NUR4467 Exam 3 Questions And
Complete Answers
Intracranial Pressure (ICP) - Answer pressure that may accumulate inside the brain,
LOC decreases
can be due to
- submersion injury/ near drowning
- infection
- cerebral trauma
- hemorrhage
- tumor
- congenital or acquired obstruction to CSF flow
- swelling
- fluid and electrolyte imbalances
clinical manifestations
*infants*
o Irritability, poor feeding
o High-pitched cry, difficult to soothe
o Fontanels: tense bulging
o Cranial sutures: separated
o Eyes: setting-sun sign
o Scalp veins: distended
*children*
o Headache
o Forceful vomiting, blurry vision
o Seizures
,o Drowsiness, lethargy, decreased activity
o Inability to follow simple commands
*late signs*
o Bradycardia
o Decreased motor response to command and sensory response to painful stimuli
o Alterations in pupil size/reactivity
o Extension or flexion posturing
o Decreased consciousness and then coma
submersion injury/ near drowning - Answer a major cause of accidental death in
children that can occur with even small quantity of water (even as small as a pail of
water)
- survival for at least 24 hours after submersion
- cerebral hypoxia: brain cells die within 4-6 minutes
- aspiration: occurs with most injuries and can lead to pulmonary edema, atelectasis,
airway spasm, and acute pneumonitis
- hypothermia
- prognosis is based on length of submersion
- TEACH PREVENTION
lumbar puncture - Answer cerebrospinal fluid culture to identify organism; appearance
and cell count of CSF can help with diagnosis and intervention
- if fluid is clouded, turbid, has elevated WBC count, and protein is present—BACTERIAL
- if fluid is clear or slightly cloudy, negative gram stain, normal or slightly elevated WBC
count and protein—ASEPTIC
meningitis - Answer inflammation of the meninges (EMERGENCY)
clinical manifestations
§ More acute than viral/aseptic, with sudden onset
§ Patient looks ill—toxic appearance with fever
§ Headaches
§ Chills
,§ Changes in sensorium
§ Photophobia
§ Nuchal rigidity
§ Infants—high-pitched cry, bulging fontanels, other s/s of increased ICP
§ Kernig and Brudzinski sign—may not be elicited in infants and younger children
nursing management
o Manage hydration, ventilation, ICP reduction, treat shock
o Quiet with minimal stimuli
o Monitor pain
o HOB elevated, side-lying position
o Isolation precautions
o Prophylactic antibiotics for individuals who were in contact
o Family support—education, consider possible long-term effect
Acute Flaccid Myelitis (AFM) - Answer - rare but serious polio-like disease in children
- sudden onset of arm or leg weakness
- affects the nervous system and causes muscles and reflexes to become weak
encephalitis - Answer inflammation of the CNS with altered function of brain and spinal
cord
primarily viral cause
- herpes simplex
- mosquitoes and ticks
cerebral trauma (head injury, TBI) - Answer major causes in childhood
- falls
- motor vehicle injuries
- bicycle or sports-related injuries
types
- *concussion*: alteration in neurologic or cognitive function with or without loss of
consciousness
, - *contusion/laceration*: visible bruising and tearing of tissue
- *skull fractures*: results from direct blow or injury to the skull
Glasgow Coma Scale (GCS) - Answer a scale used to assess the consciousness of a
patient upon physical examination, typically in patients with neurological concerns or
complaints
- pupillary reaction
- vitals
- motor function
- posturing (decorticate and decerebrate)
- reflexes
decorticate - Answer flexion into body, cerebral cortex
decerebrate - Answer extended away from body, more severe due to midbrain or
brainstem involvement
Reye's syndrome - Answer potentially serious or deadly disorder in children that is
characterized by vomiting and confusion
metabolic encephalopathy associated with other organ involvement and may be caused
by aspirin therapy
characterized by
- fever
- profound impaired consciousness
- disordered hepatic function
DIAGNOSIS - liver biopsy
RECOVERY - good if recognized and treated early
seizure disorders - Answer caused by excessive and abnormal neuronal discharges in
the brain
categories
- *partial*: local, small
- *generalized*: both hemispheres without local onset (tonic-clonic, absence)
