS: C-Lethargy and confusion

In the postictal phase, after a tonic-clonic seizure, the child may remain semiconscious and difficult to arouse. The average duration of the postictal phase is usually 30 minutes. The child may remain confused or sleep for
several hours. He or she may have mild impairment of fine motor movements. The child may have visual and
speech difficulties and may vomit or complain of headache

Question 41

41. What is the antiepileptic medication that requires monitoring of vitamin D and folic acid?
    a. Topiramate (Topamax)
    b. Valproic acid (Depakene)
    c. Gabapentin (Neurontin)
    d. Phenobarbital (Luminal)

Answer 41

ANS: D-Phenobarbital (Luminal)

Children taking phenobarbital or phenytoin should receive adequate vitamin D and folic acid because
deficiencies of both have been associated with these drugs.

Question 42

42. A 2-year-old child starts to have a tonic-clonic seizure. The childs jaws are clamped. What is the most
    important nursing action at this time?

a. Place a padded tongue blade between the childs jaws.
b. Stay with the child and observe his respiratory status.
c. Prepare the suction equipment.
d. Restrain the child to prevent injury

Answer 42

ANS: B-Stay with the child and observe his respiratory status.

It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The nurse must
remain calm, stay with the child, and prevent the child from sustaining any harm during the seizure. The nurse
should not move or forcefully restrain the child during a tonic-clonic seizure and should not place a solid
object between the teeth. Suctioning may be needed but not until the seizure has ended.

Question 43

43. A child has been admitted with status epilepticus. An emergency medication has been ordered. What
    medication should the nurse expect to be prescribed?

a. Lorazepam (Ativan)
b. Phenytoin (Dilantin)
c. Topiramate (Topamax)
d. Ethosuximide (Zarontin)

Answer 43

ANS: A-Lorazepam (Ativan)

For in-hospital management of status epilepticus, intravenous diazepam or lorazepam (Ativan) is the first-line
drug of choice. Lorazepam is the preferred agent because of its rapid onset (25 minutes) and long half-life
(1224 hours) with few side effects.

Question 44

44. A child is on phenytoin (Dilantin). What should the nurse encourage?
    a. Fluid restriction
    b. Good dental hygiene
    c. A decrease in vitamin D intake
    d. Taking the medication with milk

Answer 44

ANS: B-Good dental hygiene

Chronic treatment with phenytoin may cause gum hypertrophy. Children taking phenobarbital or phenytoin
should receive adequate vitamin D and folic acid because deficiencies of both have been associated with these
drugs. The medication should not be taken with milk, and fluids should be encouraged, not restricted.

Question 45

45. A child has a seizure disorder. What test should be done to gather the most specific information about the
    type of seizure the child is having?

a. Sleep study
b. Skull radiography
c. Serum electrolytes
d. Electroencephalogram (EEG)

Answer 45

ANS: D-Electroencephalogram (EEG)

An EEG is obtained for all children with seizures and is the most useful tool for evaluating a seizure disorder. The EEG confirms the presence of abnormal electrical discharges and provides information on the seizure type
and the focus. The EEG is carried out under varying conditionswith the child asleep, awake, awake with
provocative stimulation (flashing lights, noise), and hyperventilating. Stimulation may elicit abnormal
electrical activity, which is recorded on the EEG. Various seizure types produce characteristic EEG patterns:
high-voltage spike discharges are seen in tonic-clonic seizures, with abnormal patterns in the intervals between
seizures; a three-per-second spike and wave pattern is observed in an absence seizure; and absence of electrical
activity in an area suggests a large lesion, such as an abscess or subdural collection of fluid.

Question 46

46. A child develops syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a complication to
    meningitis. What action should be verified before implementing?

a. Forcing fluids
b. Daily weights with strict input and output (I and O)
c. Strict monitoring of urine volume and specific gravity
d. Close observation for signs of increasing cerebral edema

Answer 46

ANS: A-Forcing fluids

The treatment of SIADH consists of fluid restriction until serum electrolytes and osmolality return to normal
levels. SIADH often occurs in children who have meningitis. Monitoring weights, keeping I and O and specific
gravity of urine, and observing for signs of increasing cerebral edema are all part of the nursing care for a child
with SIADH.

Question 47

47. When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised if a
    week ago the child had recovered from what?

a. Measles
b. Influenza
c. Meningitis
d. Hepatitis

Answer 47

ANS: B-Influenza

The etiology of Reye syndrome is not well understood, but most cases follow a common viral illness, typically
influenza or varicella.

Question 48

48. If an intramuscular (IM) injection is administered to a child who has Reye syndrome, the nurse should
    monitor for what?

a. Bleeding
b. Infection
c. Poor absorption
d. Itching at the injection site

Answer 48

ANS: A-Bleeding

The nurse should watch for bleeding from the site. Because of related liver dysfunction with Reye syndrome,
laboratory studies, such as prolonged bleeding time, should be monitored to determine impaired coagulation.

Question 49

49. A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very
    irritable with a temperature of 102 F. What should the nurses care plan include?

a. Observing the childs voluntary movement
b. Checking the Babinski reflex every 4 hours
c. Checking the Brudzinski reflex every 1 hour
d. Assessing the level of consciousness (LOC) and vital signs every 2 hours

Answer 49

ANS: D-Assessing the level of consciousness (LOC) and vital signs every 2 hours

Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is carried out at
frequent intervals on a child with meningitis. The nurse should avoid actions that cause pain or increase
discomfort, such as lifting the childs head, so the Brudzinski reflex should not be checked hourly. Checking the
Babinski reflex or childs voluntary movements will not help with assessing the childs status.

Question 50

50. A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse expects which
    results for the cerebrospinal fluid that can confirm the diagnosis of meningitis?

a. WBCs; glucose
b. RBCs; normal WBCs
c. glucose; normal RBCs
d. Normal RBCs; normal glucose

Answer 50

ANS: A-WBCs; glucose

A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured and samples are obtained for
culture, Gram stain, blood cell count, and determination of glucose and protein content. The findings are
usually diagnostic. The patient generally has an elevated white blood cell count, often predominantly
polymorphonuclear leukocytes. The glucose level is reduced, generally in proportion to the duration and
severity of the infection.