HESI Case Study( peds)
Meet the Clients: Casey and John Martin
Six-month-old Casey Martin and her 4-year-old brother, John Martin sustain head injuries when
the car driven by their mother is struck head on at an intersection. Although Casey is in an infant
seat, her head is severely shaken. John unbuckles his car seat and his head strikes the dash
board with force.
The Martins are transported to the emergency department (ED) where Mrs. Martin is treated
and released. The children are triaged as needing immediate intervention.
The nurse recognizes that epidural hematomas have which characteristic?
Rapid brain decompression
To prepare Casey's parents for her CT scan, which explanation by the nurse is accurate?
A nurse from the ED will remain with Casey to monitor her constantly.
Which symptom is most characteristic of ICP in infants?
Separated cranial sutures
While conducting Casey's neurological assessment, the nurse notes possible damage to cranial
nerve III as evidenced by which of the following symptoms?
Ptosis and dilated pupils
Which data should the nurse include in documenting Casey's ocular findings?
Lid lag for both eyes and dilated pupils
While providing care for a child with an epidural hematoma, which nursing interventions are
most essential? (Select all that apply)
-Frequent neuro assessment
-Maintain the airway and monitor O2 sat
-Implement seizure precautions
-Monitor fluid status and osmolality
Meet the Clients: Casey and John Martin
Six-month-old Casey Martin and her 4-year-old brother, John Martin sustain head injuries when
the car driven by their mother is struck head on at an intersection. Although Casey is in an infant
seat, her head is severely shaken. John unbuckles his car seat and his head strikes the dash
board with force.
The Martins are transported to the emergency department (ED) where Mrs. Martin is treated
and released. The children are triaged as needing immediate intervention.
The nurse recognizes that epidural hematomas have which characteristic?
Rapid brain decompression
To prepare Casey's parents for her CT scan, which explanation by the nurse is accurate?
A nurse from the ED will remain with Casey to monitor her constantly.
Which symptom is most characteristic of ICP in infants?
Separated cranial sutures
While conducting Casey's neurological assessment, the nurse notes possible damage to cranial
nerve III as evidenced by which of the following symptoms?
Ptosis and dilated pupils
Which data should the nurse include in documenting Casey's ocular findings?
Lid lag for both eyes and dilated pupils
While providing care for a child with an epidural hematoma, which nursing interventions are
most essential? (Select all that apply)
-Frequent neuro assessment
-Maintain the airway and monitor O2 sat
-Implement seizure precautions
-Monitor fluid status and osmolality
