NUR 408 Exam 3 (Questions + Answers) Solved

Obtundation - Child aroused by stimulation Stupor - In deep sleep only vigorous and repeated stimulation Confusion - Impaired decision making Disorientation - Confusion regarding time and place What GCS assesses - Eye opening Verbal responses Motor responses Fixed and dilated pupil(s) - Neurosurgical emergency!!! Immediately report this!! -could mean trauma unless after a neuro event Pinpoint pupils OR fixed b/l pupils for more than 5 minutes - Brainstem damage Unilateral, fixed, and dilated pupil - Damage on the SAME side of the brain Oculovestibular response test (caloric test) - Instill ice water into the ear of a comatose childNEVER do when child is awake OR on a child with a ruptured tympanic membrane!! Painful CT scan - Gives a visualized, horizontal and vertical cross section of the brain at any axis Nuclear brain scan - Uses radioisotope that accumulates where the blood-brain barrier is defective Encephalography - Identifies shifts in midline structures of the brain as a result of intracranial lesions MRI - Visualization of morphologic features of target structures and tissue discrimination that is unavailable with any other techniques Priority nursing intervention when child is unconscious after a fall - Establish an airway -respiratory effectiveness is PRIMARY concern when child is unconscious Then neurological assessment and determination of a neck injury Drug used to treat a child with IICP from cerebral edema - Mannitol -osmotic diuretic -administered IV Contusion - Visible bruising and tearing of cerebral tissue Petechial hemorrhage - Type of contusion, but not necessarily associated with amnesia Diastatic fracture - Traumatic separations of cranial suturesBasilar fracture - Involves the basilar part of the frontal, ethmoid, sphenoid, temporal, and occipital bone Compound fracture - Bone exposed through the skin Depressed fracture - Bone is pushed inward, causing pressure on the brain Subdural hematoma - Bleeding between the DURA and CEREBRUM Epidural hemorrhage - Bleeding between the DURA and SKULL S/S of brainstem injury - Deep, rapid, periodic or intermittent, gasping respirations Wide fluctuations or noticeable slowing of pulse Widening pulse pressure Extreme fluctuations in BP Most essential part of a nursing assessment to detect early signs of worsening condition after a head injury - LOC -come before changes in vital signs and focal neurologic signs Significance of bacterial meningitis in children - Residual damage can occur from undiagnosed or untreated or inadequately treated bacterial meningitis Prevention of bacterial meningitis - Vaccine to prevent H influenzae type B -leading causes are group B strep and E ColiViral encephalitis - Transmitted by mosquitos and ticks Most cases appear in summer Reducing risk of Reye's syndrome - Avoid aspirin and ibuprofen for children with varicella or those suspected of having influenza Causes of Reye's syndrome - Viral illness -flu or varicella/chickenpox Priority nursing interventions for child with Reye's syndrome - Monitor I&O -essential for adjusting fluid volumes to prevent dehydration and cerebral edema