Acute Neuro

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

Which Glasgow Coma Scale score is indicative of a severe head injury?

7

Which of the following types of skull fractures may be evident by Battle's sign?

Basilar

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

Infection

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions.

A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.

Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time?

Propofol (Diprivan)

A client the nurse is caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury.

Which reflects basic nursing measures in the care of the client with viral encephalitis?

Providing comfort measures

Which of the following is not a manifestation of Cushing's Triad?

Tachycardia

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply.

Turn the client to the side. Provide verbal reassurance.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.

The earliest sign of serious impairment of brain circulation related to increased ICP is:

A change in consciousness.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

Acute

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Basilar

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

Cloudy cerebral spinal fluid Purpura of hands and feet

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.

Elevated systolic blood pressure Wide pulse pressure

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply.

Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Record intake and output.

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

Respiratory irregularities Slow bounding pulse Widened pulse pressure

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

Subdural

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Take daily weights.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Alteration in level of consciousness (LOC)

A middle-aged male has been brought to the emergency department by ambulance after being found unconscious by police with injuries consistent with an assault. Injuries on the man's face and skull necessitate prompt assessment for traumatic brain injury. What neuroimaging tests are best able to yield clinically meaningful data? Select all that apply.

Computed tomography (CT) Magnetic resonance imaging (MRI)

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.

Decreased glucose Increased protein Increased white blood cells

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

Epidural

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage?

Hyperthermia

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur.

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?

The client with a basilar fracture

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?

Watchful waiting and close monitoring

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply.

Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics

A client with fungal encephalitis receiving IV amphotericin B reports fever, chills, and body aches. What action by the nurse is appropriate?

Administer diphenhydramine and acetaminophen per orders.

A client is suspected to have bacterial meningitis. What is the priority nursing intervention?

Administer prescribed antibiotics.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining level of consciousness (LOC)

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?

Epidural hematoma

A patient is being treated in hospital for St. Louis encephalitis. When planning this patient's care, the nurse should be aware that this specific variant of encephalitis creates a potential for what nursing diagnosis?

Excess fluid volume

A nurse is assessing a client who has sustained a traumatic brain injury. The client's Glasgow Coma Score (GCS) is 15. Which assessment would the nurse most likely document? Select all that apply.

Eye opening response: spontaneous Best motor response: obeys command Best verbal response: oriented

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

A patient has been admitted to the intensive care unit (ICU) for the treatment of bacterial meningitis. The ICU nurse is aware of the need for aggressive treatment and vigilant nursing care because meningitis has the potential to cause what sequela?

Increased intracranial pressure (ICP)

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

A client is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this client to evaluate the brain structure?

MRI

The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient?

The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.