N406 Exam 3 Cerebral Dysfunction

A nurse is assessing an 8-month-old infant for a suspected central nervous system complication. Which finding should the nurse identify as a classic manifestation of increased intracranial pressure (ICP) in an infant?

Tense, bulging fontanel and a high-pitched cry.

The nurse is performing an admission assessment on a 6-year-old child with a head injury. Which assessment finding should the nurse recognize as a sign of increased intracranial pressure (ICP) specific to a child of this age?

Nausea and vomiting, especially in the morning.

A nurse is caring for a child who has a ventriculoperitoneal (VP) shunt. The nurse knows that a VP shunt is primarily placed to drain cerebrospinal fluid (CSF) from the ventricles of the brain to which body cavity?

Peritoneal cavity

A nurse is using the Glasgow Coma Scale (GCS) to evaluate a pediatric client following a motor vehicle accident. The nurse knows that the GCS evaluates which three clinical parameters?

Eye opening, verbal response, and motor response.

The nurse is tracking trends in the Glasgow Coma Scale (GCS) for a child admitted with cerebral edema. What is the primary clinical role of observing and monitoring a client’s level of consciousness (LOC) using this scale?

To detect life-threatening complications such as progressive cerebral edema.

A nurse is caring for a 5-year-old child who was admitted following a near-drowning incident. The nurse calculates the child’s Pediatric Coma Scale score to be 7. Which action should the nurse immediately prepare for?

Assisting with immediate endotracheal intubation and mechanical ventilation.

A nurse is reviewing the chart of a child who was admitted to the pediatric intensive care unit (PICU) with a severe closed head injury. The child's Pediatric Coma Scale score is currently documented as a 4. The nurse knows that a score of 5 or less is associated with which clinical outlook?

A poor outcome.

A nurse is caring for an adolescent client with suspected meningitis. The nurse knows that meningitis is an infectious process infecting the central nervous system (CNS) that is primarily transmitted via which route?

Droplet transmission.

A nurse is conducting a parent education group at a community clinic. Which vaccine should the nurse emphasize as a vital preventative measure against bacterial meningitis?

The Haemophilus influenzae type b (Hib) vaccine.

The nurse is reviewing the pathophysiology of meningitis with a group of nursing students. The nurse explains that when an infectious pathogen invades the CNS, it triggers inflammation, swelling, and what secondary structural brain consequence?

Purulent exudates and tissue damage to the brain.

A child is suspected of having bacterial meningitis. Which diagnostic procedure does the nurse anticipate the provider will perform to obtain cerebrospinal fluid (CSF) for definitive culture and analysis?

Lumbar puncture.

A nurse is reviewing the cerebrospinal fluid (CSF) analysis results for a child suspected of having bacterial meningitis. Which combination of findings is diagnostic for bacterial meningitis?

Increased CSF pressure, cloudy appearance, high protein concentration, and low glucose level.

The nurse is administering ordered pharmacological therapies to a child who was just diagnosed with bacterial meningitis. Which two classifications of medication should the nurse expect to administer?

Antibiotics and steroid therapy.

A nurse is monitoring a child who is recovering from bacterial meningitis. The nurse should perform focused ongoing assessments to screen for which long-term complications of this infection?

Hydrocephalus, vision and hearing loss, delayed growth and development, seizures, and cranial nerve palsy.

A nurse is assisting the healthcare provider with a lumbar puncture on a school-aged child. Which action is a nursing priority during the procedure?

Assist with proper positioning and continuously monitor respiratory status, consciousness, heart rate, and pain level.

A 7-year-old child is brought to the emergency department presenting with persistent nausea and vomiting, progressive neurological deterioration, and an elevated serum ammonia level. The history reveals the child was given aspirin last week while recovering from a viral infection. What condition do these findings suggest?

Reye Syndrome

The nurse is reviewing the laboratory profile of a child admitted with suspected Reye Syndrome. Which two laboratory abnormalities are classic indicators of this disease process?

Elevated serum ammonia levels and hypoglycemia.

A nurse is designing a care plan for a child hospitalized with Stage III Reye Syndrome. Which nursing interventions should be included to manage the metabolic and physiological effects of this disorder?

Monitor in a hospital setting with frequent neurological checks, hydration, correcting acid-base imbalances, and protecting from coagulation injuries.

A nurse is caring for an 8-year-old child with a known history of epilepsy. The child begins to experience a simple partial seizure with motor signs. Which action should the nurse implement during the seizure activity?

Do not restrain the child's movements, remove harmful objects from the area, redirect to a safe area, and talk in a calm, reassuring manner.

A child in a pediatric unit suddenly falls to the floor and exhibits rigid muscle contractions followed by rhythmic jerking of all extremities. What is the nurse's priority action during this tonic-clonic seizure?

