Neurologic Conditions

Question 1

Down Syndrome (trisomy 21)

Answer 1

1. Risk increases with maternal age.
2. Assessment:
   a. small head with slow brain growth, upward slanting palpebral fissures (the opening between the eyelids), Brushfield spots (marbling and speckling of the iris), broad flat nose and low-set ears, protruding tongue (small oral cavity), short stature with pudgy hands, transverse palmar/simian crease (a single crease across the palm), hypotonia, mild to moderate intellectual disability
3. Due to a protruding tongue and small oral cavity, the child should be fed using a small but long, straight-handled spoon to push food toward the back and side of the mouth; hypotonia and protruding tongue may interfere with infant feeding.
4. Increased risk of associated problems, such as congenital heart defects, strabismus, chronic myelogenous leukemia, thrombocytopenia, and a weaker immune response to infection.
   a. Due to atlantoaxial instability (partial dislocation and loose joint between C1 and C2), the child is at risk for compression of cervical nerves; and needs physician clearance for activities such as somersaults.
5. No specific treatment exists beyond ordinary care for the individual with cognitive delays; promote adaptation; provide play and communication based on the child’s mental age rather than their chronological age.

Question 2

Inborn errors of metabolism

Answer 2

includes multiple conditions resulting from altered biochemistry; enzyme; abnormalities resulting in accumulation of a reactant that may or may not have toxic neurologic effects

Question 3

Phenylketonuria (PKU)

Answer 3

results from a defect in hydroxylation of phenylalanine to form tyrosine; the resulting buildup of dietary phenylalanine results in brain damage and intellectual disability. The urine has a musty odor.

Eliminate dietary phenyl ketones, such as in high-protein foods (milk, meat, eggs, beans, and nuts).

Question 4

Galactosemia

Answer 4

is a defieciency in a galactose enzyme that results in liver failure, renal ubular problems, and cataracts.

Eliminate dietary galactose (generally available as lactose).

Question 5

Maple Syrup Urine Disease (MSUD)

Answer 5

is a deficiency of the decarboxylase that degrades some amino acids resulting in altered tonicity and seizures; the urine has the odor of maple syrup.

Restrict branched-chain amino acids in the diet as in high-protein foods (milk, meat, eggs, beans, and nuts).

Question 6

Cerebral Palsy (CP)

Introduction

Answer 6

1. is a neuromuscular disorder resulting from damage to or aberrant structure of the brain area that controls motor function.
   a. Etiologies include trauma (hemorrhage); anoxia before, during, or after birth; or infection.
   b. Commonly seen in children born prematurely.
2. CP is a nonprogressive disorder.
3. Disabilities associated with CP:
   a. abnormal muscle tone & coordination (spastic, athetoid, ataxic or mixed)
   b. intellectual disability of varying degrees in 18% to 50% (most children with CP have at least a normal IQ but cannot demonstrate it on standardized tests)
   c. speech, vision, or hearing disturbances
   d. dental anomalies
   e. seizures
   f. poor self-image and self-esteem
4. Assess for difficulty sucking or poor swallowing in the newborn period.

Question 7

Cerebral Palsy: Spastic

Answer 7

hypertonicity with poor posture control, leg scissoring, persistent primitive reflexes, altered quality of speech, poor coordination, and persistent muscle contraction (resulting in contractures).

Question 8

Cerebral Palsy: Dyskinetic-Athetotic

Answer 8

abnormal, constant, involuntary wormlike movements that disappear during sleep and increase with stress, especially affecting the facial muscle; decreased ability on fine motor skills; and no contractures.

Question 9

Cerebral Palsy: Ataxic

Answer 9

poor equilibrium and muscle coordination, and an unsteady wide-based gait.

Question 10

Cerebral Palsey: Rigid

Answer 10

simultaneous contraction of the contracting and extensor muscles, resulting in resistance to movement, diminished reflexes, and severe contractures.

Question 11

Seizures:
I. Focal Onset

Answer 11

Previously called simple and complex partial seizures; originates in one hemisphere.

Can be aware or have impaired awareness; can be motor or non-motor onset.

Question 12

Seizures:
II: Generalized Onset

Answer 12

Motor or non-motor; initial onset appears in both hemispheres.

