Adv Neuro & Musc. FINAL Review
Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply. 1. Monitor vital signs. 2. Monitor neurological status. 3. Monitor the dressing for signs of infection. 4. Monitor for signs of increased intracranial pressure. 5. Drain cerebrospinal fluid when the intracranial pressure is elevated.
1, 2, 3, 4. A subarachnoid bolt is inserted into the subarachnoid space and is used to measure intracranial pressure. Because a subarachnoid bolt is placed in the subarachnoid space, it is not capable of draining cerebrospinal fluid, which is produced in the ventricles. Therefore, the option to drain cerebrospinal fluid is not an intervention. The remaining options are appropriate interventions.
The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply. 1. Reduced ICP 2. Increased diuresis 3. Increased osmotic pressure of glomerular filtrate 4. Reduced tubular reabsorption of water and solutes 5. Reabsorption of sodium and water in the loop of Henle
1, 2, 3, 4. Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma. The incorrect option would cause fluid retention through reabsorption, thereby increasing ICP.
The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity
1, 2, 3, 4. Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse would place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Flat, with head turned to the side 4. Head of bed elevated 30 to 45 degrees 5. Head of bed elevated with the neck extended
1, 2, 4. The client who is at risk for or who has increased ICP would be positioned so that the head is in a neutral, midline position. The nurse would avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed needs to be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.
The nurse is planning to perform an assessment of the client's level of consciousness following a head injury using the Glasgow Coma Scale. Which assessments would the nurse include in order to calculate the score? Select all that apply. 1. Eye opening 2. Reflex response 3. Best verbal response 4. Best motor response 5. Pupil size and reaction
1, 3, 4. Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response are necessary parts of a total assessment of the neurological status of a client but are not part of this particular scale.
The nurse is reviewing the laboratory results from a lumbar puncture performed in a client with a diagnosis of meningitis. Which laboratory findings are expected to be noted with bacterial meningitis? Select all that apply. 1. Elevated protein level 2. Increased glucose level 3. Elevated CSF pressure 4. Increased white blood cells (WBCs) 5. Clear appearance of the cerebrospinal fluid (CSF)
1, 3, 4. If a bacterial infection of CSF is present, findings include reduced glucose level, an elevated protein level, increased WBCs, a cloudy appearance of CSF, and an elevated CSF pressure.
A client with a history of spinal cord injury is beginning medication therapy with baclofen. The nurse determines that the client understands the side/adverse effects of the medication if the client makes which statement? 1. "The medication may make me drowsy." 2. "The medication can cause high blood pressure." 3. "The medication may cause me to have some muscle pain." 4. "The medication may increase my sensitivity to bright light."
1. "The medication may make me drowsy." Baclofen is a central-acting skeletal muscle relaxant useful in treating muscle spasticity, usually in upper motor neuron injury. Side/adverse effects include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. The other options are incorrect.
A client is scheduled to begin medication therapy with valproic acid. The nurse looks for the results of which laboratory test(s) before administering the first dose? 1. Liver function tests 2. Renal function tests 3. Pulmonary function test 4. Pancreatic enzyme studies
1. Liver function tests Gastrointestinal effects from valproic acid are common and typically mild, but hepatotoxicity, although rare, is serious. To minimize the risk of fatal liver injury, liver function is evaluated before initiation of treatment and periodically thereafter. The other options are unrelated to the use of this medication.
The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? 1. Private room 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room
1. Private room Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort (as appropriate) client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.
The nurse is teaching a client with paraplegia from a spinal cord injury measures to maintain skin integrity. Which instruction will be most helpful to the client? 1. Shift weight every 2 hours while in a wheelchair. 2. Change bedsheets every other week to maintain cleanliness. 3. Place a pillow on the seat of the wheelchair to provide extra comfort. 4. Use a mirror to inspect for redness and skin breakdown twice a week.
1. Shift weight every 2 hours while in a wheelchair. To maintain skin integrity, the client needs to shift weight in the wheelchair every 2 hours and use a pressure relief pad. A pillow is insufficient to relieve the pressure. While the client is in bed, the bottom sheet needs to be free of wrinkles and wetness. Sheets would be changed as needed and more frequently than every other week. The client needs to use a mirror to inspect the skin twice daily (morning and evening) to assess for redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin care.
