Question

In: Nursing

The nurse is assigned to care for a child with a brain injury who has a...

The nurse is assigned to care for a child with a brain injury who has a temporal lobe herniation and increasing intracranial pressure. Which signs should the nurse identify as indicative of this type of injury? Select all that apply.

1. Flaccid paralysis

2. Pupil response to light

3. Ipsilateral pupil dilation

4. Compression of the sixth cranial nerve

5. Shifting of the temporal lobe laterally across the tentorial notch

Expert Solution

The nurse assigned to care for the child with a brain injury who has a temporal lobe herniation and increasing intracranial pressure should identify the following signs as indicative of this type of injury.

2. PUPIL RESPONSE TO LIGHT:

In normal conditions the pupils dilate when the light is dim and constrict when there is enough light rays that enter the eye which is contolled by the occulomotor nerve. Here the child have a brain injury with increased intracranial pressure and temporal lobe herniation which puts pressure on the brain stem. This eventually compresses the occulomotor nerve ( IIIrd cranial nerve ) resulting in dilatation of the pupil most commonly in the affected side.

3. IPSILATERAL PUPIL DILATION :

Ipsilateral pupil means, pupil of the affecyed side. This is one of the hallmark signs. Because of the compression of the occulomotor nerve the ipsilateral pupil fails to constrict and hence remain ditated . This can be assessed by checking the pupillary light reflex or reaction (pupil remains dilated here.)

5. SHIFTING OF THE TEMPORAL LOBE LATERALLY ACROSS THE TENTORIAL NOTCH:

This can be evident by the ipsilateral pupillary dilatation due to the compression of the occulomotor nerve which happens only when the temporal lobe shifts tentorial notch thus putting pressure over the brain stem.

Why others are not a sign of the injury:

1.FLACCID PARALYSIS:

Paralysis means weakness or loss of control over the mucles in any part of the body which is not common in this condition. However if there is compression of the ipsilateral cerebral peduncle can result in contralateral hemiparesis ( weakness on one entire side of the body).

4. COMPRESSION OF THE SIXTH CRANIAL NERVE :

The function of the sixth cranial nerve- ABDUCENS NERVE is to send signal to the lateral rectus muscle of the eye which the helps in movement of eyes away from the nose (outward). However in the child's case the pressure exerted on the brain stem compresses only the occulomotor nerve(IIIrd cranial nerve) while the other two nerves namely - trochlear (IVth cranial nerve) and abducens ( VIth cranial nerve ) remains intact

Nightingale answered 2 years ago

A nurse is caring for a client who has a traumatic brain injury. The client, who...

A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first? a. Blood glucose b. Urinary output c. Motor responses d. Blood pressure

The registered nurse is assigned to care for a pediatric client who is receiving immune suppressants....

The registered nurse is assigned to care for a pediatric client who is receiving immune suppressants. The registered nurse is precepting a student nurse. The registered nurse reviews the key nursing considerations that the student needs to consider in the care of this patient.

2. A nurse is caring for a client who has a traumatic injury to the right...

2. A nurse is caring for a client who has a traumatic injury to the right ankle. The client has an unstable fracture with only a temporary splint in place. The client is having increased pain that is unresolved with IV narcotics and has 4+ edema, pallor, and pulselessness of the right foot. What should the nurse suspect, and what interventions should be taken?

33. A nurse is providing teaching about home care to the parent of a child who...

33. A nurse is providing teaching about home care to the parent of a child who has scabies. Which of the following instructions should the nurse include in the teaching? a. wash the child’s hair with shampoo containing ketoconazole b. Treat everyone who came into close contact with the child c. Soak comb and brushes in boiling water for 10min. d. Apply petroleum jelly to the affected areas. 34. A nurse is providing teaching to the parents of a child...

An RN is assigned to care for a client with a history of a traumatic brain...

An RN is assigned to care for a client with a history of a traumatic brain injury, who was readmitted to the hospital from a long-term care setting with pneumonia. The RN notes this hospital admission is the fourth one this year. The RN self-reflects: “This client keeps coming back to the unit because he is unable to cough and clear his airway. There are frequently skin breakdown issues, and he seems frailer to me. The client is immobile and...

You are a female student nurse assigned to care for Mr. Habib, a male patient who...

You are a female student nurse assigned to care for Mr. Habib, a male patient who is Muslim. He is recovering from surgery for prostate cancer and has a suprapubic incision. He is from Iran and has some difficulty speaking English. You know very little about the Muslim faith. You have been told that his wife is always at the bedside, and she seems very nice. One nurse tells you that she cared for the patient yesterday and that he...

you are the home care nurse assigned to visit an 85 years old male patient who...

you are the home care nurse assigned to visit an 85 years old male patient who was discharged from the with new-onset left-sided heart failure.You arrive at Mr.Smith's house to find that he is having difficulty breathing and appears anxious.You quickly assess Mr.Smith's lungs and find that he has bilateral rhonchi in the upper lobes. Mr.Smith shares that he has not taken his medications this morning. You ask to see the discharge instructions and note that Mr.Smith has seen several...

You are a staff nurse working in an intensive care unit and assigned to care for...

You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old man who had coronary artery bypass graft surgery 4 days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks. The staff, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent...

registered nurse was assigned to care for a 76-year-old patient who had a stroke. Upon entering...

registered nurse was assigned to care for a 76-year-old patient who had a stroke. Upon entering the room, the nurse the patient surrounded by ID family members.The requested the family members leave the room so she conduct her initial assessment and perform any related treatments .They did so.The nurse provided care in a professional, unhurried, and gentle manner. As she was leaving, patient said,“Thank you.You are a wonderful nurse.” later, the nursing supervisor told her the patient told his family...

1. a nurse is completing an assessment following suctioning of a child who has a tracheostomy....

1. a nurse is completing an assessment following suctioning of a child who has a tracheostomy. which of the following findings should the nurse identify as an indication that the procedure has been effective? a. increased RR. b. decreased O2 sat. c. clear breath sounds. d. increased oral secretions. 2. a nurse is developing a plan of care for a 4-year-old child who has hemophilia and is experiencing acute hemarthrosis. which of the following interventions should the nurse include in...