Bilateral motor activity.

Question 13

Seizures:
Absence (petit mal)

Answer 13

Sudden onset; lasts 5 to 10 seconds; can have 100 daily; precipitated by stress, hyperventilation, hypoglycemia, fatigue, differentiated from daydreaming.

Loss of responsiveness but continued ability to maintain posture control and not fall. Symptoms may include twitching eyelids and lip smacking. No postictal symptoms.

Question 14

Seizures:
Myoclonic

Answer 14

Movement disorder (not a seizure) seen as child awakens or falls asleep; may be precipitated by touch or visual stimuli; focal or generalized; symmetric or asymmetric.

No loss of consciousness. Sudden, brief, shock-like involuntary contraction of one muscle group.

Question 15

Seizures:
Clonic

Answer 15

Opposing muscles contract and relax alternately in rhythmic pattern; may occur in one limb more than others.

Mucus production.

Question 16

Seizures:
Tonic

Answer 16

Muscles are maintained in continuous contracted state (rigid posture).

Variable loss of consciousness; pupils dilate; eyes roll up; glottis closes; possible incontinence; may foam at mouth.

Question 17

Seizures:
Tonic-Clonic

Answer 17

Violent total body seizure.

Aura; tonic first (20 to 40 seconds); clonic next; postictal symptoms.

Question 18

Seizures:
Atonic

Answer 18

Drop and fall attack; needs to wear protective helmet.

Loss of posture tone.

Question 19

Seizures:
Febrile

Answer 19

Seizure threshold lowered by elevated temperature; only one seizure per fever; common in 4% of the population under 5 when temperature is rapidly rising.

Lasts less than 5 minutes; generalized, transient, and nonprogressive; does n ot generally result in brain damage; electroencephalogram is normal after 2 weeks; may occur only once or may recur.

Question 20

Seizures:
Status Epilepticus

Answer 20

Prolonged or frequent repetition of seizures without interruption; results in anoxia, cardiac and respiratory arrest.

Consciousness not regained between seizures; lasts more than 5 minutes.

Question 21

Seizure medications

Answer 21

1. Side effects: fatigue, nausea, dizziness, possible bone marrow depression; gingival hyperplasia for children taking phenytoin (Dilantin) [this require good dental hygiene].
2. Seizure medications may interfere with hormonal contraception methods, requiring increased dose of oral contraceptive; many of the drugs are teratogenic, mandating additional sex education information to be provided to female teens.
3. Monitor serum levels of anticonvulsant medications to ensure therapeutic levels and prevent toxicity.
4. Remind child not to stop seizure medicaiton suddenly; slow tapering is required.
5. For seizures lasting more than 5 minutes; intranasal medications, such as Valtoco/ diazepam may be ordered for treatment; rectal diazepam (Diastat) may also be ordered.

Question 22

Seizure diet

Answer 22

Child may be ordered a ketogenic diet as a means to reduce seizures.
1. High-fat, low-carbohydrate, moderate protein diet that causes teh body to burn fat for energy.
2. Acceptable foods: meat, fish, eggs, cheese, natural fats; involve dietitian in teaching family.
a. Monitor weight as weight loss should be expected
3. Avoid carbohydrates found in sugary or starchy foods (grains, fruit, beans, potatoes); toothpaste also contains sugar.
4. Use normal saline instead of dextrose-containing IV fluid.

Question 22

Seizures: Vagus Nerve Stimulator (VNS)

Answer 22

Therapeutic management:
1. Educate child as appropriate and fammily regarding this adjunct therapy.
2. Indicated for children 4 years and older in whom medication has not been effective.
3. Electrodes are tunneled under the skin and stimulate the left vagus nerve (CN X).

Question 23

Increased Intracranial Pressure (ICP)

Answer 23

Introduction
1. May be caused by inflammation, tissue enlargement, or increased fluid accumulation.
2. A persistent increase in ICP destroys healthy brain tissue and alters mental function.

