c27cerebraldysfunction Flashcards
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 making
c. Arousable with stimulation
d. Confusion regarding time and place
ANS: C
Obtunded 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.
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: B
The 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.
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. 8
b. 11
c. 13
d. 15
ANS: D
The 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.
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. How should the nurse interpret these findings?
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. 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.
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. 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. Papilledema is edema and inflammation of optic nerve. It is commonly a sign of increased intracranial pressure 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.
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 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 a child who is awake 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 children who are awake.
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: 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. Pain medication is not required; however, sedation is sometimes necessary. 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
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. 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.
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: A
Respiratory 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.
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
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.
What is an appropriate nursing intervention when caring for an unconscious child?
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: C
Often 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.
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: C
A 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 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.
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 skin
c. Traumatic separations of the cranial sutures
d. Bone is pushed inward, causing pressure on the brain
ANS: B
A 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.
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: 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. 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.
When should the nurse recommend medical attention for a child with a slight head injury?
a. Experiences sleepiness
b. Vomits
c. Has a headache
d. Is confused or has 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. 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.
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. What is the next nursing action?
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. 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.
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. 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. Skull fracture, subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries.
A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. What does this finding suggest?
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 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.
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: 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 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.
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. 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. 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.
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. What is the most appropriate nursing action?
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. 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.
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: C
The 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.
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.” What is the nurse’s best reply?
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 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.
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: D
H. 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.
