Chapter 16: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder

The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform?
Assess the child’s level of consciousness.

Decreased level of consciousness is frequently the first sign of major neurologic problems after head trauma. While body temperature is an important indicator of infection, it is not a priority here. Preventing harm by setting the side rails is more important for a seizure client. The child’s eyes will correct themselves when ICP is reduced.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child’s ear. This would be documented as:
Battle sign.

Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and “raccoon eyes” (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

What finding is consistent with increased ICP in the child?
Bulging fontanel

Children with increased ICP exhibit bulging fontanels. They typically have a decreased appetite, are restless, and have trouble sleeping.

The nurse is caring for a 6-year-old child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What actions by the nurse are indicated?
• Check tubing clamps to ensure they are open.
• Ensure the tubing is not kinked.

Nursing care of an external ventricular drainage device requires the nurse ensure all connections are secure and labeled. The amount of drainage requires close observation. If drainage is absent or minimal the nurse must assess the tubing to make certain it is not clamped or kinked. The level of the drip chamber must be set at the height of the child (at the clavicle). Taking the temperature will be useful to assess for the presence of infection but that is not currently a concern. Asking the child to cough and deep breathe should not be done. Deep breathing is beneficial for all postoperative clients, but coughing may increase pressures and should be avoided.

A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)?
Cloudy appearance

In the CSF of clients diagnosed with bacterial meningitis, the pressure is elevated, the appearance is cloudy, and the leukocytes are elevated. A decreased sugar content is noted.

A 9-year-old diagnosed with neurofibromatosis is being evaluated for the presence of a brain tumor. What tests may be ordered to diagnose this condition?
• Computed tomography
• Magnetic resonance imaging

Computed tomography is used for visualization of tumors, ventricles, brain tissue, CSF, hematomas, and cysts. Magnetic resonance imaging is also useful in tumor identification. Lumbar puncture is used to measure CSF pressure and collect CSF samples for laboratory tests. Electroencephalograms detect and locate abnormal electrical discharges produced in the brain. Radiology identifies the presence of fractures, widened skull sutures, calcifications, bone erosion, or skeletal anomalies

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent what information in regard to seizures?
Convulsive activity occurs.

During seizures convulsive activity is typically noted. During a breath-holding spell, the child is bradycardiac, cyanosis occurs at the onset, and the EEG is normal.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?
Decrease environmental stimulation

A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn’t cause increased meningeal irritation.

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?
“Did you use any medications like aspirin for the fever?”

Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

The nurse and an adolescent are reviewing the adolescent’s record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger?
Drinking three cans of diet cola

Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, “It seems like my son is falling and hitting his head all of the time.” What is the best response by the nurse?
“Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns.”

The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant’s and child’s neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother’s concerns in case there is another issue causing the falls.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate?
“During delivery, your vaginal wall put pressure on the baby’s head.”

Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby’s head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

The nurse is using the pediatric Glasgow Coma Scale to assess a child’s level of consciousness. What would the nurse assess?
• Eye opening
• Verbal response
• Motor response

The nurse caring for a child with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema.

Antibiotics or antivirals are used to treat infectious disease processes. Glucocorticoids and diuretics are used to reduce cerebral edema.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem?
Head trauma

A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Positional plagiocephaly is caused by an infant’s head remaining in the same position for too long.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?
Intracranial hemorrhaging

Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection

The nurse has just admitted a 17-year-old diagnosed with bacterial meningitis. The parents of the adolescent tell the nurse, “We just don’t understand how this could have happened. Our child has always been healthy and also just received a booster vaccine last year?” How should the nurse respond?
“I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection.”

Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Questioning them about being sure would not be the best response unless there was reason to believe their information was not accurate. There is nothing to lead the nurse to believe that a different strain of bacteria caused the infection, or that the the child’s immune system is compromised

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?
Moving the infant’s head every 2 hours

Positional plagiocephaly can occur because the infant’s head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.

Any individual taking phenobarbital for a seizure disorder should be taught:
Never to discontinue the drug abruptly.

Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child’s dependency on the drug can result.

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the levels of consciousness in the order that reflects this progression.
Oriented to person, place, and time

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included?
• Oxygen gauge and tubing
• Suction at bedside
• Padding for side rails

When planning the client’s environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.

