wong's pediatric nursing c28

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Chapter 28: The Child with Cerebral Dysfunction

MULTIPLE CHOICE

1. The nurse has documented that a child’s level of consciousness is obtunded. Which describes this level of consciousness?

a. Slow response to vigorous and repeated stimulation

b. Impaired decision makingc. Arousable with stimulationd. Confusion regarding time and place

ANS: CObtunded describes a level of consciousness in which the child is arousable with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.

PTS: 1 DIF: Cognitive Level: Understand REF: 929TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

2. The nurse has received report on four children. Which child should the nurse assess first?

a. A school-age child in a coma with stable vital signs

b. A preschool child with a head injury and decreasing level of consciousness

c. An adolescent admitted after a motor vehicle accident is oriented to person and place

d. A toddler in a persistent vegetative state with a low-grade fever

ANS: BThe nurse should assess the child with a head injury and decreasing level of consciousness first (LOC). Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his surroundings would be of least worry to the nurse.

PTS: 1 DIF: Cognitive Level: Apply REF: 928TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care

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3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record?

a. 8b. 11c. 13d. 15

ANS: DThe Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient’s level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15.

PTS: 1 DIF: Cognitive Level: Understand REF: 929TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

4. 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:

a. eye trauma.b. neurosurgical emergency.c. severe brainstem damage.d. indication of brain death.

ANS: BThe sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.

PTS: 1 DIF: Cognitive Level: Analyze REF: 942TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

5. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death?

a. Papilledemab. Deliriumc. Doll’s head maneuverd. Periodic and irregular breathing

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ANS: DPeriodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of optic nerve. It is commonly a sign of increased ICP. Delirium is a state of mental confusion and excitement marked by disorientation for time and place. The doll’s head maneuver is a test for brainstem or oculomotor nerve dysfunction.


6. The nurse is taking care of a child who is alert but showing signs of increased intracranial pressure. Which test is contraindicated in this case?

a. Oculovestibular responseb. Doll’s head maneuverc. Funduscopic examination for papilledemad. Assessment of pyramidal tract lesions

ANS: AThe 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. Doll’s head maneuver, funduscopic examination for papilledema, and assessment of pyramidal tract lesions can be performed on awake children.

PTS: 1 DIF: Cognitive Level: Analyze REF: 931TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

7. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. The nurse should include which statement 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: BFor 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. Someone is able to remain with the child during the procedure.

PTS: 1 DIF: Cognitive Level: Apply REF: 933TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Health Promotion and Maintenance

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

a. Nuclear brain scanb. Echoencephalographyc. CT scand. Magnetic resonance imaging (MRI)

ANS: CA 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.

PTS: 1 DIF: Cognitive Level: Understand REF: 933TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

9. Which is the priority nursing intervention for an unconscious child after a fall?

a. Establish adequate airway.b. Perform neurologic assessment.c. Monitor intracranial pressure.d. Determine whether a neck injury is

present.

ANS: ARespiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority. A neurologic assessment and determination of whether a neck injury is present will be performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

PTS: 1 DIF: Cognitive Level: Apply REF: 935TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

10. Which drug should the nurse expect to administer to a preschool child who has increased intracranial pressure (ICP) resulting from cerebral edema?

a. Mannitol (Osmitrol)b. Epinephrine hydrochloride (Adrenalin)c. Atropine sulfate (Atropine)d. Sodium bicarbonate (Sodium bicarbonate)

ANS: A

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For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.

PTS: 1 DIF: Cognitive Level: Apply REF: 936TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

11. An appropriate nursing intervention when caring for an unconscious child should be to:

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 because antipyretics are contraindicated.

ANS: COften comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child’s position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.


12. The nurse is planning care for an 8-year-old child with a concussion. Which 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 remotely from the

site of trauma.

ANS: CA concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion, but are not necessarily associated with amnesia. A contusion is visible bruising

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and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration-deceleration injury.

PTS: 1 DIF: Cognitive Level: Understand REF: 939-940TOP: Integrated Process: Nursing Process: PlanningMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

13. The nurse is teaching nursing students about childhood fractures. Which describes a compound skull fracture?

a. Involves the basilar portion of the occipital bone

b. Bone is exposed through the skinc. Traumatic separations of the cranial

suturesd. Bone is pushed inward, causing pressure

on the brain

ANS: BA compound fracture has the bone exposed through the skin. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. Diastatic skull fractures are traumatic separations of the cranial sutures. A depressed fracture has the bone pushed inward, causing pressure on the brain.

