Chapter 66
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
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?
Administer stool softeners.
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)?
Administering a stool softener as ordered
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
Chewing
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?
Compliance with the prescribed medication regimen
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?
Declining level of consciousness (LOC)
The initial sign of increasing intracranial pressure (ICP) includes
Decreased LOC
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?
Infection
A patient with epilepsy is having a seizure. Which of the following should the nurse do after the seizure?
Keep the patient to one side (to prevent aspiration).
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:
Parkinson's disease
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
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Side-lying, to facilitate drainage of oral secretions
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:
shivering in hypothermia can increase ICP.
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/h
