Chapters 56, 57, 58, 59, 60

Which factors would the nurse associate with influencing a patient's intracranial pressure (ICP) readings? Select all that apply.

Posture Temperature Carbon dioxide levels Intraabdominal pressure

Which rationale is accurate for why a patient who is demonstrating signs of delirium is scheduled for a CT scan of the brain?

Potential head injury is causing the symptoms.

For which surgical techniques and procedures would the nurse prepare the patient scheduled for localizing brain tumors intraoperatively? Select all that apply.

Ultrasound Cortical mapping Computer-guided stereotactic biopsy Functional MRI

The patient is having some increased memory and language problems. Which diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease? Select all that apply.

Urinalysis Liver function tests Neuropsychologic testing MRI of the head

For the patient with a resolved head injury, which prevention interventions would the nurse include when providing discharge instructions? Select all that apply.

Use of car seat belts Use of child car seats Use of helmets by cyclists

When assessing a patient diagnosed with a brainstem tumor, which clinical manifestations would the nurse expect to identify? Select all that apply.

Crossed eyes Facial muscle weakness Headache on awakening

Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a patient recovering from a stroke at mealtimes?

Cut up the best for the patient

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority?

Ineffective airway clearance caused by high cervical spinal cord injury

When teaching the patient, family, and caregiver about long-term care of the patient who had a craniotomy, which instruction would the nurse include?

There are often residual changes in personality and cognition

Which cranial nerve is associated with tic douloureux?

V

Which clinical manifestation is associated with a stroke on the right side of the brain?

impulsiveness

Which type of stroke correlates with the clinical manifestations of a severe headache, hypertension, vomiting, dysarthria, and eye-movement disturbances?

intracerebral hemorrhage

After receiving information as to how metabolic disturbances cause seizures, which statements indicate effective learning? Select all that apply.

"Seizures can be caused by a decrease in oxygen levels." "Seizures can be caused by a decrease in pH of the blood." "Seizures can be caused by a decrease in blood glucose levels."

Which patient condition contraindicates testing the doll's-eye reflex when performing a neurologic assessment?

A patient with cervical spine injury

f blood flow to the brain is interrupted, how quickly does cellular death occur?

5 Minutes

About which food item would the nurse teach a patient as being a potential trigger for cluster headaches?

Alcohol

Which patient may face the greatest risk for developing delirium?

An older patient who takes multiple medications to treat various health problems

During the acute stage of a stroke, which intervention would be included in the plan of care for a patient experiencing aphasia?

Ask simple yes-and-no questions

Which aspects of care may be performed only by the RN caring for a patient who had a stroke one day ago? Select all that apply.

Assess neurologic status. Assess respiratory status.

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. Which instructions would the nurse give this patient? Select all that apply.

Avoid eating hot food or beverages. Protect the face from extreme temperatures. Check oral cavity after eating food for any residual food particles.

Which potential medications would the nurse anticipate administering to a patient with myasthenia gravis who reports difficulty with swallowing, chewing, eye movement, and facial mobility? Select all that apply.

Azathioprine (Imuran) Prednisone (Deltasone) Pyridostigmine (Mestinon)

Which intervention would the nurse implement as the highest priority after determining that a patient's Glasgow Coma Scale (GCS) score is 5?

Notify the rapid response team.

Which is a key characteristic of delirium?

Occurs abruptly

Which score range on the Mini-Cog test indicates a positive screen for dementia?

0-2

Which medication would the nurse associate with the treatment of rebound headaches?

Amitriptyline (Elavil)

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

An altered level of consciousness (LOC)

When visiting a patient prescribed phenytoin (Dilantin) for seizures, which instruction would the nurse provide the patient to prevent precipitation of seizures?

Do not stop the drug abruptly without consulting the health care provider.

Which actions would the nurse implement for a patient who had a stroke and has a BP of 166/96 mm Hg? Select all that apply.

Ensure adequate fluid intake. Continue to monitor the BP.

Which diagnostic study is used to assess soft tissue injury and neurologic changes?

MRI

Which disease process includes Lhermitte's sign as a clinical manifestation?

Multiple sclerosis

For the patient receiving emergency treatment for continuous muscle contractions and loss of consciousness secondary to head trauma, which medications would the nurse anticipate administering? Select all that apply.

Phenytoin (Dilantin) Carbamazepine (Tegretol)

Which instruction would be given to a patient who is diagnosed with Bell's palsy?

Prevent corneal drying by instillation of ointment at night with an eye shield.

Which body system is the priority focus for nursing care of the patient with Guillain-Barré syndrome?

Respiratory

Which clinical manifestation is exclusive to a complex focal seizure?

Smacking of the lips

Which assessments would the nurse include when documenting an evaluation of a patient's central nervous system (CNS)? Select all that apply.

Speech Seizures Bowel and bladder incontinence Decerebrate or decorticate posturing

Which is a priority nonoperative treatment following a spinal cord injury?

Stabilization

Which assessment finding is associated with initial manifestations of tetanus?

Stiffness in the jaw

The nurse caring for a patient with Bell's palsy expects to find which key symptom on assessment?

Unilateral lower motor facial weakness

A patient injured at work with an open cut asks the occupational health nurse whether a "tetanus shot" is needed. The nurse would base the response on which fact?

When the patient last received a tetanus toxoid booster

Which population has the highest rate of malignant brain tumors?

White males

Which factors would the nurse consider when evaluating the lumbar puncture results of a patient with bacterial meningitis? Select all that apply.

Perform a lumbar puncture after ruling out an obstruction in the foramen magnum. Lumbar puncture usually helps to confirm the diagnosis of bacterial meningitis. Lumbar puncture obtains cerebrospinal fluid (CSF) for analysis in case of bacterial meningitis.

The nurse reviews the medical records of several patients that are seen in the clinic for annual health maintenance visits and identifies that which patient is at the highest risk for Alzheimer's disease (AD)?

An 80-year-old African American female

Which patient would the charge nurse assign to the nurse floating from the acute care medical-surgical unit to the neurologic intermediate care unit?

An alert patient with viral encephalitis who needs an IV access for a scheduled acyclovir

Which interventions would the nurse implement when providing care for a patient with a diagnosis of acute meningitis? Select all that apply.

Place the patient in a comfortable position. Position the patient in a curled-up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture.

Which cranial nerve (CN) irritation, secondary to bacterial meningitis, resulted in the patient's loss of corneal reflexes?

CN V

A patient with a history of rheumatic heart disease arrives in the emergency department and informs the nurse of sudden loss of strength in the left arm without pain. The patient is unable to lift the arm and says that it "just fell." Which condition would the nurse suspect?

Embolic stroke

Administer enteral feedings to patients who are unable to swallow.

Pneumonia Urinary tract infection

When a patient presents with hypertension and reports paresthesia, tingling, and a pins-and-needles sensation, which disorder would the nurse associate the health care provider's prescription for gabapentin (Neurontin)?

Restless legs syndrome (RLS)

Which response(s) would the nurse utilize when the patient asks about the cause of migraine headaches? Select all that apply.

These headaches generally last from 4 to 72 hours. The pain is a continuous, throbbing, and pulsating pain Risk factors include low levels of education and socioeconomic status.

Which intervention would the nurse suggest for the patient with restless leg syndrome (RLS) to improve mood, sleep, and function?

Yoga

Upon review of a patient's medical history, which question would the nurse ask the patient with a history of restless legs syndrome (RLS)?

"Are you able to sleep well and feel rested?"

Which discharge instruction would the nurse provide to a patient with trigeminal neuralgia?

"Eat a diet that is high in protein."

For the patient with a head injury, for which complication related to cerebral hemorrhage and edema would the nurse monitor potential development?

Increased intracranial pressure

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? Select all that apply.

Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Initiate concurrent treatment with antacids or proton pump inhibitors.

Which risk factors would the nurse include in a teaching plan when instructing a patient about modifiable risk factors for stroke?

Smoking

Which prescribed diagnostic test, used to diagnose a tension-type headache (TTH), would the nurse anticipate explaining to the patient?

Electromyography

To obtain an accurate brain tumor diagnosis, for which prescribed diagnostic procedures would the nurse anticipate preparing the patient? Select all that apply.

Electron microscopy Immunohistochemical stains Computer-guided stereotactic biopsy

Which assessment finding would cause the nurse to suspect trigeminal neuralgia in a patient who reports severe burning of the face?

Facial twitching

Which information would the nurse elicit during a patient's health history to aid in preparing a plan of care for a patient with trigeminal neuralgia? Select all that apply.

Food habits Self-medication to decrease pain Frequency of attacks and triggers

Which lobe of the brain is affected if a patient has Broca's aphasia?

Frontal lobe

Which seizure activity would the nurse associate with a patient's jerky muscle movements of the extremities, as well as bowel and bladder incontinence during the event?

Generalized seizures

Which surgical therapy for trigeminal neuralgia is a peripheral procedure?

