Chapter 50: Cerebral dysfunction

Question 1

1. Which term is used to describe the level of consciousness when a child can be aroused with stimulation? a. Stupor
   b. Confusion
   c. Obtundation d. Disorientation

Answer 1

ANS: C
Obtundation describes the level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is indicated by impaired decision making. Disorientation is confusion regarding time and place.

Question 2

2. 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 state

Answer 2

ANS: B
When the child remains in a deep sleep, responsive only to vigorous and repeated stimulation, he or she is in a stupor. 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 can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

Question 3

3. Which does the Glasgow Coma Scale assess?
   a. Pupil reactivity and motor response
   b. Eye-opening, verbal, and motor responses
   c. Level of consciousness and verbal response
   d. Intracranial pressure and level of consciousness

Answer 3

ANS: B
The Glasgow Coma Scale assesses eye-opening, verbal, and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and intracranial pressure are not measured by the Glasgow Coma Scale.

Question 4

4. The nurse is closely monitoring a child who is unconscious after a fall and notices that he suddenly has a fixed and dilated pupil. How should the nurse interpret this finding?
   a. Eye trauma
   b. Neurosurgical emergency
   c. Severe brainstem damage
   d. Indication of brain death

Answer 4

ANS: B
Pupils that suddenly appear fixed and dilated indicate 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 neurological insult. Pinpoint pupils or bilateral pupils that remain fixed 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. One fixed and dilated pupil is not suggestive of brain death.

Question 5

5. The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which is the basis of the nurse’s response?
   a. Pain medication will be administered prior to the scan.
   b. CT scans do not cause pain.
   c. Movement is allowed once the equipment is in place.
   d. No one is able to remain in the room with the child during the test.

Answer 5

ANS: B
For CT scans, the child will not be allowed to move and 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. Someone is able to remain with the child during the procedure.

Question 6

6. Which neurological diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?
   a. Nuclear brain scan
   b. Echoencephalography
   c. Computed tomography (CT) scan
   d. Magnetic resonance imaging (MRI)

Answer 6

ANS: C
A CT scan provides visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood–brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. An MRI provides visualizations of morphological features of target structures and tissue discrimination that is unavailable with any other technique.

Question 7

7. What is the priority nursing intervention when a child is unconscious after a fall?
   a. Establish adequate airway.
   b. Perform neurological assessment.
   c. Monitor intercranial pressure.
   d. Determine whether a neck injury is present.

Answer 7

ANS: A
Respiratory effectiveness is the primary concern when caring for the unconscious child. Establishing an adequate airway is always the first priority. A neurological assessment and examination for neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

Question 8

8. Which drug is used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema?
   a. Mannitol
   b. Epinephrine hydrochloride
   c. Atropine sulphate
   d. Sodium bicarbonate

Answer 8

ANS: A
For increased ICP, mannitol, an osmotic diuretic administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulphate, and sodium bicarbonate are not used to decrease ICP.

Question 9

9. Which of the following describes a concussion?
   a. Petechial hemorrhages that cause amnesia and cognitive delay
   b. Visible bruising and tearing of cerebral tissue occurs
   c. An alteration in neurological or cognitive function with or without loss of
   consciousness
   d. A slight lesion that develops remote from the site of trauma with immediate loss
   of consciousness

Answer 9

ANS: C
A mild traumatic brain injury, or concussion, is an alteration in neurological or cognitive function with or without loss of consciousness, which occurs immediately after a head injury. Petechial hemorrhages along the superficial aspects of the brain at 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. A contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.

Question 10

10. What type of fracture involves fragmented bone that is pushed inward and causes pressure on the brain? a. Basilar
    b. Compound
    c. Open
    d. Depressed

Answer 10

ANS: D
A depressed fracture means the bone is pushed inward, causing pressure on the brain. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture means the bone is exposed through the skin. An open fracture causes communication between the skull and the scalp or surfaces of the upper respiratory tract.

Question 11

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

Answer 11

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

Question 12

12. When providing discharge teaching to the mother of a child with a slight head injury, which symptom should the nurse tell the parent to seek medical attention for immediately?
    a. Sleepiness
    b. Vomiting, even once
    c. Headache, even if slight
    d. Confusion or abnormal behaviour

Answer 12

ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behaviour; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or an unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times also requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.

Question 13

13. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in his blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect?
    a. Brainstem injury
    b. Skull fracture
    c. Subdural hemorrhage
    d. Epidural hemorrhage

Answer 13

ANS: A
Signs of brainstem injury include deep, rapid, intermittent, and gasping respirations. Wide fluctuations in or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are also consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these symptoms.

