chapter 52 near

1. What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?

a. Headache
b. Bulging fontanel
c. Tachypnea
d. Increase in head circumference

A

Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. Bulging fontanel or increased head circumference is seen in infants. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length.

2. Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain?

a. "You won't be able to move your head during the procedure."
b. "You will have to drink a special fluid before the test."
c. "You will have to lie flat after the test is finished."
d. "You will have electrodes placed on your head with glue."

A

To reduce fear and enhance cooperation during the MRI, the child should be made aware that head movement will be restricted to obtain accurate information. The child does not need to drink special liquids, lie on the back afterward, or have electrodes placed.

3. Which 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

B

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.

4. The Glasgow Coma Scale consists of an assessment of

a. pupil reactivity and motor response.
b. eye opening and verbal and motor responses.
c. level of consciousness and verbal response.
d. ICP and level of consciousness.

B

The Glasgow Coma Scale assesses eye opening, and 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 is not a part of the Glasgow Coma Scale. Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale.

5. Nursing care of the infant who has had a myelomeningocele repair should include

a. securely fastening the diaper.
b. measurement of pupil size.
c. measurement of head circumference.
d. administration of seizure medications.

C

Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Seizure medications are not routinely given to infants who do not have seizures.

6. The most common problem of children born with a myelomeningocele is

a. bladder incontinence.
b. intellectual impairment.
c. respiratory compromise.
d. cranioschisis.

A

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children, leading to incontinence. Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

7. A recommendation to prevent neural tube defects is the supplementation of

a. vitamin A throughout pregnancy.
b. multivitamin preparations as soon as pregnancy is suspected.
c. folic acid for all women of childbearing age.
d. folic acid during the first and second trimesters of pregnancy.

C

The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. Vitamin A, multivitamins, and folic acid only during specific points during the pregnancy have not been shown to prevent neural tube defects.

8. How much folic acid does the nurse tell female patients is recommended for women of childbearing age?

a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg

B

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age has contributed to a reduction in the number of children with neural tube defects. The other doses are not the recommended dose.

9. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which of the following?

a. Avoiding using any latex product
b. Using only non-allergenic latex products
c. Administering medication for long-term desensitization
d. Teaching family about long-term management of allergic manifestations

A

Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75% of this patient population. There are no non-allergenic latex products. At this time, desensitization is not an option. There are no treatment options for long-term management of allergic symptoms for latex allergy.

10. When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of which disorder?

a. Hydrocephalus
b. Syndrome of inappropriate antidiuretic hormone (SIADH)
c. Cerebral palsy
d. Reye's syndrome

A

The combination of signs is strongly suggestive of hydrocephalus. SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reye's syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

11. What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy?

a. Tremulous movements at rest and with activity
b. Sudden jerking movement caused by stimuli
c. Writhing, uncontrolled, involuntary movements
d. Clumsy, uncoordinated movements

B

Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The child's muscles are very tight, and any stimuli may cause a sudden jerking movement. Tremulous movements, slow writhing movements, and loss of kinesthetic sense are not manifestations of spastic cerebral palsy.

12. Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis?

a. CSF appears cloudy.
b. CSF pressure is decreased.
c. Few leukocytes are present.
d. Glucose level is increased compared with blood.

A

In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually decreased compared with the serum glucose level.

13. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child?

a. "You will be on your knees with your head down on the table."
b. "You will be able to sit up with your chin against your chest."
c. "You will be on your side with the head of your bed slightly raised."
d. "You will lie on your side and bend your knees so that they touch your chin."

D

The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The other positions are not used for a lumbar puncture.

14. A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure?

a. Absence
b. Atonic
c. Tonic-clonic
d. Simple partial

A

Absence seizures are very brief episodes of altered awareness. The child has a blank expression. Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms.

15. What is the best response to a father who tells the nurse that his son "daydreams" at home and that his teacher has observed this behavior at school?

a. "Your son must have an active imagination."
b. "Can you tell me exactly how many times this occurs in one day?"
c. "Tell me about your son's activity when you notice the daydreams."
d. "He is probably overtired and needs more rest."

C

The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained. Describing an active imagination or an overtired child does not address the symptoms of the father's concern. Determining the number of times the behavior occurs is not as helpful as information about the behavior.

