Medsurge2 week 5

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?

15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

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

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

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

Which of the following are the cardinal symptoms of Parkinson's disease (PD)? Select all that apply.

-Tremor -Rigidity -Akinesia -Postural disturbances

According to stroke performance measures, nonambulatory patients diagnosed with either hemorrhagic or ischemia stroke should start receiving deep venous thrombosis (DVT) prophylaxis by the end of which day?

2

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

3

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke for best functional outcome?

3 hours

An emergency department nurse understands that a 110-lb recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the patient receive?

50 mg

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

A small amount of yellow drainage at the left pin insertion site

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

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 their progress across the playground. The school nurse suspects what in this child?

An absence seizure

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma

A patient was diagnosed with an astrocytoma located in the cerebellum. On assessment, the nurse would expect to see an alteration in:

Balance and coordination.

In which location are most brain angiomas located?

Cerebellum

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

Cerebral aneurysm

Which of the following diagnostic studies provides visualization of cerebral blood vessels?

Cerebral angiography

A halo sign is indicative of which of the following complication of brain injury?

Cerebrospinal fluid (CSF) leak

Which of the following is the earliest sign of increasing ICP?

Change in level of consciousness

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Change in level of consciousness (LOC)

Which of the following insults or abnormalities can cause an ischemic stroke?

Cocaine use

An acoustic neuroma is a benign tumor of which cranial nerve?

Eighth

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute?

Encourage the client to eat semisolid foods and cold foods.

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?

Equipment to maintain infection control precautions

The patient with a brain tumor may be at increased risk for aspiration. The most important nursing intervention includes which of the following.

Evaluation of gag reflex and ability to swallow

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and change in urine clarity

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?

Flaccid

A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to complete which of the following?

Form words that are understandable or comprehend the spoken word

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery

Frequent neurologic checks *

From which direction should a nurse approach a client who is blind in the right eye?

From the left side of the client

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal

A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that:

Growth is slow and symptoms are caused by compression rather than tissue invasion.

A patient has recently been diagnosed with an acoustic neuroma. The nurse helps the patient understand that:

Hearing loss usually occurs.

A client is diagnosed with a brain angioma. When providing care to this client, the nurse would be especially vigilant in monitoring for signs and symptoms of which of the following?

Hemorrhagic stroke

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

High in protein and low in carbohydrate

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches?

Increased intracranial pressure

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris

A client with a brain tumor experiences projectile vomiting. The nurse integrates understanding of this occurrence as resulting from which of the following?

Irritation of the meduallary vagal centers

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?

Ischemic *

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.

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

Lamictal

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit *

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

Maintenance of a patent airway

Which of the following is the primary vector of arthropod-borne virus encephalitis in North America?

Mosquitoes

Which of the following is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

Which of the following is the initial diagnostic test for a stroke?

Noncontrast CT scan *

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT)

A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma:

Originated within the brain tissue.

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?

Osteoporosis

Which of the following terms is used to describe edema of the optic nerve?

Papilledema

Which of the following is a late symptom of spinal cord compression?

Paralysis

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

Phenobarbital

Which diagnostic test is used for early diagnosis of HSV-1 encephalitis?

Polymerase chain reaction (PCR)

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

What is the treatment of choice for pituitary adenomas?

Surgery

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

A patient with Parkinson's disease is experiencing an on-off syndrome. What does the nurse recognize that the patient's clinical symptoms will be?

The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication.

Which of the following is an accurate statement regarding malignant brain tumors? Select all that apply.

They can spread into surrounding tissue. They are life-threatening. They are rapidly growing.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?

Thrombolytic therapy has a time window of only 3 hours. *

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Verbal response Motor response Eye opening

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

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

The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following?

medication must be taken on time

Which of the following provides the best outcome for most tumor types?

surgery

A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? (Select all that apply.)

-Administering mannitol -Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg -Elevating the head of the bed 30 degrees

An older adult patient exhibiting clinical manifestations of a brain tumor is admitted to the hospital for testing. What tumor types does the nurse know are commonly seen in the older adult?

-Anaplastic astrocytoma -Cerebral metastasis from other sites -Glioblastoma

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

-Hemiparesis -Decreased reactivity of the pupils -Bradycardia -Coma

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

A patient is exhibiting bradykinesia, rigidity, and tremors related to Parkinson's disease. The nurse understands that these symptoms are directly related to what decreased neurotransmitter level?

