LOC
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
c. Arousable with stimulation
Rationale:
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 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
a. Oculovestibular response
Rationale:
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.
As the nurse assigned to a child diagnosed with bacterial meningitis, you know that:
a. The child will not need to be placed in isolation because antibiotics have been started.
b. Enteric precautions will remain in place for up to 48 hours.
c. Respiratory isolation will remain in place for 24 hours after antibiotics are started.
d. Due to headache, the child will want the head of the bed
c. Respiratory isolation will remain in place for 24 hours after antibiotics are started.
Which 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
a. Bulging fontanel and dilated scalp veins
Rationale:
Bulging 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.
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
d. Periodic and irregular breathing
Rationale:
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 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
b. A preschool child with a head injury and decreasing level of consciousness
Rationale:
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.
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)
a. Mannitol (Osmitrol)
Rationale:
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.
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.
d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.
Rationale:
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.
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.
a. Observe closely for signs of infection.
e. Maintain an accurate record of intake and output.
f. Monitor for abdominal distention.
Rationale:
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. 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.
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.
c. It is a transient and reversible neuronal dysfunction.
Rationale:
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 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?
**Open PPT to slide 6 or Google Peds GCS**
a. 8
b. 11
c. 13
d. 15
d. 15
Rationale:
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.
Which are clinical manifestations 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
d. Irritability
e. Distended scalp veins
Rationale:
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants.
Diplopia and blurred vision are indicative of elevated 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.
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. Headache
b. Photophobia
c. Bulging anterior fontanel
d. Weak cry
e. Poor muscle tone
c. Bulging anterior fontanel
d. Weak cry
e. Poor muscle tone
Rationale:
Assessment 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.
The infant with hydrocephalus has which of the following clinical manifestations?
a. upward eye slanting
b. stabismus
c. setting-sun sign
d. decreased head circumference
c. setting-sun sign
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.
b. Bleeding occurs between the dura and the cerebrum.
Rationale:
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.
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
b. Neurosurgical emergency
Rationale:
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 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. Tachycardia
b. Alteration in pupil size and reactivity
c. Increased motor response
d. Extension or flexion posturing
e. Cheyne-Stokes respirations
b. Alteration in pupil size and reactivity
d. Extension or flexion posturing
e. Cheyne-Stokes respirations
Rationale:
Late 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.
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) count
b. Decreased glucose
c. Normal protein
d. Elevated red blood cell (RBC) count
a. Elevated white blood cell (WBC) count
b. Decreased glucose
Rationale:
The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased glucose, and increased protein content. There should not be RBCs evident in the CSF fluid.
Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which action would be most appropriate?
a. feed the infant just before doing any procedures
b. give the infant small, frequent feedings
c. feed the infant in a horizontal position
d. give large, less frequent feedings
b. give the infant small, frequent feedings
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
a. Brainstem
Rationale:
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.
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
d. Level of consciousness
Rationale:
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.
You are caring for a child with hydrocephalus who is postoperative from a shunt revision. Which assessment finding is your priority for increased intracranial pressure (ICP)?
a. Nausea and refusal to eat postoperatively
b. Complaint of a headache
c. Irritability and wanting to sleep
d. Decrease in heart rate over the last hour
d. Decrease in heart rate over the last hour
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical
manifestations would support the diagnosis of bacterial meningitis?
1. Positive Babinski's sign and peripheral paresthesia.
2. Negative Chvostek's sign and facial tingling.
3. Positive Kernig's sign and nuchal rigidity.
4. Negative Trousseau's sign and nystagmus.
3. Positive Kernig's sign and nuchal rigidity.
Rationale:
A positive Kernig's sign (client unable
to extend leg when lying flat) and
nuchal rigidity (stiff neck) are signs of
bacterial meningitis, occurring because
the meninges surrounding the brain
and spinal column are irritated.
The most common complication that should be anticipated and observed for in an infant with myelomeningocele after surgical repair of the defect is
a. urinary stress
b. chiari malformation
c. hydrocephalus
d. latex allergy
c. hydrocephalus
You are the nurse assigned to care for a child with a basilar skull fracture. Your most important nursing observation is change in level of consciousness (LOC). You will be highly alert for:
a. Alterations in vital signs that often appear before alterations in consciousness or focal neurologic signs
b. Bleeding from the ear, which is indicative of an anterior basal skull fracture
c. Seizures, which are relatively uncommon in children at the time of head injury
d. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement
d. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement