Chapter 66 Neuro

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

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

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

3

Which signs are manifestations of the Cushing triad? Select all that apply.

HTN, bradypnea, bradycardia

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 nursewhile monitoring the client?

UTI

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

brain tumor

What is one of the earliest signs of increased ICP?

decreased LOC

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?

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

cerebral edema peaks at which time point after intracranial surgery?

24 hrs

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?

GCS

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?

Monro-Kellie

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

admin corticosteroids as ordered

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?

admin hydromorphone or sumatriptan meds for relief

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

airway clearance

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

altered resp patterns

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

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

avoid flexion of the neck with use of a cervical collar---- promotes venous drainage and prevents JVD

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

chewing

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

decerebrate

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

decorticate

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

high protein, low carb

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

keep the client on one side

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

lactated ringers

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

lamictal

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?

rising BP and bradycardia

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

seizure was 1 min in duration including tonic-clonic activity

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

shivering

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

vasodilation

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?

vasopressin --> for diabetes insipidus

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

lethargy and stupor

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?

more than 200 ml/hr

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?

my children are at greater risk to develop this disease

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?

maintains 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?

maintenance of a patent airway

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?

notify physician of a possible CSF leak

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:

parkinsons

The nurse recognizes that causes of acquired seizures include what? Select all that apply.

cerebrovascular disease, brain tumor, hyponatremia, drug and alcohol withdrawal, metabolic and toxic conditions

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

dehydrate the brain and reduce cerebral edema

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

explaining hospice care and services

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?

generalized

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

phenobarbital

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

restricting fluid intake and hydration

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

the CPP is low

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

there is a strong familial tendency

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?

drooping eyelids

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?

verapamil (Calan)