Dopamine

Parkinson's' disease (PD) results in a decreased level of which of the following neurotransmitters?

Dopamine

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?

Dysphagia

Which of the following is the only known risk factor for brain tumors?

ionizing radiation

The primary North American vector transmitting arthropod-borne virus encephalitis is the

mosquito *

the most common cause of cholinergic crisis includes which of the following

overmedication

Which of the following is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

History of smoking.

A patient is diagnosed with an intracerebral tumor. The nurse knows that the diagnosis may include which of the following? (Select all that apply.)

Astrocytoma Ependymoma Medulloblastoma

The diagnosis of multiple sclerosis is based upon which of the following tests?

MRI

A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client?

Magnetic resonance imaging

The nurse reviews the physician's emergency department progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone

When caring for a client who is post intracranial surgery what is the most important parameter to monitor?

Body temperature

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

Lethargy and stupor

The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's?

Levodopa

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?

Mannitol

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Meticulous cleanliness

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

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Severe headache *

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

diminished responsiveness.

During assessment of cognitive impairment, post stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event.

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia

Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes?

Homonymous hemianopsia

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

Hypertension Bradycardia Bradypnea

A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following?

"The surgeon will be able to remove all of the tumor."

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding?

Dysphonia

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention?

A 60-year-old African-American man

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?

Agnosia

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding

A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?

Basilar

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate

Which of the following is one of the earliest signs of increased ICP?

Decreased level of consciousness (LOC)

Which of the following advice should the nurse give a client with impaired physical mobility to prevent maceration and decrease the potential for bacterial growth?

Keep the skin clean and dry.

Which diagnostic is most commonly used for spinal cord compression?

Magnetic resonance imaging (MRI)

Which of the following is an immediate complication of acute hemorrhagic stroke? Select all that apply.

Potential for herniation Acute hydrocephalus Secondary brain injury Increased intracranial pressure

The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?

Ptosis and diplopia

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and their family?

Sweating

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test

A client comes to the clinic for evaluation because of complaints of dizzinesss and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?

cerebellum

The nurse reviews the patient's drug regimen for treatment of a brain tumor. She explains to the patient why one of the following drugs would not be prescribed, even though it might have therapeutic benefits. Which drug would not be prescribed for this patient?

coumadin

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign.

Corticosteroids are used in the management of brain tumors to

reduce cerebral edema.

The patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for

renal complications related to acyclovir therapy.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

t6

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache."

What drug, prescribed for Parkinson's disease, has neuroprotective properties?

Selegiline (Eldepryl)

Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane?

Subdural hematoma

Which Glasgow Coma Scale score is indicative of a severe head injury?

7

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 client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary."

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

132 lb->59.87 kg (0.9 X 59.87)=53.88 X .10=5.4mg

The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF?

15 to 20 mL/100 g/min

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

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

Administer medications at exact intervals ordered.

You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia

A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?

Avoid hot temperatures.

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance

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

While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Upon his arrival via squad at the ED where you practice nursing, he regained consciousness within an hour. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?

Concussion

A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following?

Decerebrate positioning implying severe dysfunction and brain pathology

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?

Ecchymosis over the mastoid

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment

Limited attention span and forgetfulness

A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?

Look for signs of increased intracranial pressure

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?

Parkinson's disease

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

Rapid, jerky, involuntary movements

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Suction the airway.

A client with diabetes is hospitalized with a TIA. When planning this client's discharge teaching the nurse knows to include which of the following?

Techniques to control blood sugar within normal ranges

At which of the following spinal cord injury levels does the patient have full head and neck control?

c5

Nursing students are reviewing the various types of brain tumors. The students demonstrate understanding of the material when they identify which of the following as the most common type?

glioma

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?

increased ICP *

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are?

Severe headache and early change in level of consciousness

The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is:

Simple to generalized seizures.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours.

A client has undergone surgery for a spinal cord tumor that was located in cervical area. The nurse would be especially alert for which of the following?

Respiratory dysfunction

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis.

A nurse on the neurological unit is caring for a client with a basilar skull fracture. Which high-risk nursing diagnosis is appropriate for this client?

Risk for meningeal infection

Which of the following are clinical manifestations associated with increased intracranial pressure (ICP)? Select all that apply.

Seizures Papilledema Headache

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor?

Spinal metastasis

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

vomits.