Chapter 61: Management of Patients with Neurologic Dysfunction

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

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 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?

"There is a strong familial tendency."

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose."

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

3

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered.

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

Administer medications at exact intervals ordered.

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)?

Administering a stool softener as ordered

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

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

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

An older client reports a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

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.

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

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

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

Elevate the head of the bed.

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?

Elevated 30 degrees

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?

GCS

During assessment of a client who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia

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

High in protein and low in carbohydrate

The nurse is caring for a client postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the client's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The client has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Lactated Ringer's

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

Lamictal

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

Lethargy and stupor

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

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

Mannitol

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

A nurse is assessing a client's urinary output as an indicator of arginine vasopressin deficiency (AVP-D). The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 mL/h

When educating a client about the use of antiseizure medication, what should the nurse inform the client is a result of long-term use of the medication?

Osteoporosis

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

Phenobarbital

The nurse is called to attend to a client having a seizure in the waiting area. What nursing care is provided for a client who is experiencing a convulsive seizure? Select all that apply.

Positioning the client on their side with head flexed forward Providing for privacy Loosening constrictive clothing

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

Restricting fluid intake and hydration

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

After a seizure, the nurse should place the client in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

A client is having a tonic-clonic seizure. What should the nurse do first?

Take measures to prevent injury.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

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

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

UTIs

Which method is used to help reduce intracranial pressure?

Using a cervical collar

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

chewing

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate.

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

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

diminished responsiveness.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

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

A nurse working in the neurologic intensive care unit admits from the emergency department a client with an inoperable brain tumor. Upon entering the room, the nurse observes that the client is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this client's prognosis?

poor

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?

unequal response