Cranial Nerves, Intracranial Pressure

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect? a) Seizures b) Shivering c) Chest pain d) Anxiety

A - Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

How do you assess Cranial Nerve 2?

"Can you read my badge?"

How do you assess Cranial Nerve 9?

"Do you have any trouble swallowing?"

How do you assess Cranial Nerve 1?

"Have you noticed any problems with smelling?"

What are some factors that affect LOC?

-Increased ICP -Cerebral infarction -Hematoma -Hydrocephalus -Intracranial hemorrhage -Tumors and Infections -Medications

How do you assess Cranial Nerve 7?

1. "Any difficulty tasting things?" 2. Assess for symmetry or eqaulity during: -Show teeth, frown, smile, puff cheeks, raise eyebrows, close eyes tightly.

What are the 5 levels of consciousness (LOC)?

1. Alert and oriented (person, place, time, event) 2. Respond to verbal stimulation 3. Respond to continuous stimulation 4. Respond to painful stimulation 5. No response

What are some nursing interventions to try to improve intracranial regulation?

1. Decrease stimulation 2. Turn down the lights 3. No tv 4. Decrease pressure/promote positioning

What 3 behaviors is the Glascow coma scale scoring?

1. Eye opening response 2. Best verbal response 3. Best motor response

What 4 things assess a persons orientation?

1. Person 2. Place 3. Time 4. Event

How do you assess Cranial Nerve 11?

1. Place your hands on pt shoulders, and have them shrug against resistance. 2. Place hand on pt cheek, have them turn their head against resistance.

Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? Record your answer using a whole number. __________ mm Hg

80mmHg

How do you assess Cranial Nerve 5?

Ask pt to close eyes, touch their face, and ask them where they felt it at. Repeat 2 times.

What LOC is this: -Unarousable -Will not stir or moan to stimuli -May exhibit slight, nonpurposeful response to stimuli without the means to withdrawal from stimuli

Coma

What LOC is this: -Unable to think rapidly and clearly -Easily bewildered, poor memory and attention span -Misinterprets stimuli, judgment impaired

Confusion

Name the Nerve: (Number and Name) -Movement of vocal cords -Assessment of speech

Cranial Nerve 10: Vagus

Name the Nerve: (Number and Name) -Movement of head and neck

Cranial Nerve 11: Spinal Accessory

Name the Nerve: (Number and Name) -Tongue movements

Cranial Nerve 12: Hypoglossal

Name the Nerve: (Number and Name) -Tests ability to smell scents

Cranial Nerve 1: Olfactory

Name the Nerve: (Number and Name) -Vision

Cranial Nerve 2: Optic

Name the Nerve: (Number and Name) -Eyeball and eyelid movement -Pupil dilation

Cranial Nerve 3: Oculomotor

Name the Nerve: (Number and Name) -Sensation of face

Cranial Nerve 5: Trigeminal

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position? a) supine b) side-lying on the affected side c) side-lying on the unaffected side d) semi-Folwer's

D - semi-fowlers A hyphema is the presence of blood in the anterior chamber of the brain. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

How do you assess Cranial Nerve 12?

Have pt stick their tongue straight out, then move from side to side.

Measuring the cerebral blood flow/cerebral perfusion pressure monitors what?

ICP

What is often assessed with every patient interaction?

LOC; alertness and orientation

The glascow coma scale measures what?

Level of consciousness (LOC)

What helps prevent hypoxemia and hypercarbia, causing an increase in ICP?

Mechanical ventilation

Myopia

Nearsightedness

What LOC is this: -Lethargic -Responsive to verbal/tactile stimuli, but quickly drifts back to sleep

Obtundation

What does PERRLA stand for? And for what nerves does it apply?

P-Pupils E-Equal R-Round R-Reactive to L-Light A-Accommodate -Used for Cranial Nerves 3, 4 and 6

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: a) Dysfunction in the brain stem. b) Dysfunction in the cerebrum. c) Dysfunction in the spinal column. d) Risk for increased intracranial pressure.

a) Dysfunction in the brain stem. Decerebrate posturing indicates damage to the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

Which of the following symptoms may occur with phenytoin level of 32 mg/dl? a. ataxia and confusion b. tonic-clonic seizure c. urinary incontinence d. sodium depletion

a. ataxia and confusion *A therapeutic phenytoin level is 10-20mg/dl. A level of 32 mg/dl is a toxic level. Symptoms of toxicity include ataxia and confusion. Incontinence may occur during or after a seizure.