Assessment after the closure of cranial sutures
1. Assess for altered level of consciousnesss (LOC), including unconsolable irritability, decreased attention span, and/or lethargy.
2. Assess for vomiting and headache.
3. Assess and record vital signs.
a. Note increased BP, decreased pulse rate, and irregular respiratory rate. (Signs can deteriorate to the point of respiratory and cardiac arrest.)
4. Assess for blurred vision, papilledema, and altered pupil reaction to light; assess for balance problems and drowsiness.
5. Monitor behavior changes.
6. Observe for and monitor seizures.
7. Assess for an altered LOC, with decreased attention span or lethargy.
8. Observe for altered motor skills, such as clumsiness and loss of balance.

Interventions
1. Elevate the head of the bed to greater than 30 degrees to decrease cerebral edema.
2. Keep head midline to assist with venous drainage.
3. Administer an osmotic diuretic (such as mannitol) to decrease cerebral edema.
4. Administer corticosteroids to decrease brain inflammation.
5. Limit fluids to decrease blood volume, which will reduce cerebral edema; maintenance fluids may be kept at three-fourths usual IV + oral (PO) maintenance fluid therapy.
6. Monitor fluids and electrolytes.
7. Perform hyperventilation with a bag-valve-mask device, if ordered.
8. Monitor the child’s LOC.
9. Avoid activities that increase ICP (pain, seizures, fever, stress, crying, coughing, straining, and non-therapeutic touch).

Question 24

Hydrocephalus

Introduction

Answer 24

1. An increase in the amount of cerebrospina fluid (CSF) in the ventricles and subarachnoid spaces of the brain.
2. It is caused by either obstruction to the flow of CSF in the ventricular system (noncommunicating hydrocephalus) or by impaird absorption of the CSF in the arachnoid space (communicating hydrocephalus).
3. Arnold-Chiari malformation is the downward displacement of cerebellar components through the foramen magnum into the cervical spinal canal; it is common in hydrocephalus associated with spina bifida.
4. May be aquired from intraventricular hemorrhage in premature infants, meningitis, and head trauma.

Question 24

Hydrocephalus

Assessment

Answer 24

1. Measure and record the child’s head circumfrence; note a rapid increase.
2. Observe for full, tense, bulging fontanels.
3. Check for widening suture lines in infants.
4. Observefor distended scalp veins.
5. Assess for signs of increased intracranial pressure.
6. Note a high-pitched cry.
7. Note the sunset sign (sclera visible above the iris).
8. Observe the child’s inability to support the head when upright.
9. Percuss the skull; note the “cracked pot” sound.
10. Perform transillumination of the skull (the light will reflect off the opposite side of the skull).
11. Assess for post-shunt insertion complications: signs of shunt blockage (signs of increased ICP, increased head circumference and a full fontanel); also observe for signs of infection.

Question 25

Hydrocephalus

Interventions status post shunt insertion

Answer 25

1. For first 24 hours, lay flat to prevent headache and loss of fluid from gravity.
2. Do not lay the child on the shunt; do not compress the shunt without provider order.
3. Support the child’s head when the child is upright.
4. Provide proper skin care to the head; turn head frequently.
5. Provide pain management and latex precautions
6. Teach parents about signs of increasing ICP.
7. If the caudal end of the shunt must be externalized because of infection, keep the bag at ear level to prevent an increase or decrease in ICP.

Question 26

Neural Tube Defects

Introduction

Answer 26

1. A group of related CNS birth defects that arise from inappropriate closure of the embryonic neural tube; each type of neural tube defect varies in the severity of associated clinical symptoms.
2. Neural tube defects are multifactorial in origin, associated with a deficiency in maternal folic acid around the time of conception.
3. There are several types of neural tube defects classified according to the portion of the CNS involved:a. Anencephaly - a condition in which both cerebral hemispheres are absent; the brain stem and cerebellum may be present; the condition is incompatible with life. Many infants are stillborn or die within hours of birth; organ donation is a consideration among anencephalic infants who are born living.b. Encephalocele - a condition involving herniation of the brain through a defect in the skull resulting in a fluid - filled sac, sometimes with brain tissue inside.c. Meningocele - a condition involving the hernial protrusion of a sacklike cyst containing meninges but not spinal cord.d. Myelomeningocele - a condition in which the posterior portion of the vertebral laminae fails to close anywhere along the spinal cord, resulting in a protruding sac containing CSF, meninges, and a portion of the spinal cord; it is the most common type of spina bifida.
   1. Failure of the spinal cord to close occurs at 3 to 4 weeks’ gestation.
   2. Multiple handicaps can result because the spinal nerves are in the sac rather than in the spinal column.
4. The defects can be found early in gestation; the amniotic fluid will contain high levels of alpha fetoprotein from the leaking CSF.

Question 27

Neural Tube Defects

Anencephaly

Answer 27

a condition in which both cerebral hemispheres are absent; the brain stem and cerebellum may be present; the condition is incompatible with life. Many infants are stillborn or die within hours of birth; organ donation is a consideration among anencephalic infants who are born living.

Question 28

Neural Tube Defects

Encephalocele

Answer 28

a condition involving herniation of the brain through a defect in the skull resulting in a fluid - filled sac, sometimes with brain tissue inside.

Question 29

Neural Tube Defects

Meningocele

Answer 29

a condition involving the hernial protrusion of a sacklike cyst containing meninges but not spinal cord.

Question 30

Neural Tube Defects

Myelomeningocele

Answer 30

a condition in which the posterior portion of the vertebral laminae fails to close anywhere along the spinal cord, resulting in a protruding sac containing CSF, meninges, and a portion of the spinal cord; it is the most common type of spina bifida.
1. Failure of the spinal cord to close occurs at 3 to 4 weeks’ gestation.
2. Multiple handicaps can result because the spinal nerves are in the sac rather than in the spinal column.

Question 31

Neural Tube Defects

Assessment for spina bifida

Answer 31

1. Check for leakage from the sac.
2. Check for infection around the sac.
3. Assess for signs and symptoms of CNS infection.
4. Assess for sensation and motor activity below the sac.
5. Measure the head circumference to establish baseline data.
6. Assess bowel and bladder function and patterns

Question 32

Neural Tube Defects

Interventions (preoperative)

Answer 32

1. Provide emotional support to parents; be aware that surgery usually occurs 24 to 48 hours after birth.
2. Prevent trauma by keeping pressure off the sac; keep the child on one side with the knees flexed or on the abdomen.
3. Institute measures to keep the sac free of infection; avoid contamination from urine or stool.
4. Prevent the sac from drying; cover it with saline-soaked sterile dressings.

Question 33

Neural Tube Defects

Assessment (postoperative)

Answer 33

1. Note the degree of leg movement in response to discomfort.
2. Note the degree of sensitivity to touch below the level of the lesion; paralysis is possible.
3. Observe for clubfoot.
4. Observe for dribbling of urine, distended bladder, or the involuntary release of stool, which may indicate a neurogenic bladder and bowel.
5. Observe for signs of increased ICP related to hydrocephalus, possibly releated to scarring of the spinal area and reduced absorptive space that occurs following surgery; measure head circumference.
6. Note if the child is meeting developmental milestones.

Question 34

Neural Tube Defects

Interventions (postoperative)

Answer 34

1. Provide routine postoperative care; provide pain management.
2. Provide thorough skin care if paralysis occurs; place child on sheepskin.
3. Provide orthopedic appliances, if necessary.
4. Prevent constipation.
5. Promote range of motion.
6. Teach clean intermittent catheterization.
7. Be aware of an increased incidence of latex allergies in this population.
   a. With latex allergy, avoid elastic in rubber pants, nipples, pacifiers and (in older children) condoms.
   b. Beaware of cross reactivity with kiwi, bananas, and avocados that can result in an allergic reaction.

Question 35

Meningitis

Answer 35

Introduction
1. Is an inflammation of the meninges, caused by viral or bacterial agents and transmitted by the spread of droplets; organisms enter the blood from the nasopharynx or the middle ear.
2. The condition is common in infants and toddlers; its incidence is greatly decreased with the administration of Haemophilus influenzae type B vaccine.

