Ch 66 Neurologic Dysfunction
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? a) "My children are at greater risk to develop this disease." b) "I will have progressive muscle weakness." c) "I will lose strength in my arms." d) "I need to remain active for as long as possible."
"My children are at greater risk to develop this disease." There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response? a) "Treatment for Parkinson's is only palliative; it keeps you comfortable." b) "Treatment aims at keeping you emotionally healthy by making you think you are doing something to fight this disease." c) "Treatment really doesn't matter; the disease is going to progress anyway." d) "Treatment aims at keeping you independent as long as possible."
"Treatment aims at keeping you independent as long as possible." Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.
The nurse is taking care of a patient with a history of headaches. The nurse takes measures to reduce headaches in the patient in addition to administering medications. Which of the following appropriate nursing interventions may be provided by the nurse to such a patient? a) Perform the Heimlich maneuver b) Use pressure-relieving pads or a similar type of mattress c) Maintain hydration by drinking eight glasses of fluid a day d) Apply warm or cool cloths to the forehead or back of the neck
Apply warm or cool cloths to the forehead or back of the neck Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the patient. A patient with transient ischemic attacks is advised to maintain the hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the patient cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the patient's body.
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? a) Visualization of a hemorrhage b) To assess visual acuity c) Access for intravenous (IV) fluids d) Aspiration of a brain abscess
Aspiration of a brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. a) Pain and stiffness of the extremities b) Low antidiuretic hormone (ADH) levels c) Cloudy cerebral spinal fluid d) Low white blood cell (WBC) count e) Low red blood cell (RBC) count f) Purpura of hands and feet
• Cloudy cerebral spinal fluid • Purpura of hands and feet The CSF will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts . Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
Which of the following is one of the earliest signs of increased ICP? a) Coma b) Decreased level of consciousness (LOC) c) Cushing's triad d) Headache
Decreased level of consciousness (LOC) Decreasing LOC is one of the earliest signs of increased ICP. Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. Decreasing LOC is one of the earliest signs of increased ICP. If untreated, increasing ICP will lead to coma. Decreasing LOC is one of the earliest signs of increased ICP.
Which interventions are appropriate for a patient with increased ICP? Select all that apply. a) Frequent oral care b) Elevating the head of the bed at 90 degrees c) Administering prescribed antipyretics d) Maintaining aseptic technique with the intraventricular catheter e) Encouraging deep breathing and coughing every 2 hours
• Administering prescribed antipyretics • Maintaining aseptic technique with the intraventricular catheter • Frequent oral care Controlling a fever is an important intervention for a patient with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate for control of fevers. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the patient is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a patient with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated at 30 to 45 degrees and in a neutral position to allow for venous drainage.
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. a) Purpura of hands and feet b) Cloudy cerebral spinal fluid c) Low white blood cell (WBC) count d) Low red blood cell (RBC) count e) Pain and stiffness of the extremities f) Low antidiuretic hormone (ADH) levels
• Cloudy cerebral spinal fluid • Purpura of hands and feet The CSF will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts . Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
Cerebral edema peaks at which timeframe post intracranial surgery? a) 72 hours b) 12 hours c) 24 hours d) 48 hours
24 hours Cerebral edema tends to peak 24 to 36 hours after surgery.
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a) 80 mm Hg b) 50 mm Hg c) 70 mm Hg d) 60 mm Hg
70 mm Hg Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).
A nurse is caring for a patient with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a) Tasting b) Swallowing c) Chewing d) Smelling
Chewing Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. Trigeminal neuralgia involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. Trigeminal neuralgia involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. Trigeminal neuralgia involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? a) At least 50% carbohydrate b) Low in fat c) Restricts protein to 10% of daily caloric intake d) High in protein and low in carbohydrate
High in protein and low in carbohydrate A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care? a) Risk of injury related to decreased LOC b) Ineffective airway clearance related to altered LOC c) Deficient fluid volume related to inability to take fluids by mouth d) Risk for impaired skin integrity related to prolonged immobility
Ineffective airway clearance related to altered LOC The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? a) Lomotil b) Labetalol c) Lamisil d) Lamictal
Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? a) Half-normal saline (0.45% NSS) b) Dextrose 5% in water (D5W) c) One-third normal saline (0.33% NSS) d) Mannitol(Osmitrol)
Mannitol(Osmitrol) With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? a) Cushing's b) Hashimoto's disease c) Monro-Kellie d) Dawn phenomenon
Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hasimoto's disease is related to the thyroid gland.
Which of the following drugs may be used after a seizure to maintain a seizure-free state? a) Phenobarbital b) Ativan c) Valium d) Cerebyx
Phenobarbital IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.
The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in the dorsal recumbent position. b) Place patient in supine position with head slightly elevated. c) Place patient in the Trendelenburg position. d) Place patient in prone position with head turned to unaffected side.