An adult client is brought to the emergency department due to a motor vehicle accident. While monitoring the client, the nurse begins to suspect increased intracranial pressure, ICP, when: a. client is orientated when aroused from sleep and goes back to sleep immediately b. blood pressure is decreased from 160/90 to 110/70 c. client refuses dinner due to anorexia d. pulse is increased from 88 to 96 with the occasional skipped beat

a. client is oriented when aroused from sleep and goes back to sleep immediately. **This behavior indicates a decrease in the level of consciousness, which is the primary sign of increased ICP.

Which of the following signs and symptoms of increased intracranial pressure, ICP, would occur first after a head injury? a. restlessness and confusion b. bradycardia c. large amounts of very dilute urine d. widened pulse pressure

a. restlessness and confusion *The earliest symptom of increased ICP is a change in mental status. **Bradycardia, widened pulse pressure and bradypnea occur as late symptoms. Voiding large amounts of very dilute urine typically occurs with damage to the posterior pituitary.

The client is having a lumbar puncture (LP) performed. The nurse would plan to place the client in which position? a. side-lying, with legs pulled up and head bent down onto the chest. b. side-lying with a pillow under the hip c. prone, in a slight Trendelenburg's position d. prone, with a pillow under the abdomen

a. side-lying, with legs, pulled up and head bent down onto the chest. **This position helps to open the spaces between the vertebrae.

A client with a subdural hematoma (a collection of blood on the brain's surface beneath the skull) becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a. to promote osmotic diuresis to reduce ICP b. to reduce intraocular pressure c. to prevent acute tubular necrosis d. to draw water into the vascular system to increase blood pressure

a. to promote osmotic diuresis to reduce ICP *Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. **Although Mannitol is used for all the other reasons, the primary reason it is used in the given case is to reduce ICP.

An adult client with a severe head injury is being monitored by the nurse for increase intracranial pressure, ICP. Which finding would be the most indicative indication of increased ICP? a. intermittent tachycardia b. polydipsia c. increased restlessness d. Tachypnea

c. Increased restlessness **Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.

Which finding would be most indicative of hydrocephalus in an infant? a) A positive glabellar reflex. b) Increased blood pressure. c) A pulsating fontanel. d) Sunsetting eyes.

d) Sunsetting eyes. Sunsetting eyes, or downward deviations of the irises, are a sign of hydrocephalus. A positive glabellar reflex, or blinking in response to taps on the forehead, and a pulsating fontanel are normal findings. Hydrocephalus in the newborn manifests as hypotension.

The nurse judges that the mother understands the term cerebral palsy when she describes it as a term applied to impaired movement resulting from which factor? a) injury to the cerebrum caused by viral infection b) malformed blood vessels in the ventricles caused by inheritance c) inflammatory brain disease caused by metabolic imbalances d) nonprogressive brain damage caused by injury

d) nonprogressive brain damage caused by injury The term cerebral palsy (CP) refers to a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction due to injury. In addition, a child may have speech or ocular difficulties, seizures, hyperactivity, or cognitive impairment. The condition of congenital malformed blood vessels in the ventricles is known as arteriovenous malformations. Viral infection and metabolic imbalances do not cause CP.

Which of the following values is considered normal for ICP? a. 35-45 mm/Hg b. 120/80 mm/Hg c. 25 mm/Hg d. 0-15 mm/Hg

d. 0-15 mm/Hg

While cooking your client could not feel the temperature of the oven. Which lobe of the brain could be dysfunctional? a. occipital b. temporal c. frontal d. parietal

d. parietal *The parietal lobe controls / regulates sensory function...including the ability to feel hot and cold. *The frontal lobe regulates thinking, planning and judgment. *The occipital lobe is primarily responsible for visual function. *The temporal lobe regulates memory.

A client with a subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a. Systolic blood pressure remains at 150 mm Hg b. Pupils are 8mm and non reactive c. BUN and creatinine levels return to normal d. urine output increases

d. urine output increases **Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. *Fixed and dilated pupils are symptoms of ICP or cranial nerve damage. **No information is given about BUN and creatinine levels or that mannitol is being given to treat renal dysfunction or blood pressure.

An 86-year-old patient looks at you when you speak to her. When you ask her the date, she says "Purple". You note left-sided weakness when she grips your fingers. What is her GCS?