16. The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures?

a. Weight loss
b. Bruising
c. Anorexia
d. Drowsiness

B

Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. Weight gain, not loss, is a side effect of valproic acid. Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications. Anorexia is not a side effect of valproic acid.

17. A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child's level of consciousness?

a. Disoriented
b. Obtunded
c. Lethargic
d. Stuporous

B

Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

18. Which type of fracture describes traumatic separation of cranial sutures?

a. Basilar
b. Linear
c. Comminuted
d. Depressed

C

Comminuted skull fractures include fragmentation of the bone or a multiple fracture line. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A linear fracture includes a straight-line fracture without dural involvement. A depressed fracture has the bone pushed inward, causing pressure on the brain.

19. Which 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.

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. 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. 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.

20. 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 nursing assessment to detect early signs of a worsening condition?

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

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 neurologic signs. Neurologic posturing is indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

21. A 5-year-old sustained a concussion after falling out of a tree. In preparation for discharge, the nurse is discussing home care with the parents. Which statement made by the parents indicates a correct understanding of the teaching?

a. "I should expect my child to have a few episodes of vomiting."
b. "If I notice sleep disturbances, I should contact the physician immediately."
c. "I should expect my child to have some behavioral changes after the accident."
d. "If I notice diplopia, I will have my child rest for 1 hour."

C

The parents are advised of probable posttraumatic symptoms. These include behavioral changes and sleep disturbances. Vomiting and diplopia should be reported immediately. Sleep disturbances may occur with postconcussive syndrome, but difficulty waking the child up should be reported.

22. Which type of seizure involves both hemispheres of the brain?

a. Focal
b. Partial
c. Generalized
d. Acquired

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 a result of a brain injury from a variety of factors; it does not specify the type of seizure.

23. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure?

a. Guide the child to the floor if standing and go for help.
b. Turn the child's body on the side.
c. Place a padded tongue blade between the teeth.
d. Quickly slip soft restraints on the child's wrists.

B

Positioning the child on his side will prevent aspiration. It is inappropriate to leave the child during the seizure. Nothing should be inserted into the child's mouth during a seizure to prevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

24. After a tonic-clonic seizure, it would not be unusual for a child to display

a. irritability and hunger.
b. lethargy and confusion.
c. nausea and vomiting.
d. nervousness and excitability.

B

In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. The other manifestations are not normally seen after a seizure.

25. What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures?

a. The child should use a soft toothbrush and floss the teeth after every meal.
b. The child will require monitoring of renal function while taking this medication.
c. Dilantin should be taken with food because it causes gastrointestinal distress.
d. The medication can be stopped when the child has been seizure free for 1 month.

A

A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

26. The father of a newborn infant with myelomeningocele asks about the cause of this condition. What response by the nurse is most appropriate?

a. "One of the parents carries a defective gene that causes myelomeningocele."
b. "A deficiency in folic acid in the father is the most likely cause."
c. "Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele."
d. "There may be no definitive cause identified."

D

The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.

27. Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

a. Rapid, shallow breathing
b. Irregular, rapid heart rate
c. Increased diastolic pressure with narrowing pulse pressure
d. Confusion and altered mental status

D

The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema. Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with ICP. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

28. The nurse should expect a child who has frequent tension-type headaches to describe headache pain as which of the following?

a. "There is a rubber-band squeezing my head."
b. "It's a throbbing pain over my left eye."
c. "My headaches are worse in the morning and get better later in the day."
d. "I have a stomachache and a headache at the same time."

A

The child who has tension-type headaches may describe the pain as a bandlike tightness or pressure, tight neck muscles, or soreness in the scalp. A common symptom of migraines is throbbing headache pain, typically on one side of the eye. A headache that is worse in the morning and improves throughout the course of the day is typical of ICP. Abdominal pain may accompany headache pain in migraines.

29. What is an appropriate nursing intervention for the child with a tension headache?

a. Assess for an aura.
b. Maintain complete bed rest.
c. Administer mild pain medication.
d. Assess for nausea and vomiting.

C

Mild pain relievers like acetaminophen or ibuprofen are appropriate for the child with a tension headache. The other measures are not warranted.