Glycerol rhizotomy

Which adverse effect would the nurse monitor for the potential development of in a patient who received a botulinum A toxin (Botox) injection?

Headache

The nurse identifies that a patient is at risk for failure of the diaphragm when the patient experiences which level of spinal cord injury?

C3-C5

For the patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?

CN III

Which medication helps to increase the bioavailability of levodopa in the brain by inhibiting the enzyme dopa-decarboxylase?

Carbidopa (Lodosyn)

Which mechanism protects the brain and promotes its functioning?

Cerebral autoregulation

When a nurse is reviewing the plan of care for a patient with meningitis with a newly employed registered nurse, which treatment outcomes would the plan include?

Hearing restored prior to discharge

Which inflammatory condition would the nurse associate to the common cause of acute nonepidemic encephalitis?

Herpes simplex virus encephalitis

When a patient has a new prescription of phenytoin (Dilantin) for seizures, the nurse would provide information for which common side effects of the medication? Select all that apply.

Hirsutism Gingival hyperplasia

For the patient with a history of cluster headaches, which advice would the nurse provide the patient to decrease the likelihood of an attack occurring during air travel overseas?

Take ergotamine (Migranal) before your flight takes off

After performing a patient's assessment, which condition supports the nurse's intervention to decline IV administration of mannitol (Osmitrol) to the patient?

Increased serum osmolality

The nurse suspects that a patient with bacterial meningitis is experiencing cranial nerve II irritation based on which assessment finding?

Papilledema and blindness

The nurse provides care for a patient with a C3 level of spinal injury. Which is the patient's potential for rehabilitation?

Ability to drive an electric wheelchair

Which interventions would be delegated to the licensed practical/vocational nurse when caring for a patient with Alzheimer's disease in a long-term care facility? Select all that apply.

Administer the ordered drug therapy.

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/minute, and respirations 24 breaths/minute, which subsequent vital signs would the nurse report immediately to the health care provider?

BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute

Which treatment helps to control a patient's spasms that are caused by tetanus?

Barbiturates

Which ethnic group has the highest incidence of stroke?

Blacks

The nurse is providing care to a patient with a spinal cord injury as the result of a motor vehicle accident. The nurse notes that the patient feels no pain in the leg on the side opposite the injury. Which spinal cord syndrome does the nurse suspect?

Brown-Séquard syndrome

For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response?

CN III

Which prescribed first-line drug would the nurse prepare to administer to a patient with trigeminal neuralgia?

Carbamazepine

A patient presents to the hospital with severe back pain that interferes with activity. A CT scan shows a metastatic tumor in the spine. IV dexamethasone is prescribed. Which is the desired effect of the medication?

Decreased tumor-related edema

Which information would the nurse relay to the patient with a newly prescribed medication, carbamazepine (Tegretol), for treatment of a new-onset seizure disorder?

Do not take this medication with grapefruit or grapefruit juice.

Which classic symptom of amyotrophic lateral sclerosis (ALS) would the nurse expect to identify when performing an assessment?

Dysphagia

After sustaining head trauma from skiing, the patient briefly lost consciousness, then was awake and alert. Which head trauma complication would the nurse associate with this patient when bleeding between the dura and the inner surface of the skull develops?

Epidural hematoma

When establishing a diagnosis of multiple sclerosis (MS), which prescribed diagnostic studies would the nurse explain to the patient? Select all that apply.

Evoked response testing Cerebrospinal fluid analysis CT scan

Which medication would the nurse anticipate administering the patient with type I diabetes mellitus who experiences a hypoglycemic event and begins to seize?

IV dextrose solution

Which dietary discharge instructions would the nurse provide a patient recovering from meningitis? Select all that apply.

Include chicken and lean meat in your diet Include whole grains, potatoes, and cereals in the diet. Divide your three main meals into small, frequent feedings.

Which information would be given to the patient with a history of transient ischemic attacks and has been prescribed aspirin? Select all that apply.

It is pain medication and an antiplatelet agent. It may cause bleeding, which should be reported immediately.

Which assessment finding demonstrates a positive response to carbamazepine in the patient with trigeminal neuralgia?

Less frequent and severe facial pain

Which neurologic factor would the nurse assess and record for a patient who had a stroke?

Level of consciousness

The nurse assists with prehospital care of a patient with a suspected C7 spinal cord injury. Which is the most important nursing intervention during this acute stage of care?

Maintaining a patent airway

Which medication is an osmotic diuretic that the nurse would prepare to administer when needing to lower a patient's intracranial pressure (ICP)?

Mannitol

Which food would be included in the diet for a patient who had a stroke and has dysphagia?

Mashed Potatoes

Which factors would the nurse consider when evaluating the lumbar puncture results of a patient with bacterial meningitis? Select all that apply

Perform a lumbar puncture after ruling out an obstruction in the foramen magnum. Lumbar puncture usually helps to confirm the diagnosis of bacterial meningitis. Lumbar puncture obtains cerebrospinal fluid (CSF) for analysis in case of bacterial meningitis.

Which intervention would the nurse delegate to the experienced unlicensed assistive personnel (UAP) when working with a patient who had a stroke?

Perform passive range-of-motion exercises to flaccid extremities

Which medications are considered to be first-line drugs for treatment of trigeminal neuralgia? Select all that apply.

Phenytoin Topiramate Gabapentin Clonazepam Carbamazepine

Which medication, taken by a patient with a history of epilepsy, would the nurse associate with gingival enlargement?

Phenytoin (Dilantin)

Which clinical manifestation would the nurse associate with a tension-type headache (TTH)?

Phonophobia

The nurse identifies that a patient with delirium is at risk for injury. Which interventions would be included in the patient's plan of care to address the safety concerns? Select all that apply.

Place a calendar within view Reorient the patient to person, place, and time as necessary.

When hydrocephalus develops, for which surgical procedure would the nurse begin preparing the patient?

Placement of a ventriculoatrial shunt

Which information is an important part of the health history for a patient with a new diagnosis of Guillain-Barré syndrome (GBS)?

Recent viral infection

The nurse reviews a patient's medical record and notes tic douloureux. Which assessment finding would the nurse expect?

Recurrent episodes of stabbing pain along the distribution of the trigeminal nerve

Which interpretation would the nurse associate with a patient's Glasgow Coma Scale score of 5 after sustaining a head injury?

The patient is unresponsive and comatose

Which treatment outcome would the nurse expect when administering antibiotic therapy and symptomatic treatment of a patient with bacterial meningitis?

The patient will return to maximal neurologic function

Which patient's dementia is caused by a neurodegenerative disorder?

The patient with Alzheimer's disease

Of the four assigned patients on the acute care unit, which patient has the highest risk for developing bacterial meningitis?

The patient with a pulmonary infection

When preparing to administer temozolomide (Temodar) to a patient with a brain tumor, which rationale supports the nurse's need to assess the patient's absolute neutrophil count to verify a count >1500/µL?

To prevent immune-related complications

Which intervention would the nurse implement when providing care for a patient with a severe migraine?

Turn off the lights and close curtains in the room.

Which cranial nerve is associated with Bell's palsy?

VII

When performing an initial baseline assessment and subsequent assessments, which actions would the nurse implement specific to the patient's neurologic status? Select all that apply.

When performing daily activities, assess the patient. Assess patient's integrated function and balance. Monitor level of consciousness and motor abilities.

Which surgery involves destruction of the sensory fibers of the trigeminal nerve using low-voltage current?

Which surgery involves destruction of the sensory fibers of the trigeminal nerve using low-voltage current?

When teaching a community group, which conditions would the nurse discuss as precipitating the development or intensity of restless legs syndrome (RLS)? Select all that apply.

pregnancy Hypertension Iron deficiency

For the patient receiving initial medications for treatment of multiple sclerosis, which medication would the nurse associate with the patient's reports of flu-like symptoms, depressed feelings, and frequent thoughts of committing suicide?

β-1a interferon (Rebif)

Arrange the steps of vagal nerve stimulation chronologically.

1.Surgical implantation of an electrode 2.Activation of the electrode by a magnet 3. Delivery of an electrical impulse from the electrode 4. Prevention of a seizure occurrence

hich Glasgow Coma Scale (GCS) score would the nurse anticipate for a patient with a moderate type of head injury?

10

Which Glasgow Coma Scale score would the nurse assign to the patient who sustained a motor-vehicle crash concussion and who is fully alert upon arrival to the emergency department?

15

Which dietary recommendations would the nurse share as a means of controlling seizures in some patients?

A diet with high fats and low carbohydrates

The nurse finds that the patient is unable to recognize familiar objects after a stroke. Which term would the nurse chart in the patient's medical record?

Agnosia

Which extracranial condition would the nurse associate with a patient's seizures?

Hypertension

The nurse who has administered a dose of risperidone to a patient with delirium would assess for which intended effect of the medication?

Lying quietly in bed

Which clinical manifestation is associated with a left-hemispheric stroke?