PTS: 1 DIF: Cognitive Level: Understand REF: 940TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

14. 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.

ANS: BA 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.

PTS: 1 DIF: Cognitive Level: Understand REF: 940-941TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

15. The nurse should recommend medical attention if a child with a slight

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head injury experiences:a. sleepiness.b. vomiting, even once.c. headache, even if slight.d. confusion or abnormal behavior.

ANS: DMedical 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. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.

PTS: 1 DIF: Cognitive Level: Apply REF: 943-944TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

16. 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 to

a. place on side.b. take blood pressure.c. stabilize neck and spine.d. check scalp and back for bleeding.

ANS: CAfter 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. The child’s position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding.


17. 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 which type of head injury?

a. Brainstemb. Skull fracturec. Subdural hemorrhaged. Epidural hemorrhage

ANS: A

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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. Skull fracture, subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries.


18. 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: DWatery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved.

PTS: 1 DIF: Cognitive Level: Apply REF: 942TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

19. A toddler fell out of a second-story window. She had a brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she “seems fine.” Which explanation should the nurse give?

a. Your child may have a brain injury and the CT can rule one out.

b. The CT needs to be done because of your child’s age.

c. Your child may start to have seizures and a baseline CT should be done.

d. Your child probably has a skull fracture and the CT can confirm this diagnosis.

ANS: AThe 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 need for the CT scan is related to the injury and symptoms, not the child’s age. The CT scan is necessary to determine whether a brain injury has occurred.

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PTS: 1 DIF: Cognitive Level: Apply REF: 933TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

20. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. Which is the most essential part of the nursing assessment to detect early signs of a worsening condition?

a. Posturingb. Vital signsc. Focal neurologic signsd. Level of consciousness

ANS: DThe 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. 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.


21. 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 to:

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: BA 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. Information on the child’s previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be safely used in individuals who have sustained head injuries and can decrease anxiety and resultant increased ICP.

PTS: 1 DIF: Cognitive Level: Apply REF: 944

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TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

22. 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.”

ANS: CThe parents are advised of probable posttraumatic symptoms that may be expected. These include behavioral changes and sleep disturbances. If the child has these clinical signs, they should be immediately reported for evaluation. Sleep disturbances are to be expected.


23. A 3-year-old child is hospitalized after a submersion injury. The child’s mother complains to the nurse, “Being at the hospital seems unnecessary when he is perfectly fine.” The nurse’s best reply should be:

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: CAll children who have a submersion injury 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 mother would not think the child is fine if oxygen were still required. The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary.


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24. The most common clinical manifestation(s) of brain tumors in children is/are:

a. irritability.b. seizures.c. headaches and vomiting.d. fever and poor fine motor control.

ANS: CHeadaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestation(s) of brain tumors in children. Irritability, seizures, and fever and poor fine motor control are clinical manifestations of brain tumors, but headaches and vomiting are the most common.


25. A 5-year-old boy is being prepared for surgery to remove a brain tumor. Nursing actions should be based on which statement?

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: BThe child 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. Some of the symptoms may be alleviated by the removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated. Children should be prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin.

PTS: 1 DIF: Cognitive Level: Apply REF: 948TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Health Promotion and Maintenance

26. The nurse is teaching nursing students about childhood nervous system tumors. Which 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.

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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: ANeuroblastoma 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. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign but metastasize.


27. 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 statement?

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: DH. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.

PTS: 1 DIF: Cognitive Level: Apply REF: 950TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

28. The vector reservoir for agents causing viral encephalitis in the United

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States is:a. tarantula spiders.b. mosquitoes.c. carnivorous wild animals.d. domestic and wild animals.

ANS: BViral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes. 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. Tarantula spiders, carnivorous wild animals, and domestic and wild animals are not reservoirs for the agents that cause viral encephalitis.

