Chapter 61: Management of Patients with Neurologic Dysfunction
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 lie flat for 24 hours after surgery." "You must avoid coughing, sneezing, and blowing your nose." "You must restrict your fluid intake." "You must report ringing in your ears immediately."
"You must avoid coughing, sneezing, and blowing your nose." Explanation: After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.
Normal and stable ICP values are less than --------
15 mm Hg.
Which is a late sign of increased intracranial pressure (ICP)? Irritability Slow speech Altered respiratory patterns Headache
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 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 his progress across the playground. The school nurse suspects what in this child? An absence seizure A complex seizure A partial seizure A tonic-clonic seizure
An absence seizure Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain.
Which medication classification is used preoperatively to decrease the risk of postoperative seizures? Diuretics Corticosteroids Anticonvulsants Antianxiety
Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.
The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? Apply warm or cool cloths to the forehead or back of the neck Maintain hydration by drinking eight glasses of fluid a day Perform the Heimlich maneuver Use pressure-relieving pads or a similar type of mattress
Apply warm or cool cloths to the forehead or back of the neck Explanation: Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.
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 type of anticonvulsant prescribed to manage the epileptic condition Recent stress level Recent weight gain and loss Compliance with the prescribed medication regimen
Compliance with the prescribed medication regimen Explanation: 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 nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? Optimizing nutrition Managing muscle weakness Explaining hospice care and services Offering family support groups
Explaining hospice care and services Explanation: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
The Monro-Kellie hypothesis explains the dynamic equilibrium of cranial contents. nonresponse of the brain to the environment. the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. why the client is awake but lacks consciousness, without cognitive or affective mental function.
the dynamic equilibrium of cranial contents. Explanation: The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. The Cushing response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the client is wakeful but devoid of conscious content, without cognitive or affective mental function.
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 3 6 9 15
3 Explanation: 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.
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? Encourage coughing and deep breathing. Position the client with the head turned toward the side of the brain tumor. Administer stool softeners. Provide sensory stimulation.
Administer stool softeners. Explanation: 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 positions is used to help reduce intracranial pressure (ICP)? Avoiding flexion of the neck with use of a cervical collar Keeping the head flat, avoiding the use of a pillow Rotating the neck to the far right with neck support Extreme hip flexion, with the hip supported by pillows
Avoiding flexion of the neck with use of 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.
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? Epilepsy Trigeminal neuralgia Hypostatic pneumonia Brain tumor
Brain tumor Explanation: The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? What is normal CPP range? The CPP is high. The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate.
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 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? Cerebellar function Glasgow Coma Scale Cranial nerve function Mental status evaluation
Glasgow Coma Scale Explanation: An altered level of consciousness (LOC) is present when the client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum, with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. 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. Cerebellar function, cranial nerve function, and mental status evaluation are all elements of the neurologic assessment.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? Low in fat Restricts protein to 10% of daily caloric intake High in protein and low in carbohydrate At least 50% carbohydrate
High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
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
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 is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Dextrose 5% in water (D5W) Half-normal saline (0.45% NSS) One-third normal saline (0.33% NSS) Lactated Ringer's
Lactated Ringer's Explanation: With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A bounding pulse Bradycardia Hypertension Lethargy and stupor
Lethargy and stupor Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.
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
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 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? 50 to 100 mL/h 100 to 150 mL/h 150 to 200 mL/h More than 200 mL/h
More than 200 mL/h Explanation: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Giving him a barbiturate Placing him on mechanical ventilation Performing a lumbar puncture Elevating the head of his bed
Performing a lumbar puncture Explanation: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.
Which of the following drugs may be used after a seizure to maintain a seizure-free state? Valium Phenobarbital Ativan Cerebyx
Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Positioning the patient on his or her side with head flexed forward Providing for privacy Restraining the patient to avoid self injury
Positioning the patient on his or her side with head flexed forward Providing for privacy Loosening constrictive clothing During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. Cloudy cerebral spinal fluid Pain and stiffness of the extremities Purpura of hands and feet Low white blood cell (WBC) count Low red blood cell (RBC) count Low antidiuretic hormone (ADH) levels
Purpura of hands and feet Cloudy cerebral spinal fluid
A client with neurologic 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
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 neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Shivering Cool, dry skin Urine output of 100 mL/hr
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
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? Severe depression Choreiform movements Urinary tract infection Emotional apathy
Urinary tract infection Explanation: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.
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 normal. flaccid. decorticate. decerebrate.
decerebrate. Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to control fever. control shivering. dehydrate the brain and reduce cerebral edema. reduce cellular metabolic demand.
dehydrate the brain and reduce cerebral edema. Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.
To meet the sensory needs of a client with viral meningitis, the nurse should: minimize exposure to bright lights and noise. promote an active range of motion. increase environmental stimuli. avoid physical contact between the client and family members.
minimize exposure to bright lights and noise. Explanation: Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the dorsal recumbent position. supine position with the head slightly elevated. prone position with the head turned to the unaffected side. Trendelenburg position.
supine position with the head slightly elevated. Explanation: After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.
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 equal response rapid response constricted response
unequal response Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.