Impaired speech

Which type of stroke is a patient at risk for if atrial fibrillation is untreated?

embolic stroke

"Drop attacks" are a characteristic of which type of seizure?

Atonic seizure

Which Glasgow Coma Scale (GCS) score would the nurse assign an unconscious patient who opens the eyes in response to pain but who does not respond to any other stimulus, moans to any verbal communication, and demonstrates flexion withdrawal?

8

For the patient who sustained a head injury in a motor vehicle crash, which primary injury interventions would the nurse include in the patient's plan of care? Select all that apply.

Administer oxygen. Maintain neck alignment. Establish/maintain IV access.

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates respiratory distress. The nurse anticipates that which interventions will be included in the patient's treatment plan? Select all that apply.

Administer oxygen. Perform tracheal suctioning if crackles are present. Perform assisted coughing.

A patient has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How would the nurse best promote the health of the patient's integumentary system?

Alternate the patient's positioning between supine and side-lying

Which assessment factor is included in a Mini-Cog study?

Ask patients to draw and read the hands of a clock and point out a specific time.

A patient diagnosed with Guillain-Barré syndrome who has a weak gag reflex would be at risk for which complication?

Aspiration of food into the airways

For the patient with multiple sclerosis, which action would the nurse classify as a priority intervention when developing the patient's plan of care?

Assist the patient in identifying the factors that precipitate exacerbations.

For the intubated and mechanically ventilated patient, the development of which potential side effect of dexmedetomidine (Precedex) would the nurse anticipate monitoring?

BP changes

Which assessment finding supports the health care provider adding tetrabenazine (Xenazine) to the current medications of sertraline (Zoloft) and paroxetine (Paxil) for treatment of the patient's psychiatric disorders associated with Huntington's disease?

Chorea

After treatment for meningitis, which disorder would the nurse associate with a patient's unresolved clinical manifestations of left upper and lower limb weakness, reduced vision, and slurred speech?

Cerebral abscess

Which diagnostic study is the most reliable to identify the source of a subarachnoid hemorrhage?

Cerebral angiography

Which nursing intervention would be included in the plan of care for a patient who is admitted with a stroke and is complaining about having liquid stools?

Checking for stool impaction

Which diagnostic tests are a priority for a patient who had a stroke and needs a cardiac assessment? Select all that apply

Chest X ray Cardiac markers Electrocardiogram

The family of a patient with Alzheimer's disease (AD) asks if the diagnosis has been confirmed. How would the nurse respond?

Confirmation occurs by examining brain tissue after death."

Which identified clinical manifestation would the nurse associate with those exhibited with a cluster headache?

Conjunctivitis

Which interventions would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? Select all that apply.

Consider administering light sedation agents. Observe the skin area under the restraints. Use effective restraints in an agitated patient.

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis?

Decrease in glucose level

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Decreased cerebral blood flow (CBF)

A patient with disorganized, distorted thinking and slow or accelerated incoherent speech is demonstrating which cognitive problem?

Delrium

The adult child of an older patient states, "Since the discharge from the hospital two days ago, my parent won't eat and is confused." Which issue would the nurse suspect is occurring with the patient?

Delrium

Which type of waveform would the nurse document for a patient receiving intracranial pressure (ICP) monitoring and the waveform represents venous pulsations?

Dicrotic wave

A patient with a spinal cord injury experiences a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures does the nurse teach the patient and the caregiver about to assist with bowel evacuation? Select all that apply.

Eat 20 to 30 g of fiber per day. Consume 2 to 3 liters of fluid per day.

Which intervention would the nurse implement when a patient has cerebrospinal fluid (CSF) rhinorrhea?

Elevate the head of the patient's bed to 30 degrees

A patient with quadriplegia who has been hospitalized for one month is at a risk of developing pressure injury (PI). Which steps does the nurse take to prevent this complication? Select all that apply.

Evaluate the nutritional status of the patient. Monitor urinary incontinence. Check bony prominences for signs of pressure sores.

To promote self-care and independence in patients with Parkinson's disease, which interventions would the nurse provide family members? Select all that apply.

Have the patient wear slip-on shoes. Provide the patient with an elevated toilet seat. Encourage the patient to elevate the legs on an ottoman when sitting.

In addition to inquiring about the effectiveness of the newly prescribed medication sumatriptan (Imitrex) at a six-week follow-up appointment, which question would the nurse ask the patient?

Have you experienced any chest discomfort?

For the patient with a history of severe migraines who is reporting throbbing headaches after eating, which foods may trigger the patient's throbbing headache? Select all that apply.

Hot dog Ice cream orange Juice

Which degenerative neurologic disorder exhibits a deficiency of ϒ-aminobutyric acid (GABA) and acetylcholine?

Huntington's disease

Which disorder can cause dementia and is considered ventricular?

Hydrocephalus

An experienced nurse is teaching a novice nurse about interventions for a patient with a stroke. Which statement by the novice nurse indicates a need for further teaching?

I should refrain from distracting the patient during a sudden emotional outburst

Which behavior would be exhibited by a patient who has suffered a right-brain stroke?

Impulsive and impatient

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14?

Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4

Which intervention would the nurse perform immediately when a patient, on migraine therapy, complains of a severe headache and vision problems, and the patient's temperature is 101°F (38.3°C)?

Inform the health care provider.

Which intervention would the nurse implement when a patient, receiving treatment for viral meningitis since last week, arrives at the hospital reporting a persistent severe headache?

Inform the patient that headaches can occur after recovery.

For the patient with a basilar skull fracture, for which intervention prescribed by the health care provider would the nurse contact the prescriber for clarification?

Insert nasogastric (NG) tube and connect to low, intermittent suction.

Which information will a transcranial Doppler (TCD) ultrasonography provide?

It measures the velocity of blood flow.

Which medication overdose may lead to paradoxical intoxication in a patient with parkinsonism?

Levodopa (L-dopa)

Which prescribed medication would the nurse associate with a beneficial treatment to prevent cluster headaches?

Lithium (Lithium)

During the patient's initial assessment upon awakening after being comatose for seven hours, which clinical manifestations would the nurse anticipate identifying? Select all that apply.

Loss of concentration Loss of social restraint Euphoria and mood swings

When providing care for a patient who sustained a traumatic brain injury, which condition indicates the need to maintain closure of the patient's eyes as a nursing intervention?

Loss of the corneal reflex

Which diagnostic test would the nurse anticipate for a patient with progressive weakness suspected of having multiple sclerosis?

Magnetic resonance imaging (MRI

In the mnemonic "DELIRIUM," the M represents which cause of delirium?

Metabolic disorders

Which factors would the nurse consider when preparing to administer the pharmacologic therapy for a patient with an increased intracranial pressure (ICP)? Select all that apply.

Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous IV sedatives. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy?

Monitor the patient for increased intracranial pressure (ICP).

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

Movement of the eye in the sideward direction occurs, with neck extension.

When teaching a patient with cluster headaches, which factor would the nurse include as a potential trigger?

Napping

A patient is admitted to the nursing unit after surgery. During the night, the patient suddenly becomes very agitated. What actions would the nurse take? Select all that apply.

Notify the patient's family member of the change in the patient's behavior. Reassess the patient including vital signs, physical assessment, and laboratory results. Reorient and reassure the patient about being safe and assign a sitter to be with the patient. Notify the health care provider of the patient's behavior and current physical assessment.

Which medication would the nurse associate with the primary drug of choice when treating tonic-clonic seizures?

Phenytoin (Dilantin)

For patients with amyotrophic lateral sclerosis (ALS), which treatment goal focuses on preventing a common cause of death in patients with ALS?

Reduced risk of aspiration

The nurse is planning psychosocial support for a patient who suffered a stroke and the family. Which factor most likely will have the greatest impact on positive family coping with the situation?

Rehabilitation potential of the patient

The nurse would instruct the patient recovering from a head injury and his or her caregiver to report the development of which symptoms immediately to the health care provider? Select all that apply.

Seizures Stiff neck Increased drowsiness

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?

Semi-Fowler's

A patient with spinal cord injury is suspected of having venous thromboembolism (VTE). Low-molecular-weight heparin is prescribed. Before initiating the drug, the nurse performs which assessments? Select all that apply.

Signs of any internal bleeding Any history of recent surgeries

Which pupil comparisons would the nurse perform when completing a neurologic assessment of the eyes? Select all that apply.

Size Shape Reactivity Movement

A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply.

Smoking cessation Cholesterol screening BP screening Early warning signs of a stroke

For the patient presenting with watery sanguineous nasal drainage after falling from a first-floor roof, which diagnostic method validates the nurse's suspicion of rhinorrhea?

The halo Test

Which condition is associated with trismus?

Tetanus

If taken daily, which prescribed medication prevents the development of a migraine attack?

Topiramate (Topamax)

Which method of measurement is the gold standard for obtaining intracranial pressures (ICPs)?

Ventriculostomy

Which artery would be obstructed if a patient sustained a stroke and is experiencing cranial nerve deficits?

