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The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this?
- A. Eye trauma
- B. Brain death
- C. Severe brainstem damage
- D. Neurosurgical emergency
Correct Answer: D
Rationale: A sudden fixed and dilated pupil in an unconscious child signals a neurosurgical emergency, often due to increased intracranial pressure or unilateral brain damage. Eye trauma is less likely, brain death involves bilateral fixed pupils, and pinpoint pupils suggest brainstem damage.
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What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child?
- A. Suction the child frequently.
- B. Turn the childs head side to side every hour.
- C. Provide environmental stimulation.
- D. Avoid activities that cause pain or crying.
Correct Answer: D
Rationale: Avoiding pain or crying prevents ICP increases, as these raise intracranial pressure. Frequent suctioning, head turning, and environmental stimulation can elevate ICP and are contraindicated or require careful management, such as pre-suction hyperventilation.
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.
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.
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.
What term is used to describe a childs level of consciousness when the child is arousable with stimulation?
- A. Stupor
- B. Confusion
- C. Obtundation
- D. Disorientation
Correct Answer: C
Rationale: Obtundation describes a child arousable with stimulation but with reduced alertness. Stupor requires vigorous stimulation, confusion involves impaired decision-making, and disorientation pertains to time and place confusion.