CoursePoint - Chapter 61: Management of Patients with Neurologic Dysfunction

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements? A. "A secondary headache is associated with an organic cause, such as a brain tumor." B. "A secondary headache is one for which no organic cause can be identified." C. "A secondary headache is located in the frontal area." D. "A migraine headache is an example of a secondary headache."

A. "A secondary headache is associated with an organic cause, such as a brain tumor." A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A. Administer stool softeners. B. Provide sensory stimulation. C. Position the client with the head turned toward the side of the brain tumor. D. Encourage coughing and deep breathing.

A. Administer stool softeners. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? A. Aspiration of a brain abscess B. Visualization of a hemorrhage C. To assess visual acuity D. Access for intravenous (IV) fluids

A. Aspiration of a brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

Which positions is used to help reduce intracranial pressure (ICP)? A. Avoiding flexion of the neck with use of a cervical collar B. Extreme hip flexion, with the hip supported by pillows C. Keeping the head flat, avoiding the use of a pillow D. Rotating the neck to the far right with neck support

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

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A. Compliance with the prescribed medication regimen B. The type of anticonvulsant prescribed to manage the epileptic condition C. Recent stress level D. Recent weight gain and loss

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

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. A. Opening the patient's jaw and inserting a mouth gag B. Loosening constrictive clothing C. Positioning the patient on his or her side with head flexed forward D. Restraining the patient to avoid self injury E. Providing for privacy

B, C, E During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

Cerebral edema peaks at which time point after intracranial surgery? A. 12 hours B. 24 hours C. 48 hours D. 72 hours

B. 24 hours Cerebral edema tends to peak 24 to 36 hours after surgery.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. Low in fat B. High in protein and low in carbohydrate C. At least 50% carbohydrate D. Restricts protein to 10% of daily caloric intake

B. High in protein and low in carbohydrate A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A. Sleeping quietly after the seizure B. Seizure was 1 minute in duration including tonic-clonic activity C. Seizure began at 1300 hours D. The client cried out before the seizure began

B. Seizure was 1 minute in duration including tonic-clonic activity Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? A. Semi-Fowler's, to promote breathing B. Side-lying, to facilitate drainage of oral secretions C. High Fowler's, to prevent aspiration D. Supine, to rest the muscles of the extremities

B. Side-lying, to facilitate drainage of oral secretions To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? A. smelling B. chewing C. swallowing D. tasting

B. chewing Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? A. "For many people with epilepsy, the disorder is synonymous with mental illness." B. "Cases of epilepsy are often associated with intellectual level." C. "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." D. "In most people, epilepsy is usually synonymous with intellectual disability."

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

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? A. Risk of injury B. Deficient fluid volume C. Airway clearance D. Risk for impaired skin integrity

C. Airway clearance The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as A. normal B. decorticate C. decerebrate D. flaccid

C. decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? A. constricted response B. rapid response C. unequal response D. equal response

C. unequal response In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? A. "You must report ringing in your ears immediately." B. "You must restrict your fluid intake." C. "You must lie flat for 24 hours after surgery." D. "You must avoid coughing, sneezing, and blowing your nose."

D. "You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A. Damage to the optic nerve B. Damage to the facial nerve C. Damage to the vagal nerve D. Damage to the olfactory nerve

A. Damage to the optic nerve Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? A. Declining level of consciousness (LOC) B. Involuntary posturing C. Pupillary asymmetry D. Irregular breathing pattern

A. Declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? A. Excessive urine output and decreased urine osmolality B. Oliguria and decreased urine osmolality C. Oliguria and serum hyperosmolarity D. Excessive urine output and serum hypo-osmolarity

A. Excessive urine output and decreased urine osmolality Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? A. Increased ICP B. Exacerbation of uncontrolled hypertension C. Increase in cerebral perfusion pressure D. Infection

A. Increased ICP Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? A. Hashimoto's disease B. Monro-Kellie C. Dawn phenomenon D. Cushing's

B. Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: A. Huntington disease B. Parkinson disease C. seizure disorder D. multiple sclerosis

B. Parkinson disease Although antiparkinson drugs are used in some clients with Huntington disease, these drugs are most commonly used in the medical management of Parkinson disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.

Which of the following drugs may be used after a seizure to maintain a seizure-free state? A. Cerebyx B. Phenobarbital C. Ativan D. Valium

B. Phenobarbital IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? A. Colorectal carcinoma B. Pituitary carcinoma C. Laryngeal carcinoma D. Esophageal carcinoma

B. Pituitary carcinoma Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur. Surgery to treat esophageal carcinoma usually is palliative and involves esophagogastrectomy with jejunostomy. Laryngeal carcinoma may necessitate a laryngectomy. To treat colorectal cancer, the surgeon removes the tumor and any adjacent tissues and lymph nodes that contain cancer cells.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? A. Elevating the head of the bed 90 degrees B. Encouraging oral fluid intake C. Administering a stool softener as ordered D. Suctioning the client once each shift

C. Administering a stool softener as ordered To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

Which is a late sign of increased intracranial pressure (ICP)? A. Headache B. Slow speech C. Altered respiratory patterns D. Irritability

C. Altered respiratory patterns Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? A. Trigeminal neuralgia B. Hypostatic pneumonia C. Brain tumor D. Epilepsy

C. Brain tumor The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? A. Suction the client's mouth and pharynx B. Place a cooling blanket beneath the client C. Turn the client to the side during a seizure and do not restrain movements D. Provide oxygen or anticonvulsants, whichever is available

C. Turn the client to the side during a seizure and do not restrain movements When a client is in a seizure, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. The nurse should suction the mouth and pharynx after a seizure has occurred, not during the seizure. Anticonvulsants may be administered to reduce the chances of seizure. Oxygen should not be given to clients with seizures. Clients with respiratory distress are given oxygen. Finally, a cooling blanket is placed beneath the client when hyperthermia occurs, not a seizure.

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? A. Managing muscle weakness B. Optimizing nutrition C. Offering family support groups D. Explaining hospice care and services

D. Explaining hospice care and services The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? A. Lamisil B. Labetalol C. Lomotil D. Lamictal

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

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? A. 100 to 150 mL/h B. 150 to 200 mL/h C. 50 to 100 mL/h D. More than 200 mL/h

D. More than 200 mL/h For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A. Lethargy and stupor B. Bradycardia C. A bounding pulse D. Hypertension

A. Lethargy and stupor As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A. Midbrain B. Cortex C. Medulla D. Diencephalon

A. Midbrain Damage to the midbrain causes decerebrate posturing that's characterized by abnormal extension in response to painful stimuli. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: A. carefully move the client to a flat surface and turn him on his side B. hold the client's arm still to keep him from hitting anything C. allow the client to remain in the chair but move all objects out of his way D. place an oral airway in the client's mouth to maintain an open airway

A. carefully move the client to a flat surface and turn him on his side When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non-elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

What is one of the earliest signs of increased ICP? A. decreased level of consciousness (LOC) B. coma C. Cushing triad D. headache

A. decreased level of consciousness (LOC) Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? A. vasodilation B. vasoconstriction C. hypertension D. increased PaO

A. vasodilation Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? A. Document signs and symptoms of inflammation B. Administer corticosteroids as ordered C. Assess for weight loss D. Give acetaminophen per orders

B. Administer corticosteroids as ordered Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? A. Flat B. Elevated 30 degrees C. Elevated no more than 10 degrees D. Turned onto the operative side

B. Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? A. Jacksonian B. Generalized C. Absence D. Sensory

B. Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Half-normal saline (0.45% NSS) B. Lactated Ringer's C. One-third normal saline (0.33% NSS) D. Dextrose 5% in water (D5W)

B. Lactated Ringer's With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? A. Emotional apathy B. Urinary tract infection C. Severe depression D. Choreiform movements

B. Urinary tract infection Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: A. elevated temperature B. diminished responsiveness C. decreasing blood pressure D. pupillary changes

B. diminished responsiveness Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: A. hypothermia can cause death to the client B. shivering in hypothermia can increase ICP C. hypothermia is indicative of malaria D. hypothermia is indicative of severe meningitis

B. shivering in hypothermia can increase ICP Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? A. Attains desired fluid balance B. Demonstrates optimal cerebral tissue perfusion C. Maintains a patent airway D. Displays no signs or symptoms of infection

C. Maintains a patent airway Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? A. Administering prescribed antipyretics B. Maintaining adequate hydration C. Restricting fluid intake and hydration D. Hyperoxygenation before and after tracheal suctioning

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

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 9 B. 6 C. 12 D. 3

D. 3 LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Complete a head-to-toe assessment B. Administer morning dose of anticonvulsant C. Administer Percocet as ordered D. Elevate the head of the bed

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