Chapter 66: Management of Patients With Neurologic Dysfunction

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? - Jacksonian - Absence - Generalized - Sensory

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? - The type of anticonvulsant prescribed to manage the epileptic condition. - Recent stress level - Recent weight gain and loss - Compliance with the prescribed medication regimen

Lactated Ringer's

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? - Dextrose 5% in water (D5W) - Half-normal saline (0.45% NSS) - One-third normal saline (0.33% NSS) - Lactated Ringer's

Hypocortisolism

Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition? - Hypocortisolism - Hypoglycemia - Hyperglycemia - Hypercalcemia

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? - Visualization of a hemorrhage - Aspiration of a brain abscess - Access for intravenous (IV) fluids - To assess visual acuity

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 - dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.

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? - An absence seizure - A complex seizure - A partial seizure - A tonic-clonic seizure

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? - Elevate the head of the bed. - Complete a head-to-toe assessment. - Administer morning dose of anticonvulsant. - Administer Percocet as ordered.

Restricting fluid intake and hydration

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? - Maintaining adequate hydration - Administering prescribed antipyretics - Restricting fluid intake and hydration - Hyperoxygenation before and after tracheal suctioning.

3

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? - 3 - 6 - 9 - 12

Maintenance of a patent airway

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 actions would be the first priority? - Positioning to prevent complications - Maintenance of a patent airway - Assessment of pupillary light reflexes - Determination of the cause

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? - Optimizing nutrition - Managing muscle weakness - Explaining hospice care and services - Offering family support groups

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

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? - Apply warm or cool cloths to the forehead or back of the neck. - Maintain hydration by drinking eight glasses of fluid a day. - Perform the Heimlich maneuver - Use pressure-relieving pads or a similar type of mattress.

Lethargy and stupor

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? - A bounding pulse - Bradycardia - Hypertension - Lethargy and stupor

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 - normal. - flaccid. - decorticate. - decerebrate.

Change in level of consciousness

Which is the earliest sign of increasing intracranial pressure? - Vomiting - Change in level of consciousness - Headache - Posturing