13 (Eye: 4, Verbal: 3, Motor: 6)

A trauma patient moans, bends her arms towards her chest, and points her toes when you attempt to start an IV. What is her GCS?

6. (Eye: 1, Verbal: 2, Motor: 3)

To assess a client's cranial nerve function, a nurse should assess: a) gag reflex. b) arm drifting. c) hand grip. d) orientation to person, time, and place.

A - gag reflex The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

Decorticate or Decerebrate posturing: -Neck extended, jaw clenched -Arm pronated, extended -Legs extended -Feet are plantar flexed

Decerebrate Posturing

Decorticate or Decerebrate posturing: -Upper arms close to sides -Elbows, wrists, fingers flexed -Legs extended, internally rotated -Feet are plantar flexed

Decorticate Posturing

An increase in intracranial pressure = _______ LOC

Decreased Level of Consciousness

What LOC is this: -Not aware/oriented to time, place or person

Disoriented

Later signs of intracranial pressure (ICP) include which of the following? a. increased pulse rate b. projectile vomiting c. decreased blood pressure d. narrowed pulse pressure

b. projectile vomiting *Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: a) 88 mm Hg. b) 48 mm Hg. c) 68 mm Hg. d) 52 mm Hg.

d) 52 mm Hg.

Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury? a) Atonic urinary bladder b) Widened pulse pressure c) Flaccid paralysis d) Hyperactive reflexes

d) Hyperactive reflexes The spinal shock causes a loss of reflex activity below the level of the injury, resulting in bladder atony and flaccid paralysis. When the reflex arc returns, it tends to be overactive, resulting in spasticity. The reflexes and bladder become hypertonic during this phase of spinal shock resolution; sensation does not return. A widened pulse pressure is not associated with the resolution of spinal shock.

When caring for an adolescent who is at risk for injury related to intracranial pathology following a motor vehicle collision, which of the following nursing actions is the priority? a) Maintaining stable intracranial pressure b) Maintaining good body alignment c) Monitoring vital signs d) Monitoring cardiac rhythm

A - maintaining stable intracranial pressure Increased intracranial pressure contributes to increasingly severe pathology, including potential for brain stem herniation, so maintaining stable intracranial pressure is priority. Monitoring vital signs and monitoring cardiac rhythm are important but only represents a portion of the necessary nursing care. Maintaining good body alignment will prevent musculoskeletal problems but is not a priority.

Name the Nerve: (Number and Name) -Facial Muscle Contraction -Taste

Cranial Nerve 7: Facial

What LOC is this: -Completely unarousable and unresponsive to any stimuli -Absence of brainstem reflexes -Absence of corneal, pharyngeal, tendon, papillary, and plantar reflexes

Deep coma

Hyperopia

Farsightedness

How do you assess Cranial Nerve 10?

Have pt open mouth, use pen light to observe soft palate, have pt say "aah", and assess if the soft palate rose.

Name the Nerve: (Number and Name) -Ability to hear

Cranial Nerve 8: Acoustic

What LOC is this: -Alert; oriented to time, place and person -Comprehends written and spoken words

Full Consciousness

How do you assess Cranial Nerve 8?

Have pt close eyes, whisper/light snap in one ear, and ask the pt to identify which ear they heard it in

How do you assess Cranial Nerve 3, 4, 6?

1. Pupil size and shape 2. Assess ptosis 3. Pupillary Light Reflex: shine light into eyes -Direct reflex: shine light directly into one pupil -Consensual reflex: opposite pupil should constrict while light is shining on the other eye. 4. Conversion reflex: test near/far-sightedness *Eyes should come together -Have pt look at something in close proximity (conversion and constriction) -Have pt switch focus to something in the distance (dilation) 5. 6 Cardinal Fields of Gaze -Make an H or N in the air

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? a) hyperbilirubinemia b) hyperactivity c) bulging fontanels d) increased muscle tone

C - bulging fontanels A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if the bleeding was severe.

Name the Nerve: (Number and Name) -Eye movement (1 Muscle) *There are 2 cranial nerves that both have this function*

Cranial Nerve 4: Trochlear Cranial Nerve 6: Abducens

Name the Nerve: (Number and Name) -Ability to taste

Cranial Nerve 9: Glossopharyngeal

What is ptosis?

Eyelid drooping

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a) fever. b) hypoxia. c) visual disturbance. d) gait alteration

B - Hypoxia Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lowering brain stem functions.

