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A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. What sign or symptom is considered a manifestation of postconcussion syndrome and does not necessitate medical attention?
- A. Vomiting
- B. Blurred vision
- C. Behavioral changes
- D. Temporary loss of consciousness
Correct Answer: C
Rationale: Behavioral changes, such as irritability or sleep disturbances, are expected in postconcussion syndrome and typically don?t require medical attention. Vomiting, blurred vision, or loss of consciousness warrant evaluation for complications like increased ICP.
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What 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.
Correct Answer: B
Rationale: Subdural hematoma involves bleeding between the dura and cerebrum from ruptured cortical veins. Bleeding between dura and skull is epidural, arterial bleeding with rapid compression is typical of epidural hematomas, and parietotemporal location is more common in epidural cases.
A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse immediately assesses airway, breathing, and circulation. What should be the next nursing action?
- A. Place the child on his side.
- B. Take the childs blood pressure.
- C. Stabilize the childs neck and spine.
- D. Check the childs scalp and back for bleeding.
Correct Answer: C
Rationale: After ensuring airway, breathing, and circulation, stabilizing the neck and spine prevents further trauma in a suspected head or spinal injury. Positioning, blood pressure checks, or bleeding assessments follow to avoid exacerbating potential spinal injuries.
The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings?
- A. Neurologic health
- B. Severe brain damage
- C. Decorticate posturing
- D. Decerebrate posturing
Correct Answer: A
Rationale: Presence of Moro, tonic neck, and withdrawal reflexes in a 2-month-old indicates normal neurologic function for age. These reflexes are expected and do not suggest brain damage, decorticate, or decerebrate posturing, which involve abnormal motor responses.
The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral function. The nurse should include what statement in preparing the child?
- A. The scan will not hurt.
- B. Pain medication will be given.
- C. You will be able to move once the equipment is in place.
- D. Unfortunately no one can remain in the room with you during the test.
Correct Answer: A
Rationale: CT scans are painless, requiring immobilization, and this should be emphasized to reduce anxiety. Pain medication isn?t needed, movement is restricted during the scan, and a caregiver can often stay with the child, depending on facility protocols.
What test is never performed on a child who is awake?
- A. Dolls head maneuver
- B. Oculovestibular response
- C. Assessment of pyramidal tract lesions
- D. Funduscopic examination for papilledema
Correct Answer: B
Rationale: The oculovestibular response (caloric test) uses painful ice water instillation, performed only in comatose children. Dolls head maneuver, pyramidal tract assessment, and funduscopic exams are non-painful and can be done on awake children.