Vertebral artery

A student nurse asks the registered nurse about risk factors for developing Alzheimer's disease (AD). Which response by the nurse is accurate?

"Diabetes greatly increases a person's chances of developing AD."

After determining that the patient has a tension-type headache (TTH), which patient statement supports the nurse's finding?

"I feel some pressure on my neck during the headache."

Which statement by the novice nurse demonstrates understanding of the care required for a patient admitted earlier today with a diagnosis of post-head injury concussion?

"I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

Which points would the nurse teach a patient with trigeminal neuralgia who is scheduled for microvascular decompression of the trigeminal nerve? Select all that apply.

"It will be performed by making a small hole behind your ear." "It involves displacement of the blood vessels pressing on the nerve."

After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy?

"It will directly measure the pressure within the ventricles of my brain."

The RN is teaching a student nurse about acute care for a patient with ischemic stroke. The patient's BP is 230/120 mm Hg. Which statement made by the student nurse indicates the need for further teaching?

"Large amounts of fluid should be provided."

How many years apart are tetanus and diphtheria toxoid boosters given? Record the answer using a whole number. __________ years

10

How many doses of the meningococcal conjugate vaccine (MCV4) (Menactra) are recommended for the prevention of bacterial meningitis?

2

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and BP of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number. _______ mm Hg

39 The CPP is calculated by subtracting the ICP from the MAP; 64 - 25 = 39.Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As CPP decreases, autoregulation fails and cerebral blood flow is decreased.

A patient presents with an open wound. The nurse reviews the patient's history and determines that a tetanus booster is not necessary. This determination was made because the patient was immunized against tetanus within the past how many years? Record the answer as a whole number. _______ years

5

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data?

5 to 15 mm Hg

Which disorder would the nurse associate with a patient's clinical manifestations of a throbbing headache and photophobia occurring prior to the headache's onset, as well as a history of this type of headache?

A migraine headache

While the patient with Parkinson's disease, who is unresponsive to drug therapy, considers the surgical options presented by the health care provider, which procedures would the nurse anticipate providing as additional resources? Select all that apply.

Ablation Transplantation Deep-brain stimulation

Which information would the nurse provide a patient and the caregiver as discharge instructions related to care during the first three days after sustaining a head injury?

Abstain from alcohol during this time.

Which prescribed medication would the nurse anticipate administering to the patient complaining of a severe headache, neck stiffness, and intensified pain upon exposure to sound?

Acetaminophen (Tylenol)

Which topics would the nurse include in a teaching plan about self-care for a patient who is diagnosed with Bell's palsy? Select all that apply.

Administration of corticosteroid medications Dark glasses and artificial tears to protect the eyes

A patient has had three episodes of trigeminal neuralgia and has stopped eating food, fearing that chewing would trigger pain. Which instruction would the nurse give that would help to maintain a proper nutritional status of this patient? Select all that apply.

Advise the patient to consume food that is easy to chew. Advise the patient to eat small quantities of food more frequently. Advise the patient to eat food that is rich in carbohydrates and proteins.

When would the nurse schedule and prepare the patient with meningitis for a prescribed lumbar puncture procedure? Select all that apply.

After the blood culture test Before starting the antibiotic therapy After the CT scan Before the MRI scan

The patient with Parkinson's disease lost 35 pounds (15.9 kg) over the last two months, and a swallow study indicates ability to swallow without aspiration. Which intervention would the nurse discuss with the patient and spouse to improve nutritional intake?

Allow adequate time for the patient to eat each of six small meals

A patient who is hospitalized with a spinal cord injury experiences poor dietary intake. Which measures does the nurse take to improve the patient's nutritional status? Select all that apply.

Allow adequate time to eat. Encourage intake of dietary fiber. Keep a calorie count of the food taken. Provide a pleasant eating environment. Encourage the family to bring in special foods.

For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the health care provider?

An ICP of 20 mm Hg

Which clinical manifestation would the nurse associate with a patient reporting a headache, with disturbed consciousness, and whose imaging studies indicate cerebral edema in the white matter?

An increase in the cerebral extracellular fluid volume occurred.

Which medical condition places a patient at a higher risk for an embolic stroke?

Atrial fibrillation

Which parameter would the nurse assess when examining a patient with a history of tension-type headaches (TTHs)?

Auscultate carotid artery sounds.

For the patient with cluster headaches, which therapy requires equipment to monitor the skin temperature of the patient's fingers?

Biofeedback therapy

Which tests would be done for screening patients who are at risk for a stroke? Select all that apply.

Blood pressure Blood sugar Serum chloestrol

Which data in a patient's health history would be associated with an increased risk for developing Alzheimer's disease (AD)? Select all that apply.

Body mass index (BMI) of 32.7 A 10-year history of type 2 diabetes mellitus Takes two antihypertensive medications and maintains a BP 150/88 mm Hg

For the patient with a head injury and suspected temporal fracture, which clinical manifestations would the nurse need to assess further? Select all that apply.

Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region

After a fall at home, a patient is hospitalized and diagnosed with conus medullaris syndrome. The nurse expects which assessment findings? Select all that apply.

Bowel incontinence Urinary incontinence Hypotonicity of the lower limbs

Which clinical manifestation does the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?

Bradycardia

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply.

Bradycardia Irregular respirations Increasing systolic BP

Which clinical manifestations are characteristics of Cushing's triad? Select all that apply.

Bradycardia Systolic hypertension Widening pulse pressure

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition?

Brain abscess

Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled?

Cancel the lumbar puncture and contact the prescribing provider.

Which diagnostic test determines cerebral blood flow?

Cerebral angiography

Which type of herniation would the nurse associate with imaging studies indicating the presence of lateral displacement of the patient's brain tissue beneath the falx cerebri?

Cingulate herniation

A patient with a T3 level spinal cord injury has been discharged from the hospital with an indwelling catheter. Which instructions does the nurse give to the patient regarding catheter care? Select all that apply.

Cleanse the catheter regularly. Check for the presence of any folds or kinks in the catheter tube. Observe the urine for cloudiness or change in odor.

Which type of seizure would the nurse suspect when family members report that the patient suddenly lost consciousness and fell, and the patient's left leg exhibited jerky movements for a few seconds?

Clonic seizure

For which condition would the nurse administer 100% oxygen immediately?

Cluster headache

Which condition would the nurse anticipate integrating into the patient's plan of care when the patient reports swelling around one eye, gum pain, unilateral lacrimation, and nasal congestion after applying perfume?

Cluster headache

Which underlying condition would the nurse associate with a patient scheduled for invasive nerve block therapy?

Cluster headache

Which type of headache would the nurse associate with the patient's report of the headache occurring "on the right side of my head, around my right eye, and having a sharp, penetrating type of pain"?

Cluster headaches

What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces?

Comminuted

Which type of skull fracture would the nurse associate with an x-ray report indicating multiple linear fractures and the presence of a fragmented bone?

Comminuted type

Upon review of a patient's admission orders for treatment of a migraine headache, the nurse notes that the medication list includes sumatriptan (Imitrex). During the admission assessment, which intervention would the nurse implement when the patient reports having experienced a stroke last month?

Contact the health care provider about the patient's history and prescribed sumatriptan.

Which collaborative treatment would be prescribed for an adult patient who is diagnosed with mild cognitive impairment (MCI)?

Continued monitoring

The nurse is caring for a patient diagnosed with tetanus who has been given tetanus immune globulin (TIG). Which interventions would be the focus of collaborative care? Select all that apply.

Control of spasms with diazepam Tracheostomy for mechanical ventilation

Which interventions would the nurse implement for the patient with bacterial meningitis who develops seizures? Select all that apply.

Convey an attitude of caring. Administer antiseizure medications. Keep a familiar person at the patient's bedside.

When caring for a patient with Bell's palsy, the nurse would monitor for which complications? Select all that apply.

Corneal abrasions Psychologic withdrawal Mucous membrane trauma

Which position would the nurse expect a patient to display as decerebrate posturing when diagnosed with an elevated intracranial pressure (ICP) causing serious disruption of motor fibers in the midbrain and brain stem?

Decerebrate positioning

Which clinical manifestations would the nurse anticipate identifying in a patient suspected of having a disruption of motor fibers in the midbrain after sustaining a head injury?

Decerebrate posturing

Which response would the nurse document when a patient with a brain injury experiences the motor function changes depicted in the image?

Decorticate posturing

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

Decorticate posturing

Which tests would be of greatest benefit to obtain information about cerebral blood flow in a patient who had a stroke? Select all that apply.

Duplex scanning Digital subtraction angiography Transcranial doppler ultrasongrapghy

For the patient with Parkinson's disease who is taking levodopa with carbidopa (Sinemet), the nurse would monitor the potential development of which side effect(s)? Select all that apply.

Dyskinesia Involuntary eyelid movements Severe nausea and vomiting

Which information would the nurse provide the caregiver of a patient with acute seizures regarding actions to implement if another seizure occurs at home? Select all that apply.