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status of the client suggest to the nurse? a) The test was not performed accurately; there was too much light in the examination room. b) This is a normal response after a head injury, and the pupils will be expected to return to normal. c) Decreased intracranial pressure d) Increased intracranial pressure

D - increased intracranial pressure Movement of the eyes should be a balanced and coordinated function. Both pupils should be equal, reactive, and responsive to light and accommodation. Increased intracranial pressure is indicative of compression of the third, fourth, and sixth cranial nerves. The other choices are not reflective of neurologic status.

What LOC is this: -Does not move simultaneously -Unresponsive to stimuli -Vigorous and painful stimuli may provoke moaning or stirring -Withdrawal from stimuli without arousal

Semicomatose

What LOC is this: -Generally unresponsive -Briefly aroused by verbal, repeated, painful stimuli -May move away from stimuli

Stupor

If one has damage to their head, what happens to the pressure?

There is a constant, elevated pressure.

A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: a) 12 to 18 months. b) 6 to 8 months. c) 2 to 3 months. d) 9 to 10 months.

a) 12 to 18 months. Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months.

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider (HCP) if which finding is noted? a) Absent Moro reflex b) Bronze-colored skin c) Urine specific gravity of 1.018 d) Maculopapular chest rash

a) Absent Moro reflex An absent Moro reflex, lethargy, opisthotonos, and seizures are symptoms of bilirubin encephalopathy, which, although rare, can be life-threatening. Bronze discoloration of the skin and maculopapular chest rash is normal and is caused by phototherapy. They will disappear once the phototherapy is discontinued. A urine specific gravity of 1.001 to 1.020 is normal in term neonates. The Moro reflex is an infantile reflex normally present in all infants/newborns up to 4 or 5 months of age as a response to a sudden loss of support when the infant feels as if it is falling. It involves three distinct components: spreading out the arms (abduction) unspreading the arms (adduction) crying (usually) The primary significance of the Moro reflex is in evaluating the integration of the central nervous system.

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) Irregular breathing pattern c) Pupillary asymmetry d) Involuntary posturing

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 child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal? a) Decrease intracranial pressure. b) Lower the arousal level. c) Produce hypoxia. d) Ensure a patent airway.

a) Decrease intracranial pressure. Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.

Choice Multiple question - Select all answer choices that apply. The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which signs and symptoms? Select all that apply. a) bulging fontanel b) mood swings c) headache d) emesis e) irritability

a) bulging fontanel d) emesis e) irritability Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.

A client has atrial fibrillation. The nurse should monitor the client for: a) crebrovascular accident. b) cardiac arrest. c) hHeart block. d) ventricular fibrillation.

a) crebrovascular accident. Because of the poor emptying of blood from the atrial chambers, there is an increased risk for clot formation around the valves. The clots become dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication of atrial fibrillation.

A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle which resulted in head trauma. Which of the following signs or symptoms would be cause for concern? a. repeated vomiting b. bulging anterior fontanel c. inability to read short words from a distance of 18 inches d. signs of sleepiness at 10 pm

a. repeated vomiting *Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life-threatening. *Repeated vomiting can be an early sign of pressure stimulating the vomiting center in the medulla. The fontanel is closed in a four-year-old. The inability to read and signs of sleepiness would be an expected finding for a four-year-old.

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: a) Tachycardia. b) An altered level of consciousness. c) A depressed fontanel. d) Slurred speech.

b) An altered level of consciousness. One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which of the following is the appropriate nursing intervention? a) Reassessing vital signs in 15 minutes b) Contacting the physician c) Inserting a Foley catheter to monitor urine output d) Increasing the rate of IV fluids

b) Contacting the physician The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.

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

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.

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? a) Elevating the head of his bed b) Performing a lumbar puncture c) Placing him on mechanical ventilation d) Giving him a barbiturate

b) Performing a lumbar puncture The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

Choice Multiple question - Select all answer choices that apply. A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. a) Give the prescribed dose of oral phenytoin. b) Place a pillow under the client's head. c) Assist the client to the floor. d) Turn the client to the side. e) Insert an oral suction device to remove secretions in the mouth.

b) Place a pillow under the client's head. c) Assist the client to the floor. d) Turn the client to the side. During a seizure, the nurse should assist the client to the floor to reduce the risk of falling and turn the client on the side to help clear the mouth of oral secretions. If available, it is appropriate to place a pillow under the client's head to protect against injury. It is inappropriate to introduce anything into the mouth during a seizure