Assessment
1. Note seizures.
2. Observe for signs of increased ICP: vomiting, irritability.
a. Infants and young toddlers may exhibit a high-ptched cry, bulging fontanel, and poor feeding.
b. Older children and adolescents may exhibit nuchal rigidity, headache.
3. Assess for abormal postures such as:
a. Opisthotonos (hyperextension of the neck and spine), may occur later in the course of illness.
b. Brudzinski’s sign (the child will flex the knees and hips in response to passive neck flexion).
c. Kernig’s sign (the child will complain of pain when their knees are flexed and their legs are raised).
4. Observe for a petechial or purpuric rash, which is associated with particular types of bacterial infection (meningococcal).
5. Note that lumbar puncture will show increased CSF pressure, cloudy color, increased white blood cells and protein counts, and a decreased glucose count if the meningitis is caused by bacteria.

Interventions
1. Institute seizure precautions.
2. Isolate the child for at least 24 hours after antibiotic therapy begins.
3. Assess the child’s neurologic status frequently to monitor for increased ICP.
4. Provide a low stimulus environment.
5. Keep the child flat in bed.
6. Move the child gently.
7. Administer parenteral antibiotics, as ordered.

Question 36

Brain Tumor

Introduction

Answer 36

1. The second most prevalent type of cancer and most common solid tumor in children.
2. The condition is commonly diagnosed when the child is between ages of 5 and 10.
3. One-half to two thirds of brain tumors in children are infratentorial, commonly involving the cerebellum or brain stem; remaining tumors are supratentorial and mainly involve the cerebrum.
4. Common brain tumors include glioma, medulloblastoma, astrocytoma, ependymoma, and crainopharyngioma.
5. Prognosis varies based on the type and location of the tumor.

Question 37

Brain Tumor

Assessment

Answer 37

1. Symptoms stem from the tumor’s pressure on adjacent neural tissues and/or on flow of CSF.
2. The young child is typically difficult to diagnose because of the elasticity of the skull and normally poor coordination.
3. ICP may increase.
4. Alterations in neurologic function, especially visual auity and behavior changes, may occur, including in a decline in school performance.
5. Headache, commonly an initial sign, usually occurs in the early morning on arising and during sneezing, coughing, and straining.
6. Vomiting, hypotonia, posturing, seizures, and altered vital sign may occur.
7. Other common signs and symptoms include ataxia (uncoordinated gait), cranial nerve palsies, anorexia, head tilt, nystagmus, decreased reflexes, vertigo, and a change in dexterity.
8. Assess for signs and symptoms of craniopharyngioma: pressure on the pituitary resulting in diabetes insipidus, visual problems, difficulty regulating body temperature, altered growth patterns, and altered CSF pressure.

Question 38

Brain Tumor

Interventions (preoperative)

Answer 38

1. Prepare the child for a CT or MRI scan.
2. Prepare the child for radiotherapy prior to tumor removal, in an attempt to shrink the tumor.
3. Advise the child and parents to expect facial edema and hair loss from chemotherapy.
4. Discuss surgical preparation.

Question 39

Brain Tumor

Interventions (postoperative)

Answer 39

1. Position the child on the nonoperative side to minimize pressure and prevent the brain from shifting into the space vacated by the tumor.
2. Make sure the child lies flat on either side if surgery was infratentorial to maintain a steady ICP; elevate the head of the bed slightly if surgery was supratentorial to promote venous drainage.
3. Provide pain management.
4. Provide incision care.
5. Assess neuro status and child’s LOC and ease of arousal; note any changes indicative of increasing ICP and report immediately.
6. Relieve eye edema with cool compresses; lubricate the eyes to prevent corneal irritation.
7. Prevent increased ICP by telling the child to avoid straining for stool or coughing forcefully.
8. Initiate seizure precautions.
9. Administer vasopressin (Pitressin) to treat diabetes insipidus for crainopharyngioma and replace lost fluid as ordered.

Question 40

Head Injuries

Introduction

Answer 40

1. Head injuries are a common cause of death in children older than age 1.
2. The extent of the brain injury is directly related to the force of penetration or impact.
3. An epidural, intracranial hemorrhage is bleeding into the spaces between the dura mater and the skull.
4. A subdural hemorrhage is bleeding between the dura mater and the arachnoid layer of the meninges.
5. A concussion is a transient state of neurologic dysfunction caused by a jarring of the brain; it is the most common head injury.
   a. It may or may not be accompanied by a loss of consciousness.
   b. If not completely healed before resuming activities, another head trauma could result in second impact syndrome, which could lead to sudden death.
6. A skull fracture may be linear (simple), depressed (depression of a bone toward the brain), or basilar (at the skull base).
7. Shaken Baby Syndrome is now called Abusive Head Trauma and often results in significant tearing of blood vessels (including retinal hemorrhages) with high morbidity and mortality.