Ease the patient to the floor. Loosen constrictive clothes. Protect the patient from any injury.

Which instructions would the nurse give a patient about methods to reduce the risk of having a stroke? Select all that apply.

Eat a diet low in saturated fats Maintain normal BP Limit consumption of alcohol to moderate levels

After receiving discharge instructions regarding dietary restrictions to prevent migraine headaches, the patient reports a recurrence of migraine attacks at a follow-up visit. Which patient action would the nurse attribute to the migraine recurrence?

Eating Cheese

Which information would the nurse include in a teaching plan about the onset of embolic stroke?

Embolic stroke occurs rapidly

A patient with a spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient tells the nurse, "I can't believe this is happening to me." How does the nurse respond? Select all that apply.

Encourage the patient to set daily goals. Encourage the patient to participate in care. Teach the patient what to expect during the rehabilitation period.

Which interventions would the nurse include in the care plan for a patient with chronic tension headaches? Select all that apply.

Encouraging the patient to perform yoga in the mornings Massaging the patient's shoulders with warm coconut oil Encouraging the patient to practice deep-breathing exercises

Which factors would the nurse evaluate before administering temozolomide (Temodar) as treatment for a patient's brain tumor? Select all that apply.

Evidence indicates that temozolomide is able to cross over the blood-brain barrier. Myelosuppression occurs and requires an absolute neutrophil count before giving. Temozolomide directly interferes with tumor growth by converting to a reactive agent

Which assessments would the nurse perform when utilizing the Glasgow Coma Scale (GCS) to assess a patient admitted with a head injury and requiring regular neurologic and vital sign assessments? Select all that apply.

Eye opening Best verbal response Best motor response

Which assessment would the nurse teach a patient to report as part of the warning signs of stroke, using the mnemonic FAST?

Facial drooping

While utilizing the Glasgow Coma Scale (GCS) to assess a patient's level of consciousness, which potential responses would the nurse document under best motor response? Select all that apply.

Flexion withdrawal Localization of pain Obedience of command

Which manifestations would a nurse observe in a patient with mild cognitive impairment (MCI)? Select all that apply.

Forgets recent events Frequently misplaces items Has increasing difficulty finding desired words

For the patient recovering from cranial surgery involving a bone flap, which interventions would the nurse implement to prevent an increased intracranial pressure (ICP)? Select all that apply.

Frequently assess the patient's neurologic status. Do not position the patient's surgical site in a dependent position. Closely monitor fluid and electrolyte levels and serum osmolality.

How is Guillain-Barré syndrome (GBS) different from Bell's palsy?

GBS is a potentially fatal disorder.

Which noninvasive surgical procedure is often performed in patients with trigeminal neuralgia?

Gamma knife radiosurgery

Which diagnosis is supported by the symptom of areflexia?

Guillain-Barré syndrome

Which clinical manifestations would the nurse expect to identify when assessing a patient with a brain abscess within the occipital lobe? Select all that apply.

Headache and fever Nausea and vomiting Visual impairment and hallucinations

Which manifestations in a patient with a T4 spinal cord injury alerts the nurse to the possibility of autonomic dysreflexia?

Headache and increased BP

Which common causes would the nurse consider when assessing the patient reporting a headache that is worse in the morning and aggravated with movement, results in vomiting without preceding nausea, and is suspected of having an increased intracranial pressure?Select all that apply.

Hematoma Head injury Brain tumor

Which condition presents with a sudden onset of a headache, vomiting, and decreased level of consciousness?

Hemorrhagic stroke

When feeding a patient with a stroke on the left side, in which position would the nurse place the patient?

High Fowler's position

Which finding supports the nurse's suspicion of a drug-associated side effect from the administration of topiramate (Topamax) therapy to a patient?

Hypoglycemia

When teaching the pathophysiology of a cluster headache, the nurse would teach that cluster headaches activate which part of the brain?

Hypothalmus

When managing a patient with a brain injury, of which potential secondary intracranial injuries would the nurse monitor development? Select all that apply.

Hypoxia Ischemia Hypotension Increased intracranial pressure

Which issue would the nurse prioritize when planning care for a patient in the acute phase of an ischemic stroke?

Impaired breathing

The nurse is preparing educational materials about the differences between the facial characteristics of Bell's palsy and those of trigeminal neuralgia. Which characteristics of Bell's palsy would the nurse include? Select all that apply.

Inability to whistle Inability to wrinkle brow

The nurse is preparing educational materials about the differences between Bell's palsy and trigeminal neuralgia. Which information would the nurse include about Bell's palsy?

It affects the seventh cranial nerve, whereas trigeminal neuralgia affects the fifth

Which explanation is accurate regarding the rationale for why memantine is prescribed for a patient with dementia?

It blocks the action of glutamate

A patient with trigeminal neuralgia asks the nurse about how antiseizure drugs would prevent painful episodes. Which explanation would the nurse give in order to explain the mechanism of action of the drug?

It blocks the transmission of nerve impulses from the trigeminal nerve

How would the nurse explain a transient ischemic attack (TIA) to the spouse of a patient who just had a TIA?

It can be a warning of an impending stroke.

A nurse advises a patient with Bell's palsy to use a facial sling. Which benefits would the nurse teach the patient to encourage the use of the facial sling? Select all that apply.

It facilitates eating. It supports facial muscles. It improves mouth alignment.

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? Select all that apply.

Keep suction equipment readily available at the patient's bedside Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first seven days after injury.

Which clinical manifestation would the nurse associate with a cluster headache?

Lacrimation

The nurse is providing teaching to a group of nursing students about the actions of the primary medications used to treat trigeminal neuralgia. Which points would the nurse include in the education? Select all that apply.

Lamotrigine blocks the nerve firing. Nortriptyline can be used to treat constant burning.

For the patient voicing complaints of pain on the left side of the head, nausea, vomiting, and sensitivity, which potential condition would the nurse associate with the prescriber's treatment of corticosteroids?

Migraine

Which intervention would the nurse implement to reduce the mental distortion experienced by the patient with meningitis?

Minimize environmental stimuli

For the treatment of a patient's tension-type headache (TTH), about which newly prescribed medication would the nurse prepare information for the patient?

Mirtazapine (Remeron)

Which interventions would the nurse implement to promote positive outcomes for the patient experiencing increased intracranial pressures (ICPs) in the neurologic intensive care unit? Select all that apply.

Monitor ICP. Elevate the head of the bed to 30 degrees. Maintain systolic arterial pressure of 100 to 160 mm Hg.

The nurse would assess for trigeminal neuralgia in patients with which conditions? Select all that apply.

Multiple sclerosis Shingles

Which medication classification would the nurse expect of a new medication prescribed to treat the major symptoms of a patient's multiple sclerosis (MS)?

Muscle relaxant

Which patient statements, made during the nurse's neurologic assessment, support the health care provider's diagnosis of cluster headache? Select all that apply.

My cheeks also ache during the headache." "My skin appears pale during the headache." "I don't feel like sitting in one place during the headache."

For the patient with an aggressive form of multiple sclerosis who is not responding to teriflunomide (Aubagio) and dalfampridine (Ampyra), the prescriber changed the medications to natalizumab (Tysabri) and mitoxantrone (Novantrone). Later, when the patient developed progressive multifocal leukoencephalopathy, which prescribed medication might be responsible?

Natalizumab

For which complication would the nurse monitor potential development while providing care for a patient with meningitis and ventricle adhesions that prevent the normal flow of cerebrospinal fluid?

Noncommunicating hydrocephalus

For the patient who receives scheduled doses of phenytoin (Dilantin) and begins to experience diplopia, the nurse would immediately determine the presence of which clinical manifestation?

Nystagmus or confusion

Upon hearing a patient with an increased intracranial pressure (ICP) begin to snore, the nurse relates the sound to which potential finding upon assessment?

Obstruction

Which intervention would the nurse implement when a patient with a history of tension headaches complains of head pain, but the patient's vital signs and brief neurologic assessment are normal?

Obtain the patient's detailed past medical history.

When a patient's clinical manifestations include visual disturbances and seizures, which area of the brain would the nurse identify as the most likely location of the diagnosed brain tumor?

Occipital lobe

When the patient experiences visual impairment and hallucinations, in which lobe of the brain would a CT scan indicate the presence of an abscess?

Occipital lobe

Which rationale would the nurse use to explain to family members why older adult patients who fall have a high risk for developing a chronic subdural hematoma?

Older adult patients have larger subdural spaces

Administration of which drugs would be part of the treatment plan for a patient diagnosed with tetanus infection? Select all that apply.

Opioid analgesics Sedatives and muscle relaxants Tetanus toxoid and immune globulin

Which medication may cause a rebound headache effect and requires dose tapering before discontinuing the medication?

Opioids (Oxycodone)

The nurse provides care for a patient immediately after a spinal cord injury (SCI). The nurse identifies that which renal problems can occur because of the loss of autonomic and reflex control of the bladder? Select all that apply.

