Chapter 27, The Child with Cerebral Dysfunction Hockenberry, Wong's Essentials of Pediatric Nursing, 10th Edition.
The nurse has documented that a child's level of consciousness is obtunded. Which describes this level of consciousness?
- Slow response to vigorous and repeated stimulation
- Impaired decision making
- Arousable with stimulation
- Confusion regarding time and place - ANSWER-c. Arousable with stimulation
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.DIF: Cognitive Level: Understand REF: p. 874 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse has received report on four children. Which child should the nurse assess first?
- A school-age child in a coma with stable vital signs
- A preschool child with a head injury and decreasing level of consciousness
- An adolescent admitted after a motor vehicle accident is oriented to person and
- A toddler in a persistent vegetative state with a low-grade fever - ANSWER-b. A
place
preschool child with a head injury and decreasing level of consciousness
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.DIF: Cognitive Level: Apply REF: p. 873 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
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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?
- 8
- 11
- 13
- 15 - ANSWER-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.DIF: Cognitive Level: Understand REF: p. 873 TOP: Integrated Process: Nursing Process: Assessment
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?
- Eye trauma
- Neurosurgical emergency
- Severe brainstem damage
- Indication of brain death - ANSWER-b. Neurosurgical emergency
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.DIF: Cognitive Level: Analyze REF: p. 875 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death?
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- Papilledema
- Delirium
- Doll's head maneuver
- Periodic and irregular breathing - ANSWER-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.DIF: Cognitive Level: Understand REF: p. 880 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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?
- Oculovestibular response
- Doll's head maneuver
- Funduscopic examination for papilledema
- Assessment of pyramidal tract lesions - ANSWER-a. Oculovestibular response
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.DIF: Cognitive Level: Analyze REF: p. 887 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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?
- "Pain medication will be given."
- "The scan will not hurt."
- "You will be able to move once the equipment is in place."
- "Unfortunately, no one can remain in the room with you during the test." - ANSWER-
- "The scan will not hurt."
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