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Peds Chapter 52: The Child with a Neurologic Alteration
Terms in this set (41)
What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?
b. Bulging fontanel
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
B This is a manifestation of increased ICP in infants. A 10-year-old child would
have a closed fontanel.
C 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
D By 10 years of age, cranial sutures have fused so that head circumference will
not increase in the presence of increased ICP.
Which information should the nurse give to a child who is to have magnetic resonance
imaging (MRI) of the brain?
a. "Your head will be restrained 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 the head will be restricted to obtain accurate information.
B Drinking fluids is usually done for gastrointestinal procedures.
C A child should lie flat after a lumbar puncture, not during an MRI.
D Electrodes are attached to the head for an electroencephalogram.
Which term is used when a patient remains in a deep sleep, responsive only to vigorous
and repeated stimulation?
d. Persistent vegetative state
A Coma is the state in which no motor or verbal response occurs to noxious
B Stupor exists when the child remains in a deep sleep, responsive only to vigorous
and repeated stimulation.
C Obtundation describes a level of consciousness in which the child is arousable
D Persistent vegetative state describes the permanent loss of function of the
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
A Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the
pediatric coma scale.
B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses.
C Level of consciousness is not a part of the Glasgow Coma Scale.
D Intracranial pressure and level of consciousness are not part of the Glasgow
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
A 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.
B Pupil size measurement is usually not necessary.
C Head circumference measurement is essential because hydrocephalus can
develop in these infants.
D Seizure medications are not routinely given to infants who do not have seizures.
The most common problem of children born with a myelomeningocele is
a. Neurogenic bladder
b. Intellectual impairment
c. Respiratory compromise
A Myelomeningocele is one of the most common causes of neuropathic
(neurogenic) bladder dysfunction among children.
B Risk of intellectual impairment is minimized through early intervention and
management of hydrocephalus.
C Respiratory compromise is not a common problem in myelomeningocele.
D Cranioschisis is a skull defect through which various tissues protrude. It is not
associated with myelomeningocele.
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
A Vitamin A does not have a relation to the prevention of spina bifida.
B Folic acid supplementation is recommended for the preconceptual period, as well
as during the pregnancy.
C The widespread use of folic acid among women of childbearing age is expected
to decrease the incidence of spina bifida significantly.
D Folic acid supplementation is recommended for the preconceptual period, as well
as during the pregnancy.
How much folic acid is recommended for women of childbearing age?
a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg
A 1.0 mg is too low a dose.
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.
C 1.5 mg is not the recommended dosage of folic acid.
D 2.0 mg is not the recommended dosage of folic acid.
Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions
a. Avoiding using any latex product
b. Using only nonallergenic latex products
c. Administering medication for long-term desensitization
d. Teaching family about long-term management of asthma
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.
B There are no nonallergic latex products.
C At this time, desensitization is not an option.
D The child does not have asthma. The parents must be taught about allergy and
the risk of anaphylaxis.
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
b. Syndrome of inappropriate antidiuretic hormone (SIADH)
c. Cerebral palsy
d. Reye's syndrome
A The combination of signs is strongly suggestive of hydrocephalus.
B SIADH would not manifest in this way. The child would have decreased
urination, hypertension, weight gain, fluid retention, hyponatremia, and
increased urine specific gravity.
C The manifestations of cerebral palsy vary but may include persistence of
primitive reflexes, delayed gross motor development, and lack of progression
through developmental milestones.
D Reye's syndrome is associated with an antecedent viral infection with symptoms
of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.
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
A Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy.
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.
C Slow, writhing, uncontrolled, involuntary movements occur with athetoid or
dyskinetic cerebral palsy.
D Clumsy movements, loss of coordination, equilibrium, and kinesthetic sense
occur in ataxic cerebral palsy.
Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of
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.
B The CSF pressure is usually increased in acute bacterial meningitis.
C Many polymorphonuclear cells are present in CSF with acute bacterial
D The CSF glucose level is usually decreased compared with the serum glucose
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."
A The knee-chest position is not appropriate for a lumbar puncture.
B An infant can be placed in a sitting position with the infant facing the nurse and
the head steadied against the nurse's body.
C A side-lying position with the head of the bed elevated is not appropriate for a
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.
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?
d. Simple partial
A Absence seizures are very brief episodes of altered awareness. The child has a
B Atonic seizures cause an abrupt loss of postural tone, loss of consciousness,
confusion, lethargy, and sleep.
C Tonic-clonic seizures involve sustained generalized muscle contractions
followed by alternating contraction and relaxation of major muscle groups.
D There is no change in level of consciousness with simple partial seizures. Simple
partial seizures consist of motor, autonomic, or sensory symptoms
What is the best response to a father who tells the nurse that his son "daydreams" at home
and 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."
A This response does not address the child's symptoms or the father's concern.
B This behavior is consistent with absence seizures, which can occur one after the
other several times a day. Determining an exact number of absence seizures is
not as useful as learning about behavior before the seizure that might have
precipitated seizure activity.
C The daydream episodes are suggestive of absence seizures, and data about
activity associated with the daydreams should be obtained.
D This response ignores both the child's symptoms and the father's concern about
the daydreaming behavior.
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
A Weight gain, not loss, is a side effect of valproic acid.
B Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert
for any unusual bruising or bleeding.
C Drowsiness is not a side effect of valproic acid, although it is associated with
other anticonvulsant medications.
D Anorexia is not a side effect of valproic acid.
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 refers to lack of ability to recognize place or person.
B Obtunded describes an individual who sleeps unless aroused and once aroused
has limited interaction with the environment.
C An individual is lethargic when he or she awakens easily but exhibits limited
D Stupor refers to requiring considerable stimulation to arouse the individual.
Which type of fractures describes traumatic separation of cranial sutures?
A A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid,
temporal, or occipital bone.
B A linear fracture includes a straight-line fracture without dura involvement.
C Commuted skull fractures include fragmentation of the bone or a multiple
D A depressed fracture has the bone pushed inward, causing pressure on the brain.
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.
A 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.
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.
C 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.
D 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 assessing a child who was just admitted to the hospital for observation after a
head injury. The most essential part of nursing assessment to detect early signs of a
worsening condition is
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
A Neurologic posturing is indicative of neurologic damage.
B Vital signs and focal neurologic signs are later signs of progression when
compared with level-of-consciousness changes.
C Vital signs and focal neurologic signs are later signs of progression when
compared with level-of-consciousness changes.
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.
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 statement 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."
A If the child has these clinical signs, they should be immediately reported for
B If the child has these clinical signs, they should be immediately reported for
C The parents are advised of probable posttraumatic symptoms. These include
behavioral changes and sleep disturbances.
D If the child has these clinical signs, they should be immediately reported for
Which type of seizures involves both hemispheres of the brain?
A Focal seizures may arise from any area of the cerebral cortex, but the frontal,
temporal, and parietal lobes are most commonly affected.
B Partial seizures are caused by abnormal electric discharges from epileptogenic
foci limited to a circumscribed region of the cerebral cortex.
C Clinical observations of generalized seizures indicate that the initial involvement
is from both hemispheres.
D 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.
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.
A The child should be placed on a soft surface if he is not in bed; however, it is
inappropriate to leave the child during the seizure.
B Positioning the child on his side will prevent aspiration.
C Nothing should be inserted into the child's mouth during a seizure to prevent
injury to the mouth, gums, or teeth.
D Restraints could cause injury. Sharp objects and furniture should be moved out
of the way to prevent injury.
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
A Neither irritability nor hunger is typical of the period after a tonic-clonic seizure.
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.
C Nausea and vomiting are not expected reactions in the postictal period.
D The child will more likely be confused and lethargic after a tonic-clonic seizure.
What should the nurse teach parents when the child is taking phenytoin (Dilantin) to
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.
B The child should have liver function studies because this anticonvulsant may
cause hepatic dysfunction, not renal dysfunction.
C Dilantin has not been found to cause gastrointestinal upset. The medication can
be taken without food.
D Anticonvulsants should never be stopped suddenly or without consulting the
physician. Such action could result in seizure activity.
What is the most appropriate nursing response to the father of a newborn infant with
myelomeningocele who asks about the cause of this condition?
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
d. "There may be no definitive cause identified."
A The exact cause of most cases of neural tube defects is unknown. There may be a
genetic predisposition, but no pattern has been identified.
B Folic acid deficiency in the mother has been linked to neural tube defect.
C There is no evidence that children who have parents with spinal problems are at
greater risk for neural tube defects.
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
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
A 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
B Temperature elevation may occur in children with ICP.
C Changes in blood pressure occur, but the diastolic pressure does not increase, nor
is there a narrowing of pulse pressure.
D The child with a head injury may have confusion and altered mental status, a
change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema.
The nurse should expect a child who has frequent tension type of headaches to describe
headache pain as
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 of headaches may describe the pain as a bandlike
tightness or pressure, tight neck muscles, or soreness in the scalp.