Overdistention of the bladder Renal failure Rupture of the bladder No sensation of bladder fullness

When a patient with restless legs syndrome (RLS) failed to respond to gabapentin (Neurontin), which newly prescribed medication would the nurse anticipate administering?

Oxycodone (Percodan)

Which intracranial pressure waveform supports the nurse's assessment of a compromise occurring with the patient's intracranial compliance?

P2 wave is higher than P1 wave

The nurse would assess a patient with Alzheimer's disease who has increased vocalization and agitation for which issue?

Pain

When developing the plan of care for a patient with an elevated intracranial pressure (ICP), which factors guide the nursing interventions? Select all that apply.

Pain and agitation may elevate the patient's ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return.

Which clinical manifestation would the nurse associate with those of a migraine?

Paralysis

A degeneration of dopamine-producing neurons and decreased levels of dopamine are characteristics of which disease?

Parkinson's disease

Which neurodegenerative disorder has the characteristics of rigidity and bradykinesia?

Parkinson's disease

Which neurologic disorder has paradoxical intoxication as a potential adverse effect of medication therapy?

Parkinson's disease

Of the four assigned patients with skull fractures, which type of skull fracture would the nurse associate with a low-velocity injury?

Patient A

When reviewing the four assigned patients' diagnoses and associated medications, about which medication would the nurse contact the patient's prescriber for clarification?

Patient C

Which clinical manifestations would the nurse anticipate identifying in a patient who is comatose? Select all that apply.

Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent.

Which actions taken by a patient with a history of trigeminal neuralgia indicate that the patient is trying to avoid triggering another episode? Select all that apply.

Patient has stopped eating. Patient covers the face with a cloth. Patient avoids interacting with people.

Which reported behavior by a patient supports the diagnosis of memory loss associated with Alzheimer's disease (AD)?

Placing keys in the freezer

For the patient diagnosed with myasthenia gravis, which instructions would the nurse include in the patient's discharge teaching plan? Select all that apply

Plan activities with periods of rest Eat a balanced diet promoting easily chewed items Schedule medications so their peak effect is at mealtime.

Which seizure phase would the nurse identify when a patient with systemic lupus erythematosus presents to the emergency department with warm skin, pallor, lethargy, and an altered level of consciousness?

Postictal phase

When determining that the prescribed gabapentin (Neurontin) for focal seizures is ineffective, which medication, in addition to the gabapentin, would the nurse anticipate the health care provider will add to the patient's medication list?

Pregabalin (Lyrica)

Which signs and symptoms would the nurse continuously monitor in a patient with Guillain-Barré syndrome? Select all that apply.

Presence of bed sores Changes in bladder function Respiratory rate and rhythm

Which expected outcome would the nurse anticipate after administering phenytoin (Dilantin) for a patient with an increased intracranial pressure (ICP)?

Prevention of seizures

In a patient who had a change in mental status, which factors would be assessed as a possible cause for delirium? Select all that apply.

Previous health history Serum electrolyte values Medications routinely taken

For the patient with Parkinson's disease who has difficulty swallowing, which intervention would the nurse initially include in the patient's plan of care?

Provide the patient with semisolid or soft foods

Which intervention would the nurse take for a patient with trigeminal neuralgia whose oral intake is sharply reduced and is compromising his or her nutritional status?

Providing food through a nasogastric tube

Which medications that help to reduce psychotic behaviors are contraindicated in the older patient population? Select all that apply.

Quetiapine Risperidone Aripiprazole

Which interventions would the nurse implement when managing a fever for a patient with acute meningitis? Select all that apply.

Reduce fever with the use of acetaminophen. Use a cooling blanket on the patient to reduce fever. Lower temperature by using tepid-water sponge baths.

Which primary goals would the nurse identify when planning the care of a patient with a brain tumor? Select all that apply

Removing the tumor mass Identifying the tumor type and location Managing increased intracranial pressure (ICP)

Which primary goals would the nurse identify when planning the care of a patient with a brain tumor? Select all that apply.

Removing the tumor mass Identifying the tumor type and location Managing increased intracranial pressure (ICP)

Which surgical treatment would the health care provider discuss with the patient whose seizure activity failed to respond to medication therapy and who reports unusual sensations and hallucinations?

Resection of epileptogenic tissue

Which area would be a priority of care for a patient who is being admitted to the hospital and is demonstrating signs of delirium?

Safety

When preparing to administer a hypertonic saline infusion to a patient with an increased intracranial pressure (ICP), which parameters would the nurse monitor frequently? Select all that apply.

Serum sodium BP

When preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF), which surgical consent would the nurse obtain from the patient or immediate family member?

Shunt placement

The nurse reviews the medical record of a patient with poikilothermia. The nurse identifies that which history finding likely caused this condition?

Spinal cord injury

Which interventions would be included in postoperative care of a patient who has undergone aneurysmal occlusion via clipping and has a BP of 90/60 mm Hg? Select all that apply.

Start dopamine. Encourage fluid intake. Start crystalloid solution.

A patient with a spinal cord injury (SCI) at the C7 level experiences autonomic dysreflexia. Which signs and symptoms occur with this condition? Select all that apply.

Sudden onset of severe headache Sweating above the level of the SCI

Which medication would the nurse anticipate administering as a first-line therapy in treatment of severe migraines?

Sumatriptan (Imitrex)

To achieve the best outcome when providing care for a patient with an increased intracranial pressure (ICP) secondary to a mass lesion in the brain, which treatment information would the nurse provide the patient?

Surgery

Which factors would the nurse consider when assessing the surgical outcome of a patient with a brain tumor? Select all that apply.

Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time.

Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply.

Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Follow protocol standards to maintain a head-up position for the patient.

When obtaining a patient's history with migraine headaches, which clinical manifestations would the patient report? Select all that apply.

The headache is usually on one side. An aura typically precedes the headaches. Certain foods, such as chocolate, usually trigger the migraine.

For the mechanically ventilated patient, which response would the nurse use when family members inquire as to the benefit of maintaining the propofol (Diprivan) drip?

The medication has a short half-life and rapid onset of action.

Which patient's description of frequent headaches would the nurse associate with the clinical manifestations of a migraine headache?

The pain throbs and is synchronous with the beating of my heart.

Of the four assigned patients in the intensive care unit (ICU), which patient with an infection has the highest risk for developing cerebral edema?

The patient diagnosed with encephalitis

Which interpretation would the nurse associate with a positive Dextrostix test of the clear nasal discharge obtained from the patient who sustained head trauma?

The patient has cerebrospinal fluid (CSF) rhinorrhea.

A patient with paraplegia experiences convulsive movements of the lower limbs. Which information does the nurse provide to the patient and the caregivers about the spasms? Select all that apply.

The spasms can occur as a result of a variety of stimuli. Such reflexes could be positively used for bowel and bladder retraining. Medications such as baclofen or dantrolene may be prescribed to help to control the spasms

Which concepts about the pathology of botulism would the nurse teach the patient who is newly diagnosed with the disease? Select all that apply.

The spores of the organism are difficult to destroy. This neurotoxin inhibits nerve impulses from reaching the muscle. The neurotoxin produced by the bacteria is absorbed in the gastrointestinal (GI) tract.

Which points would the nurse include in a teaching plan about Bell's palsy and the reason why oral hygiene and nutrition are affected in this condition? Select all that apply.

The taste sensation is impaired. There is accumulation of food on one side of the mouth. There is pain around the jaw, which prevents the proper chewing of food.

A nurse is measuring the BP of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While he or she is speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. Which action would the nurse take?

Treat this as an emergency and call the health care provider

Which finding is consistent with a left-hemispheric stroke?

Unilateral weakness of the right extremities

Which clinical manifestation would the nurse report immediately to the health care provider when providing care for a patient with a traumatic brain injury and an increased intracranial pressure (ICP)?

Urine output of 1000 mL in one hour

The nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, the nurse instructs the patient to avoid which occurrence?

Urine retention

The nurse is providing care for a patient with a C7 spinal cord injury (SCI). Which instructions does the nurse give to the patient to prevent skin breakdown? Select all that apply.

Use a special mattress to reduce pressure. Use wheelchair cushions to reduce pressure. Use pillows to protect bony prominences when in bed.

When assessing a patient for the presence of petit mal, or absence, seizures, which classic sign would the nurse associate with this disorder?

Vacant facial expression

For the patient with bacterial meningitis who has a severe headache, which clinical manifestations would the nurse monitor to identify potential complications? Select all that apply.

Vomiting Irritability

Which statement is accurate about Guillain-Barré syndrome (GBS)?

Weakness of the limbs is acute and symmetrical.

Which instructions would the nurse give to a patient with Bell's palsy regarding preventive measures for complications related to the eye? Select all that apply.

Wear dark glasses. Tape eyelids at night. Instill artificial tears frequently.

Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

Which seizure disorder would the patient have when medication therapy failed, and the patient had a resection of epileptogenic tissue?

focal seizures

For the patient who sustained a head trauma, which type of seizure might he or she experience while on a ventilator and receiving sedation medications in the intensive care unit?

subclinical seizure

Which patient statement indicates effective learning after receiving information regarding botulinum toxin A therapy and chronic migraines?

"I will go to the health care center if I develop difficulty swallowing."

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

"tPA should be administered within 12 hours of the onset of a stroke."

In which order would the nurse anticipate a patient's seizure activity to occur?

A seizure progresses through several phases. The prodromal phase involves signs that precede a seizure. The aural phase has a sensory warning for the seizure. The ictal phase includes a full seizure. The postictal phase is the recovery period after the seizure.

A patient develops Bell's palsy weeks after being diagnosed with a middle ear infection. Which explanation would the nurse give when asked about the cause of the condition?

A virus causes inflammation, which leads to paralysis of the facial nerve

Which complementary pain management measures would be included in the plan of care for a patient with trigeminal neuralgia? Select all that apply.

Acupuncture Yoga Biofeedback

Which medication would the nurse prepare to administer to a patient admitted to the hospital with a diagnosis of viral encephalitis?

Acyclovir (Zovirax)

For the patient with hypoglycemia who has experienced a suspected seizure, which IV intervention would the nurse implement immediately?

Administer IV 0.9% sodium chloride and 5% glucose (Dextrose)

The nurse is caring for a patient who is diagnosed with bacterial meningitis. What are the priority actions by the nurse? Select all that apply.

Administer a corticosteroid along with the first dose of IV antibiotics. Collect specimens for a culture to confirm the diagnosis of bacterial meningitis. Initiate antibiotic therapy after obtaining specimen but prior to confirming diagnosis.

Which factor improves cerebral blood flow?

An increase in hydrogen ion concentration

Which pathophysiologic processes would the nurse suspect when a patient with a head injury develops a temperature of 103o F (39.4o C)? Select all that apply.

An increased cerebral blood flow is occurring. The metabolic wastes are increasing due to the head injury.

As part of the patient's migraine therapy, which prescribed medication would the nurse associate with the development of upper gastrointestinal bleeding?

Aspirin (Aspro Clear®)

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include?

BP, brain tissue, and cerebrospinal fluid

When teaching a community group about headaches, which part of the central nervous system would the nurse include as involved with the development of migraine headaches?

Cerebral cortex

Which condition would the nurse expect to find during the physical examination of a patient with cauda equina syndrome (CES)?

Complete sensation loss between the legs

The patient recovering from a stroke who is confined to bed for most of the day is at risk for which condition?

Constipation

Which interventions would the nurse implement to comfort the patient with a brain tumor who is experiencing disorientation and confusion due to perceptual problems? Select all that apply.

Create a routine. Use reality orientation. Minimize environmental stimuli.

Which aspects of the medical history of a female patient are risk factors for stroke? Select all that apply.

Current use of high-dose oral contraceptives History of migraine headaches with aura

Which type of encephalitis would the nurse anticipate integrating interventions into the plan of care for the patient with acquired immunodeficiency syndrome (AIDS)?

Cytomegalovirus encephalitis

For the patient with multiple sclerosis (MS), who has a new prescription for diazepam (Valium), which teaching points would the nurse provide? Select all that apply.

Do not stop the medication abruptly. Avoid driving while on the medication. Avoid alcohol intake with the medication.

For which potential disorder would the nurse monitor the urine output of a patient with an increased intracranial pressure and diabetes insipidus?

Hypernatremia

Which clinical manifestations would the nurse assess in a patient with Bell's palsy? Select all that apply.

Inability to smile Flaccidity of the affected side of the face Drooping of the mouth accompanied by drooling

The nurse is preparing educational materials about the differences between the facial characteristics of Bell's palsy and those of trigeminal neuralgia. Which characteristics of Bell's palsy would the nurse include? Select all that apply

Inability to whistle Inability to wrinkle brow

After 72 hours of intravenous (IV) fluid therapy for a patient who suffered a diffuse axonal traumatic brain injury (TBI), which rationale supports the nurse seeking an enteral feeding prescription?

Malnutrition promotes continued cerebral edema.

While monitoring a patient's intracranial pressure (ICP) via an intracranial device in the neurologic intensive care unit, which aspect of care requires collaborative actions by the nurse?

Monitoring the intracranial device for greater than five days

Which intervention would the nurse implement to prevent cranial nerve (CN) III palsy in a patient with meningitis?

Perform cooling techniques.

Which potential factors would the nurse associate with explaining a patient's pupils becoming fixed and unresponsive to light stimulus? Select all that apply.

Previous eye surgery Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)

Which type of brain injury would the nurse associate with the patient who sustained a subdural hematoma from a motor vehicle crash?

Primary

When diagnosed with a brain tumor and acquired immunodeficiency syndrome (AIDS), which type of tumor growth would the nurse associate with this patient?

Primary central nervous system lymphoma

For the patient diagnosed with a brain abscess, which events would the nurse associate with the development of the abscess? Select all that apply

Prior brain trauma or surgery Distant spread from a pulmonary infection Direct extension from an ear or sinus infection

Which medication has a rapid onset, short half-life, and would the nurse administer to treat a patient's anxiety and agitation secondary to an increased intracranial pressure?

Propofol (Diprivan)

Which intervention would the nurse implement when a patient experiences a generalized tonic-clonic seizure?

Protect the patient's head and extremities

When assessing a patient presenting with clinical manifestations of meningeal irritation and nuchal rigidity, which description would the nurse use to explain nuchal rigidity to the patient?

Resistance to flexion of the neck

Which assessment is a priority when caring for a patient who has been diagnosed with Guillain-Barré syndrome?

Respiratory assessment

Which disorder would the nurse associate with a patient's seizure lasting longer than five minutes and occurring in rapid succession without a return to consciousness between seizures?

Status epilepticus

Which surgical procedures would the health care provider suggest for a patient diagnosed with a transient ischemic attack due to carotid artery disease? Select all that apply.

Stenting Carotid endarterectomy Transluminal angioplasty

Which nerve also has the label of cranial nerve (CN) V?

Trigeminal nerve

Which pathophysiologic proteins are associated with Alzheimer's disease (AD)? Select all that apply.

β-Amyloid Tau protein Apolipoprotein E-4

The RN is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning?

"I will perform suctioning PRN."

When determining the type of frequent headaches that a patient experiences, which instructions would the nurse provide the patient? Select all that apply.

"Note the time of the onset of the headache." "Jot down the dates in a diary when experiencing a headache." "List the foods you consumed before the onset of a headache."

Initially, which response would the nurse use when a patient who developed seizures after a head injury reports feeling as though he or she has lost control over his or her life?

"Tell me about what you would like to do and how the seizures affect you."

When teaching the clinical manifestations of cluster headaches to a group, which statement would the nurse include?

"The pain experienced in cluster headaches is unilateral."

Which patient complaint would indicate that the individual may be experiencing clinical manifestations of a cluster headache?

"The pain wakes me up and disturbs my sleep at night."

An RN is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching?

"The patient should be placed in a supine position."

Which response would the nurse use to reply to the family of a patient admitted 12 hours ago with suspected meningitis who states, "We do not understand. We thought the spinal tap 'looked good,' according to the health care provider. Why is everyone still wearing gowns and masks?"

"The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."

When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid?

1.Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. Correct 2.Open the ventriculostomy system when ICP is greater than the prescribed pressure. Correct 3.Allow the CSF to drain for two to three minutes into the collection bag. Correct 4.Close the stopcock to return the ventriculostomy to a closed system.

Which diagnosis would the nurse associate with a patient's cerebrospinal fluid (CSF) culture findings of a white blood cell (WBC) count of 1200 cells/ µL, protein 600 mg/dL, and glucose 25 mg/dL?

Bacterial meningitis

Which objective data would the nurse record when assessing a patient with a head injury? Select all that apply.

Battle's sign Projectile vomiting Cranial nerve deficits

A patient diagnosed with moderate to severe Alzheimer's disease (AD) is being discharged home. Which instructions by the nurse are mostappropriate to give to the caregiver(s)? Select all that apply.

Be aware that pain may be manifested in changes in behavior." "Be alert to any changes in behavior, fevers, cough, or urinary pain." "Check that the patient swallows the food that is chewed because patients with AD can have difficulty swallowing."

Which clinical manifestations would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt? Select all that apply.

Blurred vision Headache and vomiting Decreased level of consciousness

After sustaining a head injury, for which clinical manifestation would the nurse monitor potential development in a patient scheduled for a lumbar puncture?

Cerebral herniation

Which instructions would the nurse include when teaching a group of caregivers to manage a patient in a late stage of Alzheimer's disease? Select all that apply.

Provide a regular schedule for toileting. Continue communication through talking and touching

Which intervention would the nurse implement when a patient's adult child becomes emotionally upset upon hearing the patient's diagnosis of Huntington's disease?