A client who had a brain attack (stroke) has suffered damage to Broca's area of the brain. Which priority assessment would the nurse perform? 1. Speech 2. Hearing 3. Balance 4. Level of consciousness
1. Speech Broca's area in the brain is responsible for the motor aspects of speech, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia. The items listed in the other options are not the responsibility of Broca's area.
A client who had a stroke (brain attack) has right-sided hemianopsia. What would the nurse plan to do to help the client adapt to this problem? 1. Teach the client to scan the environment. 2. Place all objects within the left visual field. 3. Place all objects within the right visual field. 4. Ensure that the family brings the client's eyeglasses to hospital.
1. Teach the client to scan the environment. Hemianopsia is blindness in half of the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual field deficit.
The nurse is caring for a client who is suspected of having meningitis and who is scheduled to have a lumbar puncture (LP). What are some contraindications for a client to have an LP? Select all that apply. 1. Clients with an allergy to sulfa 2. Clients with infection near the LP site 3. Clients with increased intracranial pressure 4. Clients receiving anticoagulation medications 5. Clients with a history of migraine headaches 6. Clients who have severe degenerative vertebral joint disease
2, 3, 4, 6. Contraindications for the performance of an LP include the following: clients receiving anticoagulation medications, those with infection near the LP site, those with increased intracranial pressure, and those who have severe degenerative vertebral joint disease. An allergy to sulfa or a history of migraine headaches is not a contraindication for having an LP performed.
The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20-degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation
2, 4, 5. Measures aimed at preventing increased ICP in the post-stroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20-degree flexion of the knees increases intra-abdominal pressure and consequently ICP.
The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1. Intracranial pressure changes 2. A long-term sequela of the injury 3. A worsening of the original injury 4. A short-term problem that will resolve in about 1 month
2. A long-term sequela of the injury Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.
The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? 1. Opisthotonos 2. Decorticate rigidity 3. Decerebrate rigidity 4. Flaccid quadriplegia
2. Decorticate rigidity In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. Opisthotonos is prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem.
The nurse is positioning a client who has increased intracranial pressure as a result of a head injury. Which position would the nurse plan to avoid? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees
2. Head turned to the side The head of a client with increased intracranial pressure needs to be kept in a neutral midline position. The nurse would avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed needs to be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1. Take the temperature. 2. Listen to breath sounds. 3. Observe for dyskinesias. 4. Assess extremity muscle strength.
2. Listen to breath sounds. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern in cord-injured clients unless head injury is suspected.
A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? 1. Difficulty speaking 2. Problem with understanding language 3. Difficulty controlling voluntary motor activity 4. Problem with articulating events from the remote past
2. Problem with understanding language Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.
A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1. Fever 2. Seizures 3. Hypoxia 4. Ischemia 5. Hypotension 6. Increased intracranial pressure (ICP)
3, 4, 5, 6. Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. Manifestations of secondary injury include hypoxia, ischemia, hypotension, and increased ICP that follows primary injury. It does not include fever or seizures.
The nurse is providing information to a client suspected of having meningitis who is scheduled for a lumbar puncture. Which information would the nurse provide to the client? 1. The test will probably take about 2 hours. 2. Food and fluids will be restricted after the test. 3. A signed informed consent form will be required. 4. Maintaining bed rest after the test will not be necessary.
3. A signed informed consent form will be required. Client preparation for a lumbar puncture includes obtaining an informed consent from the client because the procedure is invasive. The client is told that the test will take approximately 15 to 60 minutes. No dietary restrictions are required after the test, and the client needs to be encouraged to consume fluids. The nurse needs to inform the client about the need for bed rest after the test.
The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1. Spinal shock 2. Pulmonary embolism 3. Autonomic dysreflexia 4. Malignant hyperthermia
3. Autonomic dysreflexia The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of the seventh thoracic vertebra (T7). Autonomic dysreflexia is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. The data in the question are not associated with the conditions noted in the remaining options.
At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98° F (37.2° C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F (36.7° C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse would take which action first? 1. Reorient the client. 2. Retake the vital signs. 3. Call the primary health care provider (PHCP). 4. Administer an antihypertensive PRN (as needed).
3. Call the primary health care provider (PHCP). The important nursing action is to call the PHCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse needs to retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also needs to be administered. However, options 1, 2, and 4 are secondary nursing actions.
The nurse is caring for a client who had a stroke and is experiencing a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? 1. Disoriented to client, place, and time 2. Affect flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Unable to add and subtract; does not know who is president
3. Cannot recall what was eaten for breakfast today Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.
The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention would the nurse plan to implement? 1. Check cranial nerve functioning. 2. Determine the cause of the accident. 3. Draw blood for arterial blood gas analysis. 4. Perform a pulmonary wedge pressure measurement.
3. Draw blood for the arterial blood gas analysis. Assessment would be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. The actions in the remaining options are not priorities, although they may be a component in the assessment process, depending on the injury and client condition.
Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication? 1. Headache 2. Blurred vision 3. Elevated temperature 4. Abdominal distention
3. Elevated temperature Dantrolene is a centrally acting muscle relaxant. Malignant hyperthermia is a rare but life-threatening adverse effect that can occur with use of this medication. Therefore, an elevated temperature would alert the nurse to this potential adverse effect.
The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1. Notify the neurologist. 2. Loosen tight clothing on the client. 3. Place the client in a sitting position. 4. Check the urinary catheter tubing for kinks or obstruction.
3. Place the client in a sitting position. The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Loosening tight clothing and checking the urinary catheter can then be done, and the neurologist can be notified once initial interventions are done.
A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding
3. Slurred speech. The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there would be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
The nurse is caring for a client with a head injury who has an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1. 5 mm Hg 2. 8 mm Hg 3. 14 mm Hg 4. 22 mm Hg
4. 22 mm Hg Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.
The nurse prepares to teach a client with subarachnoid hemorrhage about the effects of nimodipine. The nurse plans to explain which information about the type and action of this medication? 1. Vasodilator that has an affinity for cerebral blood vessels 2. Beta-adrenergic blocker that will decrease blood pressure 3. Diuretic that will decrease blood pressure by decreasing fluid volume 4. Calcium channel blocker that will decrease spasm in cerebral blood vessels
4. Calcium channel blocker that will decrease spasm in cerebral blood vessels Nimodipine is a calcium channel-blocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance for rebleeding. It is typically prescribed for 3 weeks' duration.
The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What would the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage
4. Hematest-positive nasogastric tube drainage Development of a stress ulcer can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.
The nurse is caring for a client with bacterial meningitis. The nurse would anticipate that an antibiotic with which characteristics will be prescribed for the client? 1. One that has a long half-life 2. One that acts within minutes to hours 3. One that can be easily excreted in the urine 4. One that is able to cross the blood-brain barrier
4. One that is able to cross the blood-brain barrier A primary consideration regarding medications to treat bacterial meningitis is the ability of the medication to cross the blood-brain barrier. If the medication cannot cross, it will not be effective. The duration, onset, and excretion of the medication are also of general concern but apply to all medications and not specifically to those that are used to treat meningitis.
A client is scheduled to take ticlopidine. The nurse plans to take which action before implementing this medication therapy? 1. Take the client's blood pressure. 2. Obtain a prothrombin time (PT). 3. Take the client's apical heart rate. 4. Review the results of the complete blood cell (CBC) count.
4. Review the results of the complete blood cell (CBC) count. Ticlopidine is an antiplatelet agent that is used for the prevention of thrombotic stroke. Ticlopidine's effects last for the life of the platelet, 7 to 10 days. Ticlopidine also can cause neutropenia, which is an abnormally small number of mature white blood cells (WBCs). Baseline data from a CBC count are necessary before implementation of therapy, and the nurse would monitor for neutropenia during this medication therapy. If this adverse effect does occur, the primary health care provider is notified and therapy needs to be stopped. The effects of neutropenia are reversible within 1 to 3 weeks. Options 1, 2, and 3 are actions that are not specific to this medication therapy.
The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse would plan to place the client in which position? 1. Prone 2. Supine 3. Side-lying 4. Semi-Fowler's
4. Semi-Fowler's After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's bed usually is elevated 30 degrees to promote venous outflow through the jugular veins. Prone, supine, and side-lying denote incorrect positions after this surgery, and these positions could result in edema at the surgical site and increased intracranial pressure. The primary health care provider's prescriptions are always followed with regard to positioning the client.
A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1. The left side of the body 2. The right side of the body 3. Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response
1. The left side of the body Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.
A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1. Bradycardia 2. Hyperthermia 3. Hypoglycemia 4. Increased cardiac output
1. Bradycardia Neurogenic shock can occur after a spinal cord injury. Usually the body attempts to compensate massive vasodilation by becoming tachycardic to increase the amount of blood flow and oxygen delivered to the tissues; however, in neurogenic shock, the sympathetic nervous system is disrupted, so the parasympathetic system takes over, resulting in bradycardia. This insufficient pumping of the heart leads to a decrease in cardiac output. Hypoglycemia is not an indicator of neurogenic shock. Hypothermia develops because of the vasodilation and the inability to control body temperature through vasoconstriction.
The client with a traumatic brain injury (TBI) has begun to excrete copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the primary health care provider will prescribe which medication? 1. Mannitol 2. Desmopressin 3. Ethacrynic acid 4. Dexamethasone
2. Desmopressin A complication of TBI is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone is usually given to control cerebral edema secondary to brain tumors. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.
The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1. Thalamus 2. Hypothalamus 3. Limbic system 4. Reticular activating system
2. Hypothalamus The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.
The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature, widening pulse pressure, increased systolic blood pressure, and decreasing pulse and respirations. Respiratory irregularities also may occur.
The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Updating the home safety sheet 2. Leaving the client in an unchilled area of the room 3. Noting a bowel movement on the client progress note 4. Recording the amount of urine obtained with catheterization
2. Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.
To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse would place the client with an incision in the anterior or middle fossa in which position? 1. 15 degrees of Trendelenburg's 2. Side-lying with the head of the bed flat 3. With the head of the bed elevated at least 30 degrees 4. With the head of the bed elevated no more than 10 degrees
3. With the head of the bed elevated at least 30 degrees Correct positioning of the client following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always followed. The client with an incision in the anterior or middle fossa would be positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client would not be positioned to the operative side. Trendelenburg's position is contraindicated in the postoperative phase following cranial surgery.
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)
4. Autonomic dysreflexia (hyperreflexia) Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.
A client is scheduled to begin therapy with carbamazepine. The nurse would assess the results of which test(s) before administering the first dose of this medication to the client? 1. Liver function tests 2. Renal function tests 3. Pancreatic enzyme studies 4. Complete blood cell count
4. Complete blood cell count Carbamazepine may be used to treat a seizure disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia. To reduce the risk of serious hematological effects, a complete blood cell count would be done before treatment and periodically thereafter. This medication would be avoided in clients with preexisting hematological abnormalities. The client also is told to report the occurrence of fever, sore throat, pallor, weakness, infection, easy bruising, and petechiae. The results of the remaining tests listed in the options are not associated with the use of this medication.
The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action? 1. Refrain from smoking alone. 2. Take all prescribed medications on time. 3. Have the spouse nearby when showering. 4. Drink alcohol in small amounts and only on weekends.
4. Drink alcohol in small amounts and only on weekends. The client would avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or it could precipitate seizure activity. The client needs to take all medications on time to avoid decreases in therapeutic medication levels, which could precipitate seizures. To minimize the risk of injury if a seizure occurs the client would not smoke alone and would not bathe in the shower or tub without someone nearby.
A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1. Pao2 60 to 100 mm Hg, Paco2 25 to 30 mm Hg 2. Pao2 60 to 100 mm Hg, Paco2 30 to 35 mm Hg 3. Pao2 80 to 100 mm Hg, Paco2 25 to 30 mm Hg 4. Pao2 80 to 100 mm Hg, Paco2 35 to 38 mm Hg
4. Pao2 80 to 100 mm Hg, Paco2 35 to 38 mm Hg The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg. Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The Pao2 is not allowed to fall below 80 mm Hg, to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect.
The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization
4. Placing the client on a bed that provides spinal immobilization Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is unavailable, a firm mattress with a bed board under it would be used. The remaining options are incorrect and potentially harmful interventions.
