Module 9 targeted quiz

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg

70 mm Hg

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. Provide sensory stimulation. Encourage coughing and deep breathing. Position the client with the head turned toward the side of the brain tumor.

Administer stool softeners. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? Corticosteroids Diuretics Antianxiety Anticonvulsants

Anticonvulsants

A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? Assist the client to the floor, in a side-lying position, and protect him with linens. Initiate the code team response. Record the type of seizure and the time that it occurred. Put a padded tongue blade into the client's mouth and restrain his extremities.

Assist the client to the floor, in a side-lying position, and protect him with linens.

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is Widening pulse pressure Elevation of systolic blood pressure Change in level of consciousness Slowing of heart rate

Change in level of consciousness

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)? Maintain a well-lit room. Elevate the head of the bed 30 degrees. Suction the airway every hour and as needed. Turn the client every 2 hours.

Elevate the head of the bed 30 degrees.

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? Absence Jacksonian Generalized Sensory

Generalized

A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? Pry the client's mouth open to allow a patent airway. Place a cooling blanket beneath the client. Help the client sit up. Keep the client on one side.

Keep the client on one side.

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? Assessment of pupillary light reflexes Determination of the cause Maintenance of a patent airway Positioning to prevent complications

Maintenance of a patent airway

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 Assessment of pupillary light reflexes Positioning to prevent complications Determination of the cause

Maintenance of a patent airway

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

Mannitol

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? Restrain the client during the seizure. Protect the client from injury. Insert a tongue blade between the teeth. Suction the mouth during the convulsion.

Protect the client from injury.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Sleeping quietly after the seizure Seizure began at 1300 hours. The client cried out before the seizure began. Seizure was 1 minute in duration including tonic-clonic activity.

Seizure was 1 minute in duration including tonic-clonic activity. Describing the length and the progression of the seizure is a priority nursing responsibility.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? Semi-Fowler's, to promote breathing High Fowler's, to prevent aspiration Side-lying, to facilitate drainage of oral secretions Supine, to rest the muscles of the extremities

Side-lying, to facilitate drainage of oral secretions To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

A client is having a tonic-clonic seizure. What should the nurse do first? Place a tongue blade in the client's mouth. Elevate the head of the bed. Restrain the client's arms and legs. Take measures to prevent injury.

Take measures to prevent injury.

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? Manually restrain the extremities. Turn client to side-lying position. Insert an airway or bite block. Monitor vital signs.

Turn client to side-lying position.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? Place a cooling blanket on the client Administer mannitol Insert oral airway Turn the client to the side

Turn the client to the side

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? a. Provide oxygen or anticonvulsants, whichever is available b. Turn the client to the side during a seizure and do not restrain movements c. Suction the client's mouth and pharynx d. Place a cooling blanket beneath the client

Turn the client to the side during a seizure and do not restrain movements

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. place an oral airway in the client's mouth to maintain an open airway. hold the client's arm still to keep him from hitting anything. allow the client to remain in the chair but move all objects out of his way.

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

The initial sign of increasing intracranial pressure (ICP) includes sore throat. vomiting. herniation. decreased level of consciousness.

decreased level of consciousness.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: hypothermia is indicative of severe meningitis. shivering in hypothermia can increase ICP. hypothermia is indicative of malaria. hypothermia can cause death to the client.

shivering in hypothermia can increase ICP.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. 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? Involuntary posturing Declining level of consci

Declining level of consciousness (LOC)

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? Assess pupils. Assess Glasgow Coma Scale. Assess vital signs. Assess for a patent airway.

Assess for a patent airway.

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because hypothermia can cause death. hypothermia is indicative of malaria. shivering in hypothermia can increase ICP. hypothermia is indicative of severe meningitis.

shivering in hypothermia can increase ICP.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: place the client on his side, remove dangerous objects, and protect his head. place the client on his back, remove dangerous objects, and hold down his arms. place the client on his back, remove dangerous objects, and insert a bite block. place the client on his side, remove dangerous objects, and insert a bite block.

place the client on his side, remove dangerous objects, and protect his head.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? constricted response unequal response equal response rapid response

unequal response In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

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

3 LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive

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

Aspiration of a brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.