Question 41

Head Injuries

Assessment

Answer 41

1. For epidural injury, assess for a recent history of head trauma with or without loss of consciousness; note increasing headaches, a decreasing LOC, contralateral hemiparesis, and bradycardia.
2. For a subdural injury, assess for an type of head trauma, such as from falls, accidents, or abuse.
3. For basilar fracture, observe for Raccoon eyes and CNS rhinorrhea.
4. For a concussion, note the child’s LOC and memory of the accident. Assess for headache, dizziness, vision problems, change in emotions or behaviors, sleep disturbances, difficulty remembering, vomiting.
5. Assess for signs and symptoms of increased ICP.
6. Perform frequent neurologic assessments to determine quality of reflexes, pupillary reflex, and LOC using the Glasgow Coma Scale score. A separate Pediatric Glasgow Coma Scale is available for children under age 5.
7. Assess vital signs frequently.
8. Prepare for a CT scan.
9. Check ear or nose drainage for glucose (CSF tests positive for glucose).
10. Note behavioral changes, such as aggression, withdrawal,, or irritability; watch for alterations in sleep patterns, gait, or school performance.

Question 42

Head Injuries

Interventions

Answer 42

1. Prepare for surgical evaluation of the blood clot and ligation of the bleeding vessel, if necessary.
2. Promote bed rest and limit unnecessary body movements; slightly elevate the head of the bed.
3. Initiate seizure precautions.
4. Provide a quiet environment; no eye strain, including no TV, computer time, reading, or texting in order to let the brain heal.
5. Awaken the child every 2 hours to assess for LOC.
6. Monitor fluid status carefully.
   a. Maintain clear liquids until the child has not vomited for at least 6 hours.
   b. Restrict fluids as needed to decrease ICP.
7. For concussion: student may not resume school or sports activities without medical clearance.

a. Daily activities should not cause symptoms to occur.
b. Return to school part time to assure classword does not cause symptoms.
c. There is no return to sports until student can function full time in the academic setting without symptoms.
d. Educational accommodations may be needed, especially related to physical education, noise abatement, the need for rest periods and extra time for assignments.
1. Prevent injury through family and community teaching programs to stress child safety (bicycle helmets, car restraining devices, protective skating and athletic equipment).

Question 43

Lead Poisoning (Plumbism)

Answer 43

Introduction
1. Occurs in children through ingestion of lead in lead-based paint chips or paint dust, contaminated drinking water from lead-based pipes, dust from lead ammunition, battery casings, collectible toys, some are supplies and some jewelry; it is more common in children under age 6 years.
2. There is no absolute safe blood level for children; a blood lead level of concern is ≥ 3.5 ug/dl.
3. Lead is carried by the RBCs and deposited into the bone and tissues; accumulation of lead may result in anemia, kidney damage, growth delay, and most importantly, neurologic impairment, including at low doses (distractibility, impulsivity, hyperactivity, hearing loss, mild intellectual deficits); at high doses, encephalopathy, cognitive deficits, paralysis, blindness, seizures, coma, and death may occur.
4. Lead is excreted in the urine and the bile very slowly; its half-life is 10 months.
5. Lead poisoning is a chronic condition that often goes unnoticed for extended periods of time; screening for risk factors is a key intervention.

Assessment
1. Observe for nausea, vomiting, anorexia, constipation, and abdominal pain.
2. Assess for symptoms of anemia: pallor, fatigue, and tachycardia.
3. Assess kidney function.
4. Assess for neurologic signs of lead poisoning including behavioral changes, distractibility, learnin difficulty, impaired intellect, and, in severe cases, signs of encephalopathy such as seizures and coma.
5. Assess for stunted growth in chronic lead poisoning.
6. Ask parents about a history of pica, the eating of nonfood substances, which is associated with lead poisoning.
7. Ask parents about presence of construction dust or peeling paint in homes built before 1978 (when paint contained lead).