Question 14

14. A toddler fell out of a second-story window. She briefly lost consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she “seems fine.” What knowledge should the nurse base her response on?
    a. She may have a brain injury.
    b. She needs this because of her age.
    c. She may start having seizures.
    d. She probably has a skull fracture.

Answer 14

ANS: A
The child’s history of the fall, brief loss of consciousness, and vomiting four times necessitates evaluation for a potential brain injury. The severity of a head injury may not be apparent in clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child’s age, and is necessary to determine whether a brain injury has occurred.

Question 15

15. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of the nursing assessment to detect early signs of a worsening condition?
    a. Posturing
    b. Vital signs
    c. Focal neurological signs
    d. Level of consciousness

Answer 15

ANS: D
The most important nursing observation is assessment of the child’s level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurological signs. Neurological posturing indicates neurological damage. Vital signs and focal neurological signs are later signs of progression when compared to level-of-consciousness changes.

Question 16

16. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child’s level of consciousness is variable. The parents tell the nurse they think their child is in pain because of periodic crying and restlessness. What is the most appropriate action for the nurse to take?
    a. Discuss with the parents the child’s previous experiences with pain.
    b. Discuss with the practitioner what analgesia can be safely administered.
    c. Explain that analgesia is contraindicated with a head injury.
    d. Explain that analgesia is unnecessary when a child is not fully awake and alert.

Answer 16

ANS: B
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 child’s neurological status and to promote comfort and relieve anxiety. Gathering information about the child’s previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and the resultant increased intracranial pressure.

Question 17

17. A 3-year-old child is hospitalized after a submersion injury. The child’s mother complains to the nurse, “This seems unnecessary when he is perfectly fine.” What is the basis for the nurses’ response?
    a. Supplemental oxygen is required after submersion injuries.
    b. Hospitalization is probably not required.
    c. Complications can occur after a submersion injury.
    d. Observation is required for possible central nervous system problems.

Answer 17

ANS: C
All children who have a submersion injury experience should be admitted to the hospital for observation. The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary. Although many children do not appear to suffer adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur 24 hours after the incident. The child may or may not require additional oxygen.

Question 18

18. Which statement best describes a neuroblastoma?
    a. The diagnosis is usually made after metastasis occurs.
    b. Early diagnosis is usually possible because of the obvious clinical manifestations.
    c. It is the most common brain tumour in young children.
    d. It is the most common benign tumour in young children.

Answer 18

ANS: A
Neuroblastoma is a silent tumour with few symptoms until metastasis occurs. Neuroblastomas are the most common malignant extracranial solid tumours in children. The majority of tumours develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize.

Question 19

19. The mother of a 2-month-old infant tells the nurse that she worries her baby will get meningitis like her oldest son did when he was an infant. What knowledge should the nurse base her response on?
    a. Meningitis rarely occurs during infancy.
    b. Often there is a genetic predisposition to meningitis.
    c. Vaccination to prevent all types of meningitis is now available.
    d. Administration of Hib vaccine has decreased the frequency of bacterial
    meningitis.

Answer 19

ANS: D
H. influenzae type B meningitis has virtually been 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 20

20. What agents are implicated for causing viral encephalitis?
    a. Tarantula spiders
    b. Mosquitoes and ticks
    c. Carnivorous wild animals
    d. Domestic and wild animals

Answer 20

ANS: B
Most agents for viral encephalitis have arthropod vectors, such as mosquitoes and ticks. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis.

Question 21

21. What may be beneficial in reducing the risk of Reye’s 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 influenza

Answer 21

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

Question 22

22. When taking the history of a child hospitalized with Reye’s syndrome, which would the nurse anticipate that the child experienced in the recent past?
    a. Measles
    b. Varicella c. Meningitis d. Hepatitis

Answer 22

ANS: B
Most cases of Reye’s syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye’s syndrome.

Question 23

23. What is the priority nursing intervention when caring for a child with Reye’s syndrome?
    a. Monitor intake and output.
    b. Prevent skin breakdown.
    c. Observe for petechiae.
    d. Do range-of-motion (ROM) exercises.

Answer 23

ANS: A
Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing ROM exercises are important interventions in the care of a critically ill or comatose child.

Question 24

24. A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. What is the basis of the nurses’ response?
    a. Epilepsy is an easily treatable disease.
    b. Very few children have actual epilepsy.
    c. The seizure may or may not be an indication of epilepsy.
    d. Reassure the father that his child probably does not have epilepsy.