- *febrile*
Complete Answers
Intracranial Pressure (ICP) - Answer pressure that may accumulate inside the brain,
LOC decreases
can be due to
- submersion injury/ near drowning
- infection
- cerebral trauma
- hemorrhage
- tumor
- congenital or acquired obstruction to CSF flow
- swelling
- fluid and electrolyte imbalances
clinical manifestations
*infants*
o Irritability, poor feeding
o High-pitched cry, difficult to soothe
o Fontanels: tense bulging
o Cranial sutures: separated
o Eyes: setting-sun sign
o Scalp veins: distended
*children*
o Headache
o Forceful vomiting, blurry vision
o Seizures
,o Drowsiness, lethargy, decreased activity
o Inability to follow simple commands
*late signs*
o Bradycardia
o Decreased motor response to command and sensory response to painful stimuli
o Alterations in pupil size/reactivity
o Extension or flexion posturing
o Decreased consciousness and then coma
submersion injury/ near drowning - Answer a major cause of accidental death in
children that can occur with even small quantity of water (even as small as a pail of
water)
- survival for at least 24 hours after submersion
- cerebral hypoxia: brain cells die within 4-6 minutes
- aspiration: occurs with most injuries and can lead to pulmonary edema, atelectasis,
airway spasm, and acute pneumonitis
- hypothermia
- prognosis is based on length of submersion
- TEACH PREVENTION
lumbar puncture - Answer cerebrospinal fluid culture to identify organism; appearance
and cell count of CSF can help with diagnosis and intervention
- if fluid is clouded, turbid, has elevated WBC count, and protein is present—BACTERIAL
- if fluid is clear or slightly cloudy, negative gram stain, normal or slightly elevated WBC
count and protein—ASEPTIC
meningitis - Answer inflammation of the meninges (EMERGENCY)
clinical manifestations
§ More acute than viral/aseptic, with sudden onset
§ Patient looks ill—toxic appearance with fever
§ Headaches
§ Chills
,§ Changes in sensorium
§ Photophobia
§ Nuchal rigidity
§ Infants—high-pitched cry, bulging fontanels, other s/s of increased ICP
§ Kernig and Brudzinski sign—may not be elicited in infants and younger children
nursing management
o Manage hydration, ventilation, ICP reduction, treat shock
o Quiet with minimal stimuli
o Monitor pain
o HOB elevated, side-lying position
o Isolation precautions
o Prophylactic antibiotics for individuals who were in contact
o Family support—education, consider possible long-term effect
Acute Flaccid Myelitis (AFM) - Answer - rare but serious polio-like disease in children
- sudden onset of arm or leg weakness
- affects the nervous system and causes muscles and reflexes to become weak
encephalitis - Answer inflammation of the CNS with altered function of brain and spinal
cord
primarily viral cause
- herpes simplex
- mosquitoes and ticks
cerebral trauma (head injury, TBI) - Answer major causes in childhood
- falls
- motor vehicle injuries
- bicycle or sports-related injuries
types
- *concussion*: alteration in neurologic or cognitive function with or without loss of
consciousness
, - *contusion/laceration*: visible bruising and tearing of tissue
- *skull fractures*: results from direct blow or injury to the skull
Glasgow Coma Scale (GCS) - Answer a scale used to assess the consciousness of a
patient upon physical examination, typically in patients with neurological concerns or
complaints
- pupillary reaction
- vitals
- motor function
- posturing (decorticate and decerebrate)
- reflexes
decorticate - Answer flexion into body, cerebral cortex
decerebrate - Answer extended away from body, more severe due to midbrain or
brainstem involvement
Reye's syndrome - Answer potentially serious or deadly disorder in children that is
characterized by vomiting and confusion
metabolic encephalopathy associated with other organ involvement and may be caused
by aspirin therapy
characterized by
- fever
- profound impaired consciousness
- disordered hepatic function
DIAGNOSIS - liver biopsy
RECOVERY - good if recognized and treated early
seizure disorders - Answer caused by excessive and abnormal neuronal discharges in
the brain
categories
- *partial*: local, small
- *generalized*: both hemispheres without local onset (tonic-clonic, absence)
- *febrile*
