Chapter 28: The Child with Cerebral Dysfunction

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Which of the following terms is used to describe a child's level of consciousness when the child is arousable with stimulation?
a.
Stupor
b.
Confusion
c.
Obtundation
d.
Disorientation

ANS: C
Obtundation describes a level of consciousness in which the child is arousable with stimulation.

Which of the following terms 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

ANS: B
Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation.

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.

ANS: B
The Glasgow Coma Scale assesses eye opening and verbal and motor responses.

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as which of the following?
a.
Eye trauma
b.
Neurosurgical emergency
c.
Severe brainstem damage
d.
Indication of brain death

ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding.

The nurse is caring for a child with severe head trauma after a car accident. Which of the following is an ominous sign that often precedes death?
a.
Papilledema
b.
Delirium
c.
Doll's head maneuver
d.
Periodic and irregular breathing

ANS: D
Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea.

Which of the following tests is never performed on an awake child?
a.
Oculovestibular response
b.
Doll's head maneuver
c.
Funduscopic examination for papilledema
d.
Assessment of pyramidal tract lesions

ANS: A
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 nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. The nurse should include which of the following statements in 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."

ANS: 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.

Which of the following neurologic diagnostic tests gives a visualized horizontal and vertical cross section of the brain at any axis?
a.
Nuclear brain scan
b.
Echoencephalography
c.
CT scan
d.
Magnetic resonance imaging (MRI)

ANS: C
A CT scan provides a visualization of the horizontal and vertical cross sections of the brain at any axis.

Which of the following is the priority nursing intervention when a child is unconscious after a fall?
a.
Establish adequate airway.
b.
Perform neurologic assessment.
c.
Monitor intracranial pressure.
d.
Determine whether a neck injury is present.

ANS: A
Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority.

Which of the following drugs would be used to treat a child who has increased ICP resulting from cerebral edema?
a.
Mannitol
b.
Epinephrine hydrochloride
c.
Atropine sulfate
d.
Sodium bicarbonate

ANS: A
For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction.

An appropriate nursing intervention when caring for an unconscious child would be which of the following?
a.
Change the child's position infrequently to minimize the chance of increased ICP.
b.
Avoid using narcotics or sedatives to provide comfort and pain relief.
c.
Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
d.
Give tepid sponge baths to reduce fever, since antipyretics are contraindicated.

ANS: C
Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema.

Which of the following is descriptive of a concussion?
a.
Petechial hemorrhages cause amnesia.
b.
Visible bruising and tearing of cerebral tissue occur.
c.
It is a transient and reversible neuronal dysfunction.
d.
A slight lesion develops remote from the site of trauma.

ANS: C
A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head.

Which of the following types of fractures describes traumatic separation of cranial sutures?
a.
Basilar
b.
Compound
c.
Diastatic
d.
Depressed

ANS: C
Diastatic skull fractures are traumatic separations of the cranial sutures.

Which of the following statements 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.

The nurse should recommend medical attention if a child with a slight head injury experiences which of the following?
a.
Sleepiness
b.
Vomiting, even once
c.
Headache, even if slight
d.
Confusion or abnormal behavior

ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred vision, or has an unsteady gait.

A 10-year-old boy on a bicycle has been hit by a car in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be which of the following?
a.
Place on side.
b.
Take blood pressure.
c.
Stabilize neck and spine.
d.
Check 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.

An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. The nurse should suspect what type of head injury?
a.
Brainstem
b.
Skull fracture
c.
Subdural hemorrhage
d.
Epidural hemorrhage

ANS: A
Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury.

A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests:
a.
diabetic coma.
b.
brainstem injury.
c.
upper respiratory tract infection.
d.
leaking of cerebrospinal fluid (CSF).

ANS: D
Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture.

A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a CT scan is required when she "seems fine." The nurse should explain that she:
a.
may have a brain injury.
b.
needs this because of her age.
c.
may start having seizures.
d.
probably has a skull fracture.

ANS: A
The child's history of the fall, brief loss of consciousness, and vomiting four times necessitates evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan.

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. Which of the following 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.

A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. The most appropriate nursing action is which of the following?
a.
Discuss with parents the child's previous experiences with pain.
b.
Discuss with practitioner what analgesia can be safely administered.
c.
Explain that analgesia is contraindicated with a head injury.
d.
Explain that analgesia is unnecessary when child is not fully awake and alert.

ANS: B
A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and the promotion of comfort and relief of anxiety.

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. Which of the following statements made by the mother 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."

ANS: C
The parents are advised of probable posttraumatic symptoms that may be expected. These include behavioral changes and sleep disturbances.

A 3-year-old child is hospitalized after a near-drowning accident. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply would be which of the following?
a.
"He still needs a little extra oxygen."
b.
"I'm sure he is fine, but the doctor wants to make sure."
c.
"The reason for this is that complications could still occur."
d.
"It is important to observe for possible central nervous system problems."

ANS: C
All children who have a near-drowning experience should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur 24 hours after the incident.

The most common clinical manifestation(s) of brain tumors in children is which of the following?
a.
Irritability
b.
Seizures
c.
Headaches and vomiting
d.
Fever and poor fine motor control

ANS: C
Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestation(s) of brain tumors in children.

Five-year-old José is being prepared for surgery to remove a brain tumor. Nursing actions should be based on which of the following?
a.
Removal of tumor will stop the various symptoms.
b.
Usually the postoperative dressing covers the entire scalp.
c.
He is not old enough to be concerned about his head being shaved.
d.
He is not old enough to understand the significance of the brain.

ANS: B
José should be told what he will look and feel like after surgery. This includes the size of the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing.

Which of the following best describes a neuroblastoma?
a.
Diagnosis is usually made after metastasis occurs.
b.
Early diagnosis is usually possible because of the obvious clinical manifestations.
c.
It is the most common brain tumor in young children.
d.
It is the most common benign tumor in young children.

ANS: A
Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site.

The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on which of the following?
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.
Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.

ANS: D
H. influenzae type b meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely.

The vector reservoir for agents causing viral encephalitis in the United States is which of the following?
a.
Tarantula spiders
b.
Mosquitoes and ticks
c.
Carnivorous wild animals
d.
Domestic and wild animals

ANS: B
Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes and ticks. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore most cases of encephalitis appear during the hot summer months.

Which of the following may 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 and ibuprofen 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.

When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised that a week ago the child had recovered from which of the following?
a.
Measles
b.
Varicella
c.
Meningitis
d.
Hepatitis

ANS: B
Most cases of Reye syndrome follow a common viral illness such as varicella or influenza.

When caring for the child with Reye syndrome, the priority nursing intervention would be which of the following?
a.
Monitor intake and output.
b.
Prevent skin breakdown.
c.
Observe for petechiae.
d.
Do range-of-motion exercises.

ANS: A
Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema.

A young child's parents call the nurse after their child was bitten by a raccoon in the woods. The nurse's recommendation should be based on which of the following?
a.
Child should be hospitalized for close observation.
b.
No treatment is necessary if thorough wound cleaning is done.
c.
Antirabies prophylaxis must be initiated.
d.
Antirabies prophylaxis must be initiated if clinical manifestations appear.

ANS: C
Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible.

A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is which of the following?
a.
"Epilepsy is easily treated."
b.
"Very few children have actual epilepsy."
c.
"The seizure may or may not mean that your child has epilepsy."
d.
"Your child has had only one convulsion; it probably won't happen again."

ANS: C
Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures.

Which of the following types of seizures involves both hemispheres of the brain?
a.
Focal
b.
Partial
c.
Generalized
d.
Acquired

ANS: C
Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres.

Which of the following is the initial clinical manifestation of generalized seizures?
a.
Being confused
b.
Feeling frightened
c.
Losing consciousness
d.
Seeing flashing lights

ANS: C
Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation.

Which of the following types of seizures may be difficult to detect?
a.
Absence
b.
Generalized
c.
Simple partial
d.
Complex partial

ANS: A
Absence seizures may go unrecognized because little change occurs in the child's behavior during the seizure.

An important nursing intervention when caring for a child who is experiencing a seizure would be which of the following?
a.
Describe and record the seizure activity observed.
b.
Restrain the child when seizure occurs to prevent bodily harm.
c.
Place a tongue blade between the teeth if they become clenched.
d.
Suction the child during a seizure to prevent aspiration.

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.

A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school. Breathing is not impaired, but some postictal confusion occurs. The most appropriate initial action by the school nurse is which of the following?
a.
Stay with child and have someone call emergency medical service (EMS).
b.
Notify parent and regular practitioner.
c.
Notify parent that child should go home.
d.
Stay with child, offering calm reassurance.

ANS: A
The EMS should be called to transport the child because this is the child's first seizure.

A child has been seizure free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which of the following in the response?
a.
Medications can be discontinued at this time.
b.
The child will need to take the drugs for 5 years after the last seizure.
c.
A step-wise approach will be used to reduce the dosage gradually.
d.
Seizure disorders are a life-long problem. Medications cannot be discontinued.

ANS: C
A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure free for 2 years and has a normal electroencephalogram (EEG).

Children taking phenobarbital and/or phenytoin may experience a deficiency of:
a.
calcium.
b.
vitamin C.
c.
fat-soluble vitamins.
d.
vitamin D and folic acid.

ANS: D
Deficiencies of vitamin D and folic acid have been reported in children taking phenobarbital and phenytoin.

What clinical manifestations would suggest hydrocephalus in a neonate?
a.
Bulging fontanel and dilated scalp veins
b.
Closed fontanel and high-pitched cry
c.
Constant low-pitched cry and restlessness
d.
Depressed fontanel and decreased blood pressure

ANS: A
Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates.

The treatment of brain tumors in children consists of which of the following therapies? (Select all that apply.)
a.
Surgery
b.
Bone marrow transplantation
c.
Chemotherapy
d.
Stem cell transplantation
e.
Radiation
f.
Myelography

ANS: A, C, E
Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination.

Which of the following is a clinical manifestation of increased intracranial pressure (ICP) in infants? (Select all that apply.)
a.
Low-pitched cry
b.
Sunken fontanel
c.
Diplopia and blurred vision
d.
Irritability
e.
Distended scalp veins
f.
Increased blood pressure

ANS: C, D, E
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants.

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which of the following interventions should be included in the child's postoperative care? (Select all that apply.)
a.
Observe closely for signs of infection.
b.
Pump the shunt reservoir to maintain patency.
c.
Administer sedation to decrease irritability.
d.
Maintain Trendelenburg position to decrease pressure on the shunt.
e.
Maintain an accurate record of intake and output.
f.
Monitor for abdominal distention.

ANS: A, E, F
Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus.

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