Ease the child down to the floor if standing/seated, place a pillow or folded blanket under the head, loosen restrictive clothing, clear the area of hazards, and time the episode.

The nurse is observing a child who is in the middle of a generalized tonic-clonic seizure episode. The child suddenly begins to vomit. Which action must the nurse implement immediately?

Turn the child to one side.

A generalized tonic-clonic seizure has just concluded in an 8-year-old child. Which set of actions should the nurse perform during the immediate postictal period?

Time the postictal period, check for breathing, check the position of the head/tongue, keep the child on their side, and withhold food/liquids until fully alert with a returned swallowing reflex.

A child has just experienced a generalized seizure, and the nurse notes that breathing is not present after the episode has concluded. Which action should the nurse implement first?

Give rescue breathing and call emergency medical services (EMS).

A nurse is teaching a group of parents about different types of epilepsy. A parent asks about a type of seizure where the child suddenly loses all muscle tone, causing them to drop or fall to the ground instantly. Which term should the nurse use to identify this type of seizure?

Atonic and Akinetic Seizures (Drop Attacks)

The nurse is creating home safety guidelines for the parents of a 4-year-old child who was recently diagnosed with a generalized seizure disorder. Which underlying nursing management principle is the priority?

Preventing injury during seizures, managing the environment, and administering appropriate medications.

A 3-year-old child is brought to the emergency department after experiencing a brief generalized seizure at home. The parents state the child's temperature rose rapidly to 39.4°C (103°F) due to an acute ear infection, and the seizure happened right after. The child has no history of neurological infection or metabolic imbalance. What type of seizure should the nurse suspect?

Febrile Seizure

The nurse is providing discharge education to the parents of a toddler who just experienced a benign febrile seizure. Which instruction is a priority to include in the teaching plan?

Teach parents how to take the temperature, turn the child on their side during an episode, time the seizure, and never put anything in the mouth.

The nurse is assessing a 3-month-old infant with hydrocephalus. Which finding should the nurse expect to note as a direct manifestation of this condition?

An abnormal rate of head growth, a bulging fontanelle, frontal bossing, and irritability/lethargy.

A 6-year-old child with a history of hydrocephalus is admitted to the pediatric unit. Which clinical manifestations should the nurse look for, knowing they indicate a childhood presentation of increased ICP caused by hydrocephalus?

Headache in the morning, papilledema, and strabismus.

A nurse is reviewing the diagnostic history of a pediatric client with suspected hydrocephalus. The nurse knows that in infancy, the diagnosis of hydrocephalus is primarily based on what measurement?

An abnormal head circumference trend, backed by primary diagnostic tools like CT or MRI.

A child with hydrocephalus has just received a ventriculoperitoneal (VP) shunt. The nurse explains to the family that the shunt tubing is designed with excess length. What is the clinical rationale for this design?

To minimize the number of surgical revisions needed as the child grows.

The nurse is assessing a child 2 weeks after the surgical placement of a ventriculoperitoneal (VP) shunt. Which complication represents the greatest medical concern within the first month following shunt placement?

Infection

A nurse notes that a child with a VP shunt has developed a high fever, a tense fontanel, and an increased sleeping pattern. The provider diagnoses a shunt malfunction. The nurse knows that a mechanical obstruction or shunt malfunction is most frequently caused by what factors?

Mechanical obstruction such as kinking, plugging, or tube migration.

A nurse is preparing to care for a pediatric client who requires a temporary external ventricular drain (EVD) or permanent VP shunt catheter placement. To determine if fetal hydrocephalus was present before birth, the nurse notes that it can be evaluated via ultrasonography as early as what gestational age range?

14-15 weeks gestation.

The nurse is using the Pediatric Coma Scale to assess a 1-year-old infant. When evaluating the best verbal/auditory response for an infant under 2 years old, which finding corresponds to a score of 4?

Cries, but is consolable.

The nurse is caring for a toddler who is undergoing evaluation for a central nervous system disorder. The nurse notes that the child exhibits a downward deviation of the eyes where the sclera is visible above the iris. How should the nurse document this specific ocular sign?

"Setting-sun" sign

A nurse is caring for a 4-year-old child who is experiencing a tonic-clonic seizure. The child is currently lying on their back in bed. Which action should the nurse perform to maximize physical airway safety?

Place a pillow or folded blanket under the child's head and turn the child to one side if vomiting or clearing secretions is required.

The nurse is preparing a child for a diagnostic lumbar puncture to check for central nervous system pathogens. Which description represents the correct primary purpose of a lumbar puncture?

Withdrawing cerebrospinal fluid (CSF) from the subarachnoid space for analysis to diagnose infection, obstruction, or hemorrhage, or to instill medications.