Place patient in supine position with head slightly elevated. After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg position, and the prone position can increase intracranial pressure.
The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in the dorsal recumbent position. b) Place patient in the Trendelenburg position. c) Place patient in prone position with head turned to unaffected side. d) Place patient in supine position with head slightly elevated.
Place patient in supine position with head slightly elevated. After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg position, and the prone position can increase intracranial pressure.
A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention? a) Shivering b) Urine output of 100 mL/hr c) Capillary refill of 2 seconds d) Cool, dry skin
Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
Which of the following is an inaccurate manifestation of Cushing's triad? a) Tachycardia b) Hypertension c) Bradypnea d) Bradycardia
Tachycardia Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects? a) To increase urine output b) To reduce cellular metabolic demands c) To dehydrate the brain and reduce cerebral edema d) To lower uncontrolled fevers
To dehydrate the brain and reduce cerebral edema Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the patient with IICP. Although mannitol is a type of diuretic, it is not used to increase urine output. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: a) insert an indwelling urinary catheter. b) use a condom catheter instead of an invasive one. c) place the client on fluid restrictions. d) increase the frequency of the catheterizations.
increase the frequency of the catheterizations. As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.
The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome? a) 'Blood transfusions are the gold standard for the treatment of this syndrome ' b) 'Antibodies that triggered the autoimmune response are removed from your blood.' c) 'The blood removal allows for replacement of cleaner blood from a healthy person.' d) ' Plasma replacement dilutes the organisms that are causing the symptoms.'
'Antibodies that triggered the autoimmune response are removed from your blood.' Because GBS is believed to be an autoimmune disease, plasmapheresis (not blood transfusion) has emerged as a major treatment intervention. This process removes the blood, filters out the antibodies that trigger the autoimmune disease, and then returns the blood to the client. The blood removal is only a part of the process for filtering out antibodies and is not a dilution process.
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a) Assess pupils. b) Assess Glasgow Coma Scale. c) Assess for a patent airway. d) Assess vital signs.
Assess for a patent airway. A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.
Which phase of a migraine headache usually lasts less than an hour? a) Headache b) Recovery c) Prodrome d) Aura
Aura The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurological symptoms. The prodrome phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the postheadache phase, patients may sleep for extended periods.
Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar b) Extreme hip flexion supported by pillows c) Rotating the neck to the far right with neck support d) Keeping the head flat with use of no pillow
Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? a) Damage to the vagal nerve b) Damage to the olfactory nerve c) Damage to the facial nerve d) Damage to the optic nerve
Damage to the optic nerve Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? a) Decerebrate posturing and loss of corneal reflex b) Loss of gag reflex and mental confusion c) Mental confusion and pupillary changes d) Complaints of headache and lack of pupillary response
Decerebrate posturing and loss of corneal reflex Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood presure and temperature, widened pulse pressure, Chenyne-Stokes breathing, projectile vomiting, heimplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).
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? a) Exacerbation of uncontrolled hypertension b) Infection c) Increase in cerebral perfusion pressure d) Increased ICP
Increased ICP Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Shock b) Increased intracranial pressure (ICP) c) Encephalitis d) Status epilepticus
Increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.
A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a) Restricting fluid intake and hydration b) Maintaining adequate hydration c) Administering prescribed antipyretics d) Hyperoxygenation before and after tracheal suctioning
Restricting fluid intake and hydration Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients. A patient with neurological infection should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratory distress.
In your assessment of a 39-year-old victim of a motor vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure? a) Constricted response b) Unequal response c) Rapid response d) Equal response
Unequal response In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated. This is not a sign of increasing ICP. In increased ICP, the pupil response is unequal.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? a) Phenobarbital b) Furosemide (Lasix) c) Mannitol d) Vasopressin
Vasopressin Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? a) Decreased pulse rate, respirations of 20 breaths/minute b) Decreased pulse rate, abdominal breathing c) Increased pulse rate, respirations of 16 breaths/minute d) Increased pulse rate, adventitious breath sounds
Increased pulse rate, adventitious breath sounds An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? a) Seizure began at 1300 hours. b) Sleeping quietly after the seizure c) The client cried out before the seizure began. d) Seizure was 1 minute in duration including tonic-clonic activity.
Seizure was 1 minute in duration including tonic-clonic activity. Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
The nurse is caring for a patient involved in a motorcycle accident 7 days ago. Since admission the patient has been unresponsive to painful stimuli. The patient had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F rectal, urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which of the following is the priority nursing action? a) Provide ventriculostomy care. b) Administer acetaminophen (Tylenol) per orders. c) Assess for signs and symptoms of infection. d) Inspect the ICP monitor to ensure it is working properly.
Administer acetaminophen (Tylenol) per orders. The nurse needs to control the fever by administering the ordered acetaminophen (Tylenol) as the priority action. An increase in the patient's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the patient has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.
