The Child with Cerebral Dysfunction Flashcards
What test is never performed on a child who is awake?
a.
Doll’s head maneuver
b.
Oculovestibular response
c.
Assessment of pyramidal tract lesions
d.
Funduscopic examination for papilledema
ANS: B
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 doll’s head maneuver, assessment of pyramidal tract lesions, and funduscopic examination for papilledema are not considered painful and can be performed on awake children.
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the child’s 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.
ANS: D
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.
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
ANS: D
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
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.
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 is not suctioned during the seizure. If possible, the child should be placed on the side, facilitating drainage to prevent aspiration.
What effects of an altered pituitary secretion in a child with meningitis indicates syndrome of inappropriate antidiuretic hormone (SIADH)? (Select all that apply.)
a.
Hypotension
b.
Serum sodium is decreased
c.
Urinary output is decreased
d.
Evidence of overhydration
e.
Urine specific gravity is increased
ANS: B, C, D, E
The serum sodium is decreased, urinary output is decreased, evidence of overhydration is present, and urine specific gravity is increased in SIADH. Hypertension, not hypotension, occurs.
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
ANS: D
An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the child’s 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.
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
ANS: D
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.
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
ANS: A
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.
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
ANS: A
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.
What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called?
a.
Twitching
b.
Spasticity
c.
Choreiform movements
d.
Associated movements
ANS: C
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.
The nurse is preparing to admit a 5-year-old with an epidural hemorrhage. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a.
Headache
b.
Vomiting
c.
Irritability
d.
Cephalhematoma
e.
Pallor with anemia
ANS: A, B, C
The classic clinical picture of an epidural hemorrhage is a lucid interval (momentary unconsciousness) followed by a normal period for several hours, and then lethargy or coma due to blood accumulation in the epidural space and compression of the brain. The child may be seen with varying degrees of impaired consciousness depending on the severity of the traumatic injury. Common symptoms in a child with no neurologic deficit are irritability, headache, and vomiting. In infants younger than 1 year of age, the most common symptoms are irritability, pallor with anemia, and cephalhematoma.
The nurse is preparing to admit an adolescent with encephalitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a.
Malaise
b.
Apathy
c.
Lethargy
d.
Hypoactivity
e.
Hypothermia
ANS: A, B, D
The clinical manifestations of encephalitis include malaise, apathy, and lethargy. There is hyperactivity, not hypoactivity, and hyperthermia, not hypothermia.
A young adolescent experiences infrequent migraine episodes. What pharmacologic intervention is most likely to be prescribed?
a.
Opioid
b.
Lorazepam
c.
Ergotamine
d.
Sumatriptan
ANS: D
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.
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
ANS: B
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.
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.
ANS: A
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.
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
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 an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage.
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
ANS: C
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
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 child’s head
ANS: C
The EVD is inserted into the child’s 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 child’s head position will create too much pressure and potentially drain too much CSF.
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 child’s blood pressure.
c.
Stabilize the child’s neck and spine.
d.
Check the child’s scalp and back for bleeding.
ANS: C
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 child’s 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.
The nurse is preparing to admit a neonate with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a.
Jaundice
b.
Cyanosis
c.
Poor tone
d.
Nuchal rigidity
e.
Poor sucking ability
ANS: A, B, C, E
Clinical manifestations of bacterial meningitis in a neonate include jaundice, cyanosis, poor tone, and poor sucking ability. The neck is usually supple in neonates with meningitis, and there is no nuchal rigidity.
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 child’s fluid and electrolyte balance is stabilized
d.
As soon as the practitioner is notified of the culture results
ANS: B
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.
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.
ANS: B
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, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.
The nurse is preparing to admit a 7-year-old child with complex partial seizures. What clinical features of complex partial seizures should the nurse recognize? (Select all that apply.)
a.
They last less than 10 seconds.
b.
There is usually no aura.
c.
Mental disorientation is common.
d.
There is frequently a postictal state.
e.
There is usually an impaired consciousness.
ANS: C, D, E
Clinical features of complex partial seizures include the following: it is common to have mental disorientation, there is frequently a postictal state, and there is usually an impaired consciousness. These seizures last longer than 10 seconds (usually longer than 60
What term refers to seizures that involve both hemispheres of the brain?
a.
Absence
b.
Acquired
c.
Generalized
d.
Complex partial
ANS: C
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.
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
ANS: A
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.