Interventions
1. Provide lead screening at routine health visits; begin lead screening by 6 months of age.
2. Administer lead chelation therapy, which binds with the lead and excretes it from the body.
a. Blood lead levels >45 require oral or IV chelation
3. Monitor fluid status.
a. Promote fluid intake to promote excretion of lead.
b. Monitor output to evaluate kidney function.
4. Perform serial urine testing as prescribed to evaluate kidney function and lead excretion.
a. Provide parent and child education regarding lead poisoning.

Question 44

Lead poisoning prevention

Answer 44

• Prevent exposure to peeling, lead-based paint.
• If remodeling an older home, follow recommendations.
• Use only cold water from the faucet and allow it to run for 1 minute before using.
• Have water and soil tested.
• Do not store food in opened cans.
• Do not store food or drink from ceramicware or pottery containing lead.
• Ensure that children eat and drink adequate amounts of iron and calcium.

Question 45

Migraine Headaches

Answer 45

Overview
1. Migraines are often accompanied by extreme sensitivity to light and sound, nausea and vomiting.
2. Migraines are three times more common in women than in men; affect 15% of population.
3. Some children have an aura (visual disturbance, flashing lights, temporary loss of vision) before having a migraine.
4. A migraine headache typically lasts 4 to 72 hours.
5. Migraines may be triggered by a lack of food or sleep, exposure to light, hormonal changes, anxiety, and stress.
6. Migraines are believed to be inherited, but the etiology and pathophysiology are unknown.
7. The goal is to prevent attacks and improve quality of life.

Assessment
1. Thorough family history of headaches
2. Symptoms at the onset of headache (aura, lethargy, nausea)
3. Location - localized or generalized
4. Duration - how long does the headache last
5. Characteristics - any unusual characteristics associated with the headache
6. Severity of pain
7. What relieves or alleviates the headache
8. What aggravates or makes the headache worse
9. Effect on quality of life (loss of school days, work, activities)

Interventions
1. Stress reduciton management strategies
2. Relaxation exercises
3. Medicaitons and hormones, especially related to the menstrual cycle

Question 46

Following the repair of a myelomeningocele, the nurse watches for what post-operative complicaitons?

a. Hydrocephalus
b. Microcephaly
c. Seizures
d. Hypothermia

Answer 46

a

Infants after surgery to repair a myelomeningocele are at risk for hydrocephalus as a post-operative ocmplication. The reason for this is that the surgery to internalize their sac-like cyst causes a reduciton in the space for the CSF, meninges, and spinal cord which can lead to increased pressure.

Question 47

An important component of discharge teaching for the child being discharged on phenytoin (Dilantin) includes:

a. respiratory acidosis
b. tachycardia
c. gum hyperplasia
d. hearing loss

Answer 47

c

Discharge instructions to manage the side effects of gum hyperplasia should include the use of a soft toothbrush.

Question 48

The nurse would expect which of the following as an early symptom seen in a toddler with lead intoxicaiton?

a. hyperactivity
b. intellectual disability
c. diarrhea and dehydration
d. dyspnea

Answer 48

a

A child with early signs of lead intoxication may show mild behavioral changes, distractibility, hyperactivity, or learning problems. Later signs associated with lead encephalopathy include developmental delays, seizures, coma, and death. Additional manifestations are anemia, glycosuria, proteinuria, ketonuria, abdominal pain, vomiting, constipation, anorexia, and delayed linear growth.

Question 49

The nurse is caring for a 6-year-old child with a history of myelomeningocele that was repaired during infancy. Which of the following foods should the child avoid?

a. Bananas, kiwi, and avacado
b. Peanut butter, peanuts, and peanut oil
c. Dairy products
d. Meats and high protein foods

Answer 49

a

Children with myelomeningocele are sensitive to latex exposure which can result in potentially fatal anaphylactic reactions. Many children with latex allergies show an associated sensitivity to foods such as bananas, kiwi, avocados, and chestnuts.

Question 50

What is the expected course of treatment for a toddler with blood lead level of 70?

Answer 50

National standards for lead chelation therapy state that children with blood lead levels (BLL) between 45 and 70 require lead chelation with hospitalization if the child is symptomatic. The treatment for BLL > 5 varies.