30. Which statement by an adolescent indicates an understanding about factors that can trigger migraine headaches?

a. "I should avoid loud noises because this is a common migraine trigger."
b. "Exercise can cause a migraine. I guess I won't have to take gym anymore."
c. "I think I'll get a migraine if I go to bed at 9 PM on week nights."
d. "I am learning to relax because I get headaches when I am worried about stuff."

D

Stress can trigger migraines. Relaxation therapy can help the adolescent control stress and headaches. Other precipitating factors in addition to stress include poor diet, food sensitivities, and flashing lights. Visual stimuli, not auditory stimuli, are known to be a common trigger for migraines. Exercise is not a trigger for migraines. The adolescent needs regular physical exercise. Altered sleep patterns and fatigue are common triggers for migraine headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue.

31. What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)?

a. Immunosuppressive medications
b. Respiratory assessment
c. Passive range-of-motion exercises
d. Anticoagulant therapy

B

Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This is not the priority nursing intervention.

32. A child is brought to the emergency department in status epilepticus. Which medication should the nurse expect to be given initially in this situation?

a. Clorazepate dipotassium (Tranxene)
b. Fosphenytoin (Cerebyx)
c. Phenobarbital
d. Lorazepam (Ativan)

D

Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes. The other drugs are used for seizures but are not the first-line treatment for status.

33. What should be the nurse's first action when a child with a head injury complains of double vision and a headache, and then vomits?

a. Immobilize the child's neck.
b. Report this information to the physician.
c. Darken the room and put a cool cloth on the child's forehead.
d. Restrict the child's oral fluid intake.

B

Any indication of ICP such as double vision, headache, or vomiting should be promptly reported to the physician. Stabilizing the child's neck does not address the child's symptoms. Darkening the room and giving a cool cloth are comfort measures. A fluid restriction is not needed.

34. A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences?

a. The infant has 150 mL of CSF compared with 50 mL in the adult.
b. Papilledema is a common manifestation of ICP in the very young child.
c. The brain of a term infant weighs less than half of the weight of the adult brain.
d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

D

Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the child's coordination and fine muscle movements. An infant has about 50 mL of CSF compared with 150 mL in an adult. Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP. The brain of the term infant is two thirds the weight of an adult's brain.

35. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when preparing the child?

a. "Pain medication will be given."
b. "The scan will not hurt."
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."

B

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.

36. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?

a. Nuclear brain scan
b. Echoencephalography
c. CT scan
d. MRI

C

A CT scan provides a 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. MRI permits visualization of morphologic features of target structures and permits tissue discrimination that is unavailable with any other techniques.

1. What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? (Select all that apply.)

b. Occasional blood levels will be assessed.
d. It must be given in normal saline.
e. It must be filtered.

B, D, E

The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D51/2 NS. The IV dose must be filtered. The IV dose must be given in normal saline, not D51/2 NS. Dilantin has not been found to cause gastrointestinal upset, and since it is being given by the IV route, this is not a concern. The medication can be taken without food.

2. A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? (Select all that apply.)

a. Elevated white blood count (WBC)
c. Decreased glucose
d. Cloudy in color

A, C, D

The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

3. A 14-year-old is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes (Select all that apply.)

a. monitoring and maintaining systemic blood pressure.
b. administering corticosteroids.
e. monitoring for respiratory complications.

A, B, E

Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. Spinal cord injury is a catastrophic event. Discussion of long-term care should be delayed until the child is stable.

1. A 62-pound child has a spinal cord injury and is to receive steroid therapy. How much medication does the nurse draw up for the bolus dose? Record your answer in a whole number. Administer \_____ mg.

845

First calculate the child's weight in kilograms: 62/2.2 \= 28.181818 kilograms.
Next multiply the child's weight by the standard bolus dose: 28.181818 × 30 \= 845.454545 mg.
Round to the nearest whole number \= 845 mg.

2. A 62-pound child has a spinal cord injury and has completed the bolus dose of IV steroids. The nurse is preparing to hang an IV infusion of steroids for the next 23 hours. How much medication should this child get per hour? Record your answer using 1 decimal place. Administer \_______ mg/hour.

152.2

First calculate the child's weight in kilograms: 62/2.2 \= 28.181818 kilograms.
Next multiply the weight by the standard dose of 5.4 mg/kg/hour × 28.181818 \= 152.181818.
Last, round to 1 decimal place \= 152.2 mg/hour.