PTS: 1 DIF: Cognitive Level: Understand REF: 954TOP: Integrated Process: Nursing Process: PlanningMSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

29. Which is beneficial in reducing the risk of Reye syndrome?a. Immunization against the diseaseb. Medical attention for all head injuriesc. Prompt treatment of bacterial meningitisd. Avoidance of aspirin to treat fever

associated with influenza

ANS: DAlthough 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. No immunization currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or bacterial meningitis.

PTS: 1 DIF: Cognitive Level: Understand REF: 956TOP: Integrated Process: Nursing Process: PlanningMSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

30. 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:

a. measles.b. varicella.c. meningitis.d. hepatitis.

ANS: BMost cases of Reye syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye syndrome.

PTS: 1 DIF: Cognitive Level: Understand REF: 956TOP: Integrated Process: Nursing Process: Planning

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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

31. When caring for the child with Reye syndrome, the priority nursing intervention should be to:

a. monitor intake and output.b. prevent skin breakdown.c. observe for petechiae.d. do range-of-motion exercises.

ANS: AAccurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing range-of-motion exercises are important interventions in the care of a critically ill or comatose child. Careful monitoring of intake and output is a priority.


32. 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 statement?

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: CCurrent 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. Hospitalization is not necessary. The wound cleansing, passive immunization, and immune globulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine.


33. 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:

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.”

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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: CSeizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The treatment of epilepsy involves a thorough assessment to determine the type of seizure the child is having and the cause, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not make generalized comments regarding the incidence of epilepsy until further assessment is made.


34. Which type of seizure involves both hemispheres of the brain?a. Focalb. Partialc. Generalizedd. Acquired

ANS: CClinical 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.

PTS: 1 DIF: Cognitive Level: Remember REF: 957TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

35. Which is the initial clinical manifestation of generalized seizures?a. Being confusedb. Feeling frightenedc. Losing consciousnessd. Seeing flashing lights

ANS: CLoss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.

PTS: 1 DIF: Cognitive Level: Understand REF: 958TOP: Integrated Process: Nursing Process: Assessment

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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

36. Which of the following types of seizures may be difficult to detect?a. Absenceb. Generalizedc. Simple partiald. Complex partial

ANS: AAbsence seizures may go unrecognized because little change occurs in the child’s behavior during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable.


37. An important nursing intervention when caring for a child who is experiencing a seizure would be to:

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: AWhen 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. The child should not be restrained, and nothing should be placed in the child’s mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on the side, facilitating drainage.


38. 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 to:

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.

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ANS: AThe EMS should be called to transport the child because this is the child’s first seizure. Because this is the first seizure, evaluation should be performed as soon as possible. The nurse should stay with the child while someone else notifies the EMS.


39. 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 intervention 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 lifelong problem. Medications cannot be discontinued.

ANS: CA 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). Medications must be gradually reduced to minimize the recurrence of seizures. Seizure medications can be safely discontinued. The risk of recurrence is greatest within the first year.

PTS: 1 DIF: Cognitive Level: Apply REF: 960TOP: Integrated Process: Teaching/LearningMSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

40. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin (Dilantin) may experience a deficiency of:

a. calcium.b. vitamin C.c. fat-soluble vitamins.d. vitamin D and folic acid.

ANS: DDeficiencies of vitamin D and folic acid have been reported in children taking phenobarbital and phenytoin. Calcium, vitamin C, and fat-soluble vitamin deficiencies are not associated with phenobarbital or phenytoin.

PTS: 1 DIF: Cognitive Level: Understand REF: 965TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

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41. Which clinical manifestations would suggest hydrocephalus in a neonate?a. Bulging fontanel and dilated scalp veinsb. Closed fontanel and high-pitched cryc. Constant low-pitched cry and restlessnessd. Depressed fontanel and decreased blood

pressure

ANS: ABulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.


42. The nurse is monitoring a 7-year-old child post-surgical resection of an infratentorial brain tumor. Which vital sign findings indicate Cushing’s triad?

a. Increased temperature, tachycardia, tachypnea

b. Decreased temperature, bradycardia, bradypnea

c. Bradycardia, hypertension, irregular respirations

d. Bradycardia, hypotension, tachypnea

ANS: CCushing’s triad is a hallmark sign of increased intracranial pressure (ICP). The triad includes bradycardia, hypertension, and irregular respirations. Increased or decreased temperature is not a sign of Cushing’s triad.