Question 51

Sallie is a 10-year-old with epilepsy. She has been taking phenytoin for several years. Sallie complains to the nurse that she wishes that she didn’t have to take the “dumb medicine” because of the side effects. Which of the following side effects would Sallie most likely complain of?

a. Alopecia
b. Halitosis
c. Difficulty falling asleep
d. Hirsutism

Answer 51

d

Hirsutism (excessive body hair) is a common side effect of phenytoin. Alopecia and insomnia are not side effects of phenytoin. Halitosis (gum hyperplasia) is a side effect of phenytoin, with dental hygiene, halitosis can be prevented.

Question 52

Cushing’s triad

Answer 52

the trio of increased BP, decreased HR, and decreased respiratory rate indicates that the ICP is rising and may lead to herniation and cardiorespiratory collapse.

Question 53

A four-year-old is being evaluated for bacterial meningitis. Which of the following signs are often seen in the cerebral spinal fluid (CSF) obtained from an LP in bacterial meningitis?

a. Increased pressure when the CSF sample is obtained.
b. CSF that is clear and foul smelling.
c. CSF that contains a decreased protein count.
d. CSF that contains an increased glucose count.

Answer 53

a

Increased pressure is often noted when the CSF sample is obtained. In a child with bacterial meningitis, the CSF is usually cloudy with an increased protein count and decreased glucose level. CSF does not usually have a detectable odor.

Question 54

Tyler is a 10-year-old admitted with a head injury. The radiologist’s report of the CT scan states that the bleeding is located between the dura mater and the skull. The nurse knows that this type of head injury is called a(n):

a. Epidural bleed
b. Subdural hematoma
c. Intraventricular hemorrhage
d. Skull fracture

Answer 54

a

An epidural bleed is bleeding that occurs between the dura mater and the skull. A subdural hematoma is bleeding that occurs between the dura mater and the arachnoid layer of the meninges. Intraventricular hemorrhage is bleeding that occurs within the ventricles of the brain. A skull fracture is a break in one or more bones of the skull.

Question 55

The nurse is caring for Audrey, a newborn with myelomeningocele who has just been transferred from another hospital. When reviewing the plan of care, which of the following does the nurse question?

a. Monitor head circumference.
b. Anticipate corrective surgery within 24 - 48 hours.
c. Place IV in Audrey’s foot or scalp.
d. Keep Audrey in a prone position or side-lying position.

Answer 55

c

The scalp should not be used for an IV since she is at risk for hydrocephalus. The head circumference should be monitored due to the risk of hydrocephalus. Corrective surgery for myelomeningocele is usally done within 24 - 48 hours. The prone or side-lying position is preferred so that pressure to the exposed sac is avoided.

Question 56

The nurse is caring for 8-year-old jacob who has been admitted with a diagnosis of Reye syndrome. When obtaining his history, Jacob’s mom stated that she gave him aspirin while he was sick. The nurse inquires as to what type of illness Jacob had and expects Jacob’s mom to reply with which of the following?

a. Strep throat
b. Pink eye
c. Influenza
d. Rocky Mountain spotted fever

Answer 56

c

Reye syndrome is most often associated with the administration of salicylates during a viral illness such as influenza or varicella. Strep throat is a bacterial infection. Although conjunctivitis can be caused by a virus, it is not usually associated with Reye syndrome. Rocky Mountain spotted fever is associated with a bacterium-carrying tick.

Question 57

The nurse is caring for 6-year-old Ben, diagnosed with Reye syndrome. Which of the following would the nurse expect to see included in Ben’s plan of care?

a. Promote hydration trhough maintenance and bolus IV fluids.
b. Monitor liver function test results.
c. Assist with daily eye exams.
d. Provide education to Ben’s parents regarding the avoidance of aspirin in children under 10 years of age.

Answer 57

b

In Reye syndrome, liver funciton test results are monitored regularly to assess the degree of fatty changes in the liver. Since Reye syndrome is associated with increased intracranial pressure, IV fluids are usually given at less than maintenance requirements. There is no need for daily eye exams. Aspirin should not be administered to children under the age of 18.

Question 58

Phenobarbital

Answer 58

this is a barbiturate, it depresses brain function. The result is a decreased respiratory rate, heart rate, blood pressure, and body temperature.