Provide emotional and psychologic support.

The patient was exhibiting symptoms of a stroke for 45 minutes before the symptoms resolved. Which condition may this patient have experienced?

Transient ischemic attack

Which statement would the nurse include when teaching a patient about the medication classification of triptans, of which a newly prescribed medication belongs?

Triptans are most effective when taken during an aura

Which explanation regarding trismus and its relation to tetanus infection is accurate?

Trismus is stiffness of the jaw and is one of the first manifestations of tetanus

Which caregiver's actions, implemented during the patient's acute seizure episode, indicates understanding of the home care measures taught prior to discharge? Select all that apply.

Turning the patient to their side Loosening the patient's tight clothing Easing the patient to the floor, if seated

Which seizure disorder typically occurs in children and rarely continues beyond adolescence?

Typical absence seizures

Which diagnostic criterion would the nurse include for migraine headaches when explaining the difference between a migraine headache and a tension-type headache (TTH)?

Unilateral pain

Which intervention does the nurse perform in the acute care of a patient with autonomic dysreflexia?

Urinary catheterization

Which interventions does the nurse include in the teaching plan for a patient with paraplegia who is being discharged from a rehabilitation facility? Select all that apply.

Use pressure-relief devices while sitting. Change bed positions at least every two hours. Dress warmly in cold weather to prevent frostbite.

Which statements made by the caregiver of a patient who sustained a head injury indicate understanding of the patient's needs? Select all that apply

"I should not allow the patient to drive when under the influence of morphine." "I should notify the health care provider if the patient develops finger numbness.

For the patient with a seizure disorder and a history of diabetes mellitus, which statements indicate understanding of safety measures taught by the nurse? Select all that apply.

"I will refrain from drinking alcohol." "I will wear a helmet while riding a bike. "I will maintain adequate sleep and rest schedules."

The nurse provides teaching about prescribed medications to a patient who is diagnosed with Alzheimer's disease (AD). Which statement made by the patient indicates the need for further teaching?

"I will take trazodone if I become agitated."

A patient's surgical therapy for trigeminal neuralgia resulted in an altered corneal reflex. After the nurse provides education about long-term management of the reflex, which statement made by the patient indicates the need for further teaching?

"I'm glad I won't need to put drops in my eyes anymore."

Which instructions would the nurse give to a patient recently diagnosed with Bell's palsy who is being discharged to home? Select all that apply.

"It is important to do good oral hygiene after each meal." "Full recovery generally occurs in three to six months." "Dark glasses will help protect your eyes and help to cover up the paralysis."

A decreased number of acetylcholine receptors in the neuromuscular junction is a characteristic of which autoimmune disease?

Myasthenia gravis

Which factors would the nurse consider when evaluating surgical therapy as treatment for the patient with a brain tumor? Select all that apply.

Partial removal of the ore invasive gliomas and medulloblastomas occurs. Complete removal of meningiomas and oligodendrogliomas can occur. The outcome of surgical therapy depends on the type, size, and location of tumor.

A percutaneous radiofrequency rhizotomy procedure has been planned for a patient with trigeminal neuralgia. Which information would the nurse give to this patient about the procedure? Select all that apply.

Patient may experience facial numbness after the surgery. Patient may have difficulty with eye movements after the procedure. An ice pack will be placed on the jaw for three to five hours after the procedure.

When providing care for a patient with advanced Huntington's disease (HD), which interventions would the nurse implement?

Provide palliative care as the collaborative approach

Which statements reflect understanding by the newly licensed registered nurse providing care for a patient with recent placement of a ventricular shunt? Select all that apply.

"I need to wear sterile gloves whenever I palpate the patient's incision site." "I should be concerned if my patient begins to vomit or dry heave and has a headache." "I will compare my current assessment findings with the patient's preoperative assessments."

A nurse is admitting a patient with a thrombotic stroke. The patient is NPO but is requesting a drink of water. Which response by a nurse is appropriate?

"It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."

The patient with trigeminal neuralgia asks the nurse about the incidence and how this condition is diagnosed. Which responses by the nurse are accurate? Select all that apply.

"Most cases occur in people over the age of 50." "The cause and physical aspects of trigeminal neuralgia are not well known." "Every year, about 12 in 100,000 Americans are diagnosed with this condition."

Which outcome would the nurse anticipate after administering a high dose of prescribed barbiturates to the patient with an increased intracranial pressure (ICP)?

Barbiturates decrease the level of cerebral metabolism.

Which suggestions would the nurse provide the patient inquiring about complementary therapies to use in addition to prescription medications for migraine headaches? Select all that apply.

Practice yoga to possibly enhance the benefits of your prescription medication. Visit an acupuncturist to treat migraine pain, along with your usual prescription

Regarding the patient with Parkinson's disease (PD) who recently entered a long-term care facility, which action would the health care team implement to promote adequate nutrition for this patient?

Provide small, frequent meals throughout the day that are easy to chew and swallow

For which major complication would the nurse monitor development in a patient experiencing a myasthenic crisis?

Respiratory insufficiency

Which manifestations would the nurse expect a patient to exhibit who is diagnosed with dementia with Lewy bodies (DLB)? Select all that apply.

Rigidity Bradykinesia Hallucinations Postural instability

Which characteristic would the nurse assess when performing a palmar drift (pronator drift) test during a neurologic assessment?

Strength of the hands

Which type of brain tumor would the nurse associate with a patient's clinical manifestations of uncontrolled urination, excessive thirst, high serum sodium levels, and involuntary eye movements?

Thalamus and sellar tumors

Which explanation would the nurse provide the patient who asked why he or she is on 100% oxygen for cluster headaches?

The administration of 100% oxygen increases your synthesis of serotonin.

Which response occurs in the brain when a patient's systemic arterial pressure begins to deviate from the normal range?

The brain begins autoregulation functions.

A patient undergoing the Mini-Cog test is being assessed for cognitive impairment. After the clock drawing test, the patient puts the numbers in correct sequence on the clock and recalls two words that the nurse asked the patient to remember. What is the test score for this patient? Record the score using a whole number. ____

The clock drawing is a test that can be used as an assessment technique in dementia. The person undergoing testing is asked to draw a clock, put in all of the numbers, and set the hands at 10 past 11. The test is considered normal if all numbers are present in the correct sequence and position and the hands readably display the requested time. In addition, the patient is asked to repeat three previously stated words. Give one point for each recalled word and two for the normal clock drawing test result. Because this patient recalled two words and the clock drawing test was normal, the patient's score is 4.

For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? Select all that apply.

The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient is vomiting without preceding nausea.

The nurse is caring for a patient with moderate Alzheimer's disease. After assessment, the nurse determines that the patient is in Reisberg stage 6c. Which assessment findings support this determination?

The patient requires help using the toilet

Which expected outcome would be included in the plan of care for a patient who had a stroke and is experiencing residual expressive aphasia?

The patient will demonstrate alternative communication techniques

After assessing the breathing patterns of four assigned patients, which patient would the nurse suspect of having a lesion in the medulla of the brain?

The patient with cluster breathing

For the patient with recent seizure activity, which characteristic would the nurse associate with a focal seizure?

The seizure involved lip smacking and repetitive movements.

To determine the amount of cerebral spinal fluid to drain from a patient's ventricle catheter, the nurse calculates the cerebral perfusion pressure (CPP) of an unconscious patient whose BP is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. Identify the patient's CPP. Record your answer using a whole number. _____ mm Hg

58 The nurse calculates the CPP by subtracting the ICP from the mean arterial pressure (MAP). The MAP is [162 + 2(58)]/3 = 193. The nurse subtracts 35 from 93 to determine that the patient's CPP is 58 mm Hg.

The initial assessment of a patient in the postanesthesia care unit recovering from a brain tumor resection included a temperature of 100°F (37.7°C), BP of 130/76 mm Hg, pulse 64 beats/min, a urinary catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One hour later, which assessment finding would the nurse immediately report to the surgeon?

BP of 148/58 mm Hg and pulse 48 beats/min

Which assessment findings would the nurse document regarding a patient diagnosed with a right-sided brain tumor resulting in a significantly increased intracranial pressure (ICP)? Select all that apply.

Ipsilateral pupil dilation Contralateral hemiparesis Altered level of consciousness

When assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first?

Level of consciousness

Which outcome would the nurse expect after administration of IV mannitol (Osmitrol) prescribed for a patient experiencing an increased intracranial pressure (ICP)?

Reduced ICP

Which components would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure (ICP)?

Speaking, responding to stimuli, and following verbal commands

Which initial interventions would the nurse implement as emergency management of a patient who fell and presented with scalp lacerations and a depressed skull? Select all that apply.

Stabilize the cervical spine. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing.

For the patient with a brain tumor, for which diagnostic test would the nurse prepare the patient when needing to localize and detect tumor blood flow?

Angiography