Intracranial Regulation- difficult

A. vasodilation Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

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? A. vasodilation B. vasoconstriction C. hypertension D. increased PaO

A. Bradycardia B. Bradypnea C. Hypertension At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. A. Bradycardia B. Bradypnea C. Hypertension D. Tachycardia E. Pupillary constriction

C. pons. Cranial nerves V through VIII connect to the brain in the pons. Cranial nerve VII (facial nerve) affects facial expressions and muscle movements.

A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the: A. cerebral hemisphere. B. midbrain. C. pons. D. medulla.

Decerebrate

Abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward.

Decorticate

Abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight

D. Brain Tumor The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? A. Epilepsy B. Trigeminal neuralgia C. Hypostatic pneumonia D. Brain tumor

D. decreased muscle tone A client with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesions would have hyperactive reflexes, no muscle atrophy, and muscle spasticity

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit A. hyperactive reflexes B. no muscle atrophy. C. muscle spasticity. D. decreased muscle tone.

B. X CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the tastes of sugar and salt. The inability to close one eyelid indicates impairment of this nerve. CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN III is the oculomotor nerve and has to do with pupillary response, conjugate movements, and nystagmus.

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? A. III B. X C. VIII D. VII

A. "Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.

To evaluate a client's cerebellar function, a nurse should ask: A. "Do you have any problems with balance?" B. "Do you have any difficulty speaking?" C. "Do you have any trouble swallowing food or fluids?" D. "Have you noticed any changes in your muscle strength?"

C. Enkephalin Enkephalins are excitatory neurotransmitters that cause pleasurable sensations and inhibit pain transmission. Acetylcholine is an excitatory transmitter but sometimes has inhibitory parasympathetic effects. Serotonin is an inhibitory transmitter that helps control mood and sleep. Dopamine usually is inhibitory, affecting behavior and fine movement.

Which neurotransmitter inhibits pain transmission? A. Acetylcholine B. Serotonin C. Enkephalin D. Dopamine

B. Occipital The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? A. Frontal B. Occipital C. Temporal D. Parietal

D. Lactated Ringer's With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions 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 client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Dextrose 5% in water (D5W) B. Half-normal saline (0.45% NSS) C. One-third normal saline (0.33% NSS) D. Lactated Ringer's

A. Glossopharyngeal Cranial nerve IX is the glossopharyngeal nerve. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI.

Cranial nerve IX is also known as which of the following? A. Glossopharyngeal B. Vagus C. Spinal accessory D. Hypoglossal

A. "Have you noticed a change in your memory?" To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision. Reference:

To help assess a client's cerebral function, a nurse should ask: A. "Have you noticed a change in your memory?" B. "Have you noticed a change in your muscle strength?" C. "Have you had any problems with coordination?" D. "Have you had any problems with your eyes?"

A. Keep a food diary. B. Maintain a headache diary. The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. A. Keep a food diary. B. Maintain a headache diary. C. Sleep no more than 5 hours at a time. D. Exercise in a dark room. E. Use St. John's Wort.

A. CN I Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? A. CN I B. CN II C. CN III D. CN IV

A. 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 pressure and temperature, widened pulse pressure, Cheyne-Stokes breathing, projectile vomiting, hemiplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).

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. Complaints of headache and lack of pupillary response D. Mental confusion and pupillary changes