Answer 24

ANS: C
Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The treatment of epilepsy involves a thorough assessment to determine the type of seizure the child is having and the cause of events, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not base the response on generalizations that very few children have actual epilepsy or provide reassurance that it is not epilepsy until further assessment is made.

Question 25

25. Which type of seizure involves both hemispheres of the brain? a. Focal
    b. Partial
    c. Generalized d. Acquired

Answer 25

ANS: C
Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is the result of a brain injury from a variety of factors; it does not specify the type of seizure.

Question 26

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

Answer 26

ANS: C
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 seizure
    b. Generalized seizure
    c. Simple partial seizure
    d. Complex partial seizure

Answer 27

ANS: A
Absence seizures may go unrecognized because little change occurs in the child’s behaviour during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable.

Question 28

28. What is one important nursing intervention when caring for a child who is experiencing a seizure?
    a. Describe and record the seizure activity observed.
    b. Restrain the child when the seizure occurs to prevent bodily harm.
    c. Place a tongue blade between the teeth if they become clenched.
    d. Suction the child during a seizure to prevent aspiration.

Answer 28

ANS: A
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 should not be restrained, and nothing should be placed in his or her mouth, as this may cause injury. To prevent aspiration, if possible, the child should be placed on his or her side, facilitating drainage.

Question 29

29. What clinical manifestations would suggest hydrocephalus in a newborn?
    a. Bulging fontanel and dilated scalp veins
    b. Closed fontanel and high-pitched cry
    c. Constant low-pitched cry and restlessness
    d. Depressed fontanel and decreased blood pressure
    8

Answer 29

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

Question 30

30. Which is used in the treatment of brain tumours in children?
    a. Radiation
    b. Bone marrow transplantation
    c. Myelography
    d. Stem cell transplantation

Answer 30

ANS: A
Treatment for brain tumours in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow transplantation, and stem cell transplantation therapies are not used to treat brain tumours in children.

Question 31

31. What is a clinical manifestation of increased intracranial pressure (ICP) in an infant?
    a. Low-pitched cry
    b. Sunken fontanel
    c. Increased blood pressure
    d. Irritability

Answer 31

ANS: D
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.

Question 32

32. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. What intervention should be included in the child’s postoperative care?
    a. Monitor for abdominal distension.
    b. Pump the shunt reservoir to maintain patency.
    c. Administer sedation to decrease irritability.
    d. Maintain Trendelenburg position to decrease pressure on the shunt.

Answer 32

ANS: A
Abdominal distension could be a sign of peritonitis or a postoperative ileus. Pumping the shunt reservoir, administering sedation, and maintaining Trendelenburg position are not interventions associated with this condition.

Question 33

1. What symptoms were present in the child for the nurse to document the child’s level of consciousness as a stupor? Select all that apply. Express answer with small letters followed by a comma and a space—e.g., a, b, c.
   a. Limited spontaneous movement
   b. Responds to vigorous and repeated stimulation
   c. Sluggish speech
   d. Falls asleep very quickly
   e. Moaning responses to stimulation

Answer 33

ANS: B,E
The level of consciousness known as a stupor indicates that the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation or moans responses to stimuli. Limited spontaneous movement, sluggish speech, and falling asleep quickly are characteristic of lethargy.

Question 34

2. When assessing a child with increased intracranial pressure (ICP), which are considered late signs? Select all that apply. Express answer in small letters followed by a comma and a space—e.g., a, b, c.
   a. Vomiting
   b. Bradycardia
   c. Diplopia
   d. Lethargy
   e. Flexion posturing
   f. Cheyne-Stokes respirations

Answer 34

ANS: B, E, F
Late signs of increased ICP in children include bradycardia, flexion (or extension) posturing, and Cheyne-Stokes respirations. Vomiting, diplopia, and lethargy are early-onset clinical manifestations.

Question 35

3. Which are the key reflexes that demonstrate healthy neurological status in young infants? Select all that apply. Express answer in small letters followed by a comma and a space—e.g., a, b, c.
   a. Plantar reflex
   b. Moro reflex
   c. Tonic neck reflex
   d. Corneal reflex
   e. Withdrawal reflex
   f. Babinski reflex

Answer 35

ANS: B, C, E
Three key reflexes that demonstrate healthy neurological status in young infants are the Moro, tonic neck, and withdrawal (to painful stimuli) reflexes.

Question 36

4. Place the levels of consciousness descriptor terms in order, beginning with most alert state.
   a. Confusion
   b. Disorientation
   c. Coma
   d. Stupor
   e. Persistent vegetative state
   f. Obtundation
   g. Lethargy

Answer 36

ANS: A, B, C, D, E, F, G