66 management of pt with neuro dysfunction prepU
Bone flap
A section of bone removed from the skull during craniotomy procedures.
Vasopressin is the same thing as....
ADH
Which value indicates a normal intracranial pressure (ICP)? 5 mm Hg 17 mm Hg 20 mm Hg 27 mm Hg
Correct response: 5 mm Hg Explanation: ICP is usually measured in the lateral ventricles. Pressure measuring 0 to 10 mm Hg is considered normal. The other values are incorrect.
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? Positioning to prevent complications Maintenance of a patent airway Assessment of pupillary light reflexes Determination of the cause
Correct response: Maintenance of a patent airway Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Maintaining adequate hydration Administering prescribed antipyretics Restricting fluid intake and hydration Hyperoxygenation before and after tracheal suctioning
Correct response: Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.
SIADH vs Diabetes Insipidus
With diabetes insipidus, the body has insufficient ADH, and with SIADH, the body has excess (or an inappropriate amount of) ADH.
Decerebrate
extension away from body, pronation of arms/legs
Decorticate
flexion into body,
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. hypothermia is indicative of severe meningitis. hypothermia is indicative of malaria. hypothermia can cause death to the client.
Correct response: shivering in hypothermia can increase ICP. Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.
Which is a late sign of increased intracranial pressure (ICP)? Irritability Slow speech Altered respiratory patterns Headache
Correct response: Altered respiratory patterns Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? The pupils are dilated and fixed. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). Increased ICP is 12 mm Hg. Cerebral perfusion pressure (CPP) is 21 mm Hg.
Correct response: Increased ICP is 12 mm Hg. Explanation: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? Airway clearance Risk of injury Deficient fluid volume Risk for impaired skin integrity
Correct response: Airway clearance Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
What drug, prescribed for Parkinson's disease, has neuroprotective properties? Amantadine (Symmetrel) Selegiline (Eldepryl) Bromocriptine (Parlodel) Levodopa (Larodopa)
Correct response: Selegiline (Eldepryl) Explanation: Selegiline (Eldepryl), has neuroprotective properties; dopaminergic such as levodopa (Larodopa) or levodopa-carbidopa (Sinemet); amantadine (Symmetrel); dopamine agonists such as bromocriptine (Parlodel); apomorphine (Apokyn), the newest approved drug; and anticholinergics such as benztropine (Cogentin) are prescribed.
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Decerebrate Decorticate Flaccid Normal
Correct response: Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is high. The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate.
Correct response: The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: Increasing forgetfulness and confusion Tremors and muscle rigidity Visual disturbances and muscle weakness Fatigue and respiratory difficulties
Correct response: Tremors and muscle rigidity Explanation: The cardinal signs of PD are tremor, rigidity, akinesia/bradykinesia, and postural disturbances.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? Mannitol Furosemide (Lasix) Vasopressin Phenobarbital
Correct response: Vasopressin Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.
What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC) headache Cushing's triad coma
Correct response: decreased level of consciousness (LOC) Explanation: 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. If untreated, increasing ICP will lead to coma.
Which method is used to help reduce intracranial pressure? Using a cervical collar Keeping the head of bed flat Rotating the neck to the far right with neck support Extreme hip flexion, with the hip supported by pillows
Correct response: Using a cervical collar Explanation: 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.
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)? Encouraging oral fluid intake Suctioning the client once each shift Elevating the head of the bed 90 degrees Administering a stool softener as ordered
Correct response: Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Check the equipment. Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective.
Correct response: Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) Decreased muscle spasms in the lower extremities Increased muscle strength in the upper extremities Promotion of urinary continence
Correct response: Decreased muscle spasms in the lower extremities Explanation: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. It is not used to promote continence or to increase strength. Avonex and Betaseron reduce the appearance of new lesions on the MRI.
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? Pruritus Dyskinesia Lactose intolerance Diarrhea
Correct response: Dyskinesia Explanation: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Elevate the head of the bed. Complete a head-to-toe assessment. Administer morning dose of anticonvulsant. Administer Percocet as ordered.
Correct response: Elevate the head of the bed. Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
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? Flat Turned onto the operative side Elevated no more than 10 degrees Elevated 30 degrees
Correct response: Elevated 30 degrees Explanation: After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.
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 Exacerbation of uncontrolled hypertension Infection Increase in cerebral perfusion pressure
Correct response: Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? Keep the client on one side. Place a cooling blanket beneath the client. Help the client sit up. Pry the client's mouth open to allow a patent airway.
Correct response: Keep the client on one side. Explanation: The nurse will need to keep the client on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the client to the environment. If the client is confused or wandering, guide the client gently to a bed or chair. If the client becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the client is fully aware. The client does not need a cooling blanket after a seizure. The client's temperature should not be elevated from the seizure. The nurse should not pry the client's mouth open after a seizure so that the airway remains open.
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? Monro-Kellie Cushing's Dawn phenomenon Hashimoto's disease
Correct response: Monro-Kellie Explanation: 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 cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? Give the patient some mouthwash to gargle with. Request an antihistamine for the postnasal drip. Ask the patient to cough to observe the sputum color and consistency. Notify the physician of a possible cerebrospinal fluid leak.
Correct response: Notify the physician of a possible cerebrospinal fluid leak. Explanation: Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure began at 1300 hours. The client cried out before the seizure began. Seizure was 1 minute in duration including tonic-clonic activity. Sleeping quietly after the seizure
Correct response: Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
