NUR424 Chapter 66 Prep-U

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?

Drugs administered for Parkinsonism may cause a wide variety of adverse effects, which requires careful observation of the client. Over time, clients may respond less and less to their standard drug therapy and have more frequent "off episodes" of hypomobility.

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

Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients. A patient with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratory distress.

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

Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

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

Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with mental retardation or illness.

Which of the following positions are employed to help reduce intracranial pressure (ICP)?

Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate.

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?

Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis.

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

Decreasing LOC is one of the earliest signs of increased ICP. Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. Decreasing LOC is one of the earliest signs of increased ICP.

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?

Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.

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?

The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows.

Which is the priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter?

The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The patient is at risk for injury, but this is not first priority. The patient is at risk for fluid volume deficit due to a possible fluid restriction to maintain normovolemia, but this is not first priority. The patient is at risk for infection due to the placement of the intraventricular catheter, but again this is not first priority.

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

The earliest sign of increasing ICP is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

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

Each criterion in the Glasgow Coma Scale (eye opening, verbal response, and motor response) is rated on a scale from 3 to 15. A total 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 initial sign of increasing ICP includes:

The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may be herniated through the tentorium, causing pressure on the brain stem. Vomiting and headache are not initial signs of increasing ICP.

what is decerebrate?

An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF. Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing ICP. The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

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?

The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care?

The most important component of hospice care is the focus that is placed on the care of the client as well as the family. Hospice does take a team approach and coordinates care through the hospice physician, but these are not the focus. Not all hospice clients wish to die at home.