A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use?
Place a cap or similar covering on the infant’s head.

Using an infant cap can help parents deal with the malformed appearance of their child. Because the child was born with a small or missing brain, the baby will likely die within hours or days. Monitoring for increased intracranial pressure (ICP) or neurologic status are not necessary interventions.

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?
Positive Kernig sign

A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy

An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child?
• Request order for an antiemetic
• Assess intake and output every shift
• Request order for anticonvulsant

This child likely has Reye syndrome and may require an anti-emetic for severe vomiting. The nurse should monitor the child’s intake and output every shift for the development of fluid imbalance. The child may require an anticonvulsant due an increased intracranial pressure that may induce seizures. A distinctive rash is associated with the development of meningococcal meningitis. The nurse should monitor the Reye’s syndrome child’s laboratory values for indications that the liver is not functioning well

The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority?
Risk for injury

A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures is the most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to inability to swallow. All of these symptoms would make Risk for injury the highest priority.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be the most important to include in this child’s plan of care?
Risk for injury related to seizure activity

The child’s risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and the history of seizures does not impact the airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?
Signs of increased intracranial pressure (ICP)

Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who’s ill from nearly any cause but doesn’t pose a great danger to life

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):

A steroid may be prescribed to reduce inflammation and pressure on vital centers.

When assessing a neonate for seizures, what would the nurse expect to find?
• Tachycardia
• Elevated blood pressure
• Jitteriness
• Ocular deviation

Neonatal seizures may be difficult to recognize but may be manifested by tremors, jitteriness, tachycardia and elevated blood pressure, and ocular deviation. Tonic-clonic contractions typically are more common in older children.

The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child’s condition is most accurate?
“Take your time feeding your baby.”

One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate?
Teach the child and his parents to keep a headache diary.

A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.

The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, “She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them.” The most accurate description of this child’s condition would be:
The child is in status epilepticus.

Status epilepticus is the term used to describe a seizure that lasts longer than 30 minutes or a series of seizures in which the child does not return to his or her previous normal level of consciousness. The child likely is having generalized seizures, but the most accurate description of what is happening is status epilepticus. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes. With absence seizures the child loses awareness and stares straight ahead but does not fall.

In caring for a child with a seizure disorder, the primary goal of treatment is:
The child will be free from injury during a seizure.

Keeping the child free from injury is the highest priority goal. The other choices are important, but keeping the child safe is higher than the anxiety or knowledge deficit concerns. The physical always is a priority over the psychological.

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, “I don’t understand why our child had to have a lumbar puncture since the EEG was negative.” What is the best response by the nurse?
“The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures.”

Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures. A normal EEG does not rule out epilepsy because seizure activity rarely occurs during the actual testing time. A 24-hour or longer EEG can help in diagnosing a seizure disorder. Just telling the parents that it needs to be done, to be patient, or it is a routine does not address the parents’ concerns.

A 1-year-old has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents?
“The surgery was successful. Do you have any questions?”

Often what parents need most is someone to listen to their concerns. Although this is a good time for education, let the parents adjust to their baby’s appearance and adapt your teaching to their questions, comments, and knowledge level.

After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on what evidence?
The swelling crosses the midline of the infant’s scalp.

The fact that the swelling crosses the midline of the infant’s scalp indicates caput succedaneum. If the swelling is limited and does not cross the midline or suture lines, it would suggest cephalohematoma. Low birthweight does not suggest caput succedaneum. Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele

Seven-year-old Isabelle has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child’s mother tells the nurse that when Isabelle first said she had a headache, the child’s father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be best for the nurse to say to this mother?
“This might or might not be a problem. Watch Isabelle for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome.”

Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within three to five days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain including respiratory arrest.

Which of these age groups has the highest actual rate of death from drowning?

Toddlers and older adolescents have the highest actual rate of death from drowning.

The nurse is caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion?
Trouble focusing when reading

Signs and symptoms for cerebral contusions include disturbances to vision, strength, and sensation. A child suffering a concussion will be distracted and unable to concentrate. Vomiting is a sign of a subdural hematoma. Bleeding from the ear is a sign of a basilar skull fracture.

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope?
“Use this information to teach family and friends.”

Families need and want information they can share with relatives, childcare providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The boy may be able to bike ride and swim with proper precautions.

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