B A common symptom of migraines is throbbing headache pain, typically on one
side of the eye.
C A headache that is worse in the morning and improves throughout the course of
the day is typical of ICP.
D Abdominal pain may accompany headache pain in migraines.
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 pharmacologic headache relief measures.
d. Assess for nausea and vomiting.
A An aura is associated with migraines but not with tension headaches.
B Complete bed rest is not required.
C Administration of pharmacologic techniques is appropriate to assist in the
management of a tension headache.
D Nausea and vomiting are associated with a migraine but not with tension
Which statement by an adolescent indicates an understanding about factors that can trigger
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."
A Visual stimuli, not auditory stimuli, are known to be a common trigger for
B Exercise is not a trigger for migraines. The adolescent needs regular physical
C Altered sleep patterns and fatigue is a common migraine trigger for migraine
headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to
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.
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
A Children with rapidly progressing paralysis are treated with intravenous
immunoglobulins for several days. Administering this infusion is not the nursing
B Airway is always the number one priority. 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.
C 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.
D 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
A child is brought to the emergency department in generalized tonic-clonic status
epilepticus. Which medication should the nurse expect to be given initially in this
a. Clorazepate dipotassium (Tranxene)
b. Fosphenytoin (Cerebyx)
d. Lorazepam (Ativan)
A Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be
B Fosphenytoin can be given intravenously as a second round of medication if
C Phenobarbital can be given intravenously as a second round of medication if
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.
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.
A Stabilizing the child's neck does not address the child's symptoms.
B Any indication of ICP should be promptly reported to the physician.
C This intervention may facilitate the child's comfort. It would not be the nurse's
D The child's episode of vomiting does not necessitate a fluid restriction.
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
A An infant has about 50 mL of CSF compared with 150 mL in an adult.
B Papilledema rarely occurs in infancy because open fontanels and sutures can
expand in the presence of ICP.
C The brain of the term infant is two thirds the weight of an adult's brain.
D Peripheral nerves are not completely myelinated at birth. As myelinization
progresses, so does the child's coordination and fine muscle movements.
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."
A Pain medication is not required; however, sedation is sometimes necessary.
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.
C The child will not be allowed to move and will be immobilized.
D Someone is able to remain with the child during the procedure.
Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of
the brain at any axis?
a. Nuclear brain scan
c. CT scan
A A nuclear brain scan uses a radioisotope that accumulates where the blood-brain
barrier is defective.
B Echoencephalography identifies shifts in midline structures of the brain as a
result of intracranial lesions.
C A CT scan provides a visualization of the horizontal and vertical cross sections
of the brain at any axis.
D MRI permits visualization of morphologic features of target structures and
permits tissue discrimination that is unavailable with any other techniques.
What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by
the intravenous route to control seizures? Select all that apply.
a. It must be given with D5
b. The child will require monitoring of therapeutic serum levels while taking this
c. Dilantin should be given with food because it causes gastrointestinal distress.
d. It must be given in normal saline.
e. It must be filtered.
ANS: B, D, E
Correct 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 D5
1/2NS. The IV dose must be filtered.
Incorrect The IV dose must be given in normal saline, not D5
1/2NS. 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
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)
b. Decreased protein
c. Decreased glucose
d. Cloudy in color
e. Increase in red blood cells (RBC)
ANS: A, C, D
Correct The CSF laboratory results for bacterial meningitis include elevated WBC
counts, cloudy or milky in color, and decreased glucose.
Incorrect The protein is elevated and there should be no RBCs present. RBCs are
present when the tap was traumatic.
A 14-year-old girl 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
c. Minimizing environmental stimuli
d. Discussing long-term care issues with the family
e. Monitoring for respiratory complications
ANS: A, B, E
Correct 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.
Incorrect Spinal cord injury is a catastrophic event. Discussion regarding long-term
care should be delayed until the child is stable.
Prolonged seizure activity, in the form of either a single seizure lasting 30 minutes or
recurrent seizures lasting more than 30 minutes, with no return to a normal level of
consciousness is known as _________________.
The nurse caring for this patient should be aware that the causes of status epilepticus are
many. Acute CNS injury from head trauma, meningitis, or electrolyte imbalance frequently
precipitate status epilepticus.
If a child has a concussion, a second concussion will have no further ill effects. Is this
statement true or false?
A second concussion may cause more harm to the brain and even lead to possible death.
The parents of a child who has experienced a concussion should be encouraged to speak to
their health care provider about whether the child can return to activities or sports. This
condition is known as "second impact syndrome."
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