Chapter 61 Prepu

administer acetaminophen per orders

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client 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 is the priority nursing action?

Increased ICP is 12 mm Hg

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Explaining hospice care and services

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

High in protein and low in carbohydrate

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

An absence seizure

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

Osteoporosis

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Check the equipment

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

decerebrate

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

Change in level of consciousness

Which is the earliest sign of increasing intracranial pressure?

Ineffective cerebral tissue perfusion

Which is the priority nursing diagnosis when caring for a client with increased iCP who has an intraventricular catheter?

Anticonvulsants

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Phenobarbital

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Cluster

While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?

"My children are at greater risk to develop this disease."

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?

3

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function

unequal response

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

Side-lying, to facilitate drainage of oral secretions

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Pituitary carcinoma

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?

Performing a lumbar puncture

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?

Brain Tumor

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

dehydrate the brain and reduce cerebral edema

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

Assess for a patent airway

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?

24 hours

Cerebral edema peaks at which time point after intracranial surgery

Gingival hyperplasia

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Seizure was 1 minute in duration including tonic-clonic activity.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Hypocortisolism

Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition?

promote carbon dioxide elimination.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

Hallucinations and delusions

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson disease and Huntington disease is the development of what symptom in clients with advanced Huntington disease?

The dynamic equilibrium of cranial contents

The Monro-Kellie hypothesis explains

Damage to the optic nerve

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?

Airway clearance

The nurse enters the client's room and finds the client with an altered level of con sciousness (LOC). Which is the nurse's priority concern?

Aspiration of a brain abscess

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?

Administer medications at exact intervals ordered

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?

Increased ICP

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?

maintenance of a patent airway

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Administer corticosteroids as ordered.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Drooping eyelids

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

minimize exposure to bright lights and noise.

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

Lethargy and Stupor

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Rising blood pressure and bradycardia

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Avoiding flexion of the neck with a use of a cervical collar

Which positions is used to help reduce intracranial pressure (ICP)

Avoiding flexion of the neck with use of a cervical collar

Which positions is used to help reduce intracranial pressure (ICP)

Apply warm or cool cloths to the forehead or back of the neck.

Which signs are manifestations of the Cusing traid? Select all that apply. The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Herniation

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Using a cervical collar

Which method is used to help reduce intracranial pressure?

Urinary Tract Infection (UTI)

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

Generalized

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

unknown

A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is

Seasonal changes

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines?

Compliance with the prescribed medication regimen

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

shivering in hypothermia can increase ICP

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:

lethargy

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Glasgow Coma Scale

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?

Shivering

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Administer hydromorphone or sumatriptan meds for relief

A client is returning to the medical unit after surgery and has a history of migraines. Which intervention would the nurse prioritize for the overall treatment of this client?

Administering a stool softener as ordered

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Shivering in hypothermia can increase ICP

A client is treated for increased intracranial pressure ICP. It is important for the client to avoid hypothermia because

Elevated 30 degrees

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?

Maintain a patient airway

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Keep the client on one side.

A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure?

The CPP is low

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

Low

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

Restricting fluid intake and hydration

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?

More than 200ml/h

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

Infection

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

Administer stool softeners

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Chewing

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

Verapamil (Calan)

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?

choreiform movements

A nurse is caring for client diagnosed with Huntington disease. The client's plan of care includes interventions to address the client's potential for injury. Which would be included as a cause for this risk?

Monro-Kellie

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?

Diminished responsiveness

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

Lamictal

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

"A secondary headache is associated with an organic cause, such as a brain tumor."

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

Vasopressin

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?

Increase the frequency of the catheterizations

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:

Vasopressin therapy

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following?

Diplopia

A patient has been diagnosed with myasthenia gravis. The nurse documents The initial and most common manifestation of

Declining level of consciousness (LOC)

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?

Midbrain

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which of the brain?

"You must avoid coughing, sneezing, and blowing your nose."

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

Elevate the head of the bed

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Vasodilation

A c;oemt suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic functijon contributes to the increase in intracranial pressure?

Lactated Ringer's

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

carefully move the client to a flat surface and turn him on his side.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

Elevate the head of the bed.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Parkinson Disease

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Altered respiratory patterns

Which is a late sign of increased intracranial pressure (ICP)?

Decerebrate posturing and loss of corneal reflex

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?

70mm Hg

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?

52

A client with a head injury is being monitored for increased intracranial pressure (ICP). His lood pressure is 90/60 mm Hg and ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:

Notify the physician of a possible cerebrospinal fluid leak.

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Flaccid

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

Enemas

Which activity should be avoided in clients with increased intracranial pressure (ICP)?

supine position with the head slightly elevated.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

Heart failure

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

Oliguria and serum hyponatremia

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings.

Apply warm or cool cloths to the forehead or back of the neck.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?