43. Which position should the nurse place a 10-year-old child after a large tumor was removed through a supratentorial craniotomy?

a. On the inoperative side with the bed flatb. On the inoperative side with the head of

bed elevated 20 to 30 degreesc. On the operative side with the bed flat and

pillows behind the headd. On the operative side with the head of bed

elevated 45 degrees

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ANS: BIf a large tumor was removed, the child is not placed on the operative side because the brain may suddenly shift to that cavity, causing trauma to the blood vessels, linings, and the brain itself. The child with an infratentorial procedure is usually positioned on either side with the bed flat. When a supratentorial craniotomy is performed, the head of bed is elevated 20 to 30 degrees with the child on either side or on the back. In a supratentorial craniotomy, the head elevation facilitates CSF drainage and decreases excessive blood flow to the brain to prevent hemorrhage. Pillows should be placed against the child’s back, not head, to maintain the desired position.

PTS: 1 DIF: Cognitive Level: Apply REF: 948TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Physiological Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. The treatment of brain tumors in children consists of which therapies? (Select all that apply.)

a. Surgeryb. Bone marrow transplantationc. Chemotherapyd. Stem cell transplantatione. Radiationf. Myelography

ANS: A, C, ETreatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow and stem cell transplantation therapies are used for leukemia, lymphoma, and other solid tumors where myeloablative therapies are used. Myelography is a radiographic examination after an intrathecal injection of contrast medium. It is not a treatment.


2. Which are clinical manifestations of increased intracranial pressure (ICP) in infants? (Select all that apply.)

a. Low-pitched cryb. Sunken fontanelc. Diplopia and blurred visiond. Irritabilitye. Distended scalp veinsf. Increased blood pressure

ANS: D, E

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Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Diplopia and blurred vision is indicative of ICP in children. A high-pitched cry and a tense or bulging fontanel are characteristics of increased ICP. Increased blood pressure, common in adults, is rarely seen in children.


3. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which 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, FInfection 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. Pumping of the shunt may cause obstruction or other problems and should not be performed unless indicated by the neurosurgeon. Pain management rather than sedation should be the goal of therapy. The child is kept flat to avoid too rapid a reduction of intracranial fluid.

PTS: 1 DIF: Cognitive Level: Apply REF: 969TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

4. The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3-year-old child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.)

a. Elevated white blood cell (WBC) countb. Decreased glucosec. Normal proteind. Elevated red blood cell (RBC) count

ANS: A, BThe cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count,

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decreased glucose, and increased protein content. There should not be RBCs evident in the CSF fluid.

PTS: 1 DIF: Cognitive Level: Analyze REF: 954TOP: Integrated Process: Nursing Process: EvaluationMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

5. The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed? (Select all that apply.)

a. Headacheb. Photophobiac. Bulging anterior fontaneld. Weak crye. Poor muscle tone

ANS: C, D, EAssessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.


6. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant? (Select all that apply.)

a. Tachycardiab. Alteration in pupil size and reactivityc. Increased motor responsed. Extension or flexion posturinge. Cheyne-Stokes respirations

ANS: B, D, ELate signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.


ESSAY

1. A 6-year-old child is having a generalized seizure in the classroom at school. Place in order the interventions the school nurse should implement starting with the highest-priority intervention sequencing to the lowest-priority intervention. Provide

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answer using lowercase letters separated by commas (e.g., a, b, c, d, e).a. Take vital signs.b. Ease child to the floor.c. Allow child to rest.d. Turn child to the side.e. Integrate child back into the school environment.

ANS:b, d, a, c, eThe nurse should ease the child to the floor immediately during a generalized seizure. During (and sometimes after) the generalized seizure, the swallowing reflex is lost, salivation increases, and the tongue is hypotonic. Therefore, the child is at risk for aspiration and airway occlusion. Placing the child on the side facilitates drainage and helps maintain a patent airway. Vital signs should be taken next and the child should be allowed to rest. When feasible, the child is integrated into the environment as soon as possible.

PTS: 1 DIF: Cognitive Level: Apply REF: 962TOP: Integrated Process: Nursing Process: ImplementationMSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

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cognitive level

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