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The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition?
- A. Posturing
- B. Vital signs
- C. Focal neurologic signs
- D. Level of consciousness
Correct Answer: D
Rationale: Level of consciousness is the earliest and most sensitive indicator of worsening neurologic status post-head injury. Posturing and focal signs appear later, and vital sign changes are less immediate or specific in children with head injuries.
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What statement is descriptive of a concussion?
- A. Petechial hemorrhages cause amnesia.
- B. Visible bruising and tearing of cerebral tissue occur.
- C. It is a transient and reversible neuronal dysfunction.
- D. It is a slight lesion that develops remote from the site of trauma.
Correct Answer: C
Rationale: A concussion is a transient, reversible neuronal dysfunction causing brief loss of awareness post-trauma. Petechial hemorrhages and tissue tearing describe contusions, and remote lesions indicate contrecoup injuries, not concussions.
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.
The nurse is caring for a child with severe head trauma after a car accident. What is an ominous sign that often precedes death?
- A. Delirium
- B. Papilledema
- C. Flexion posturing
- D. Periodic or irregular breathing
Correct Answer: D
Rationale: Periodic or irregular breathing indicates brainstem dysfunction, often preceding apnea and death. Delirium reflects confusion, papilledema suggests chronic increased ICP, and flexion posturing indicates cerebral or corticospinal damage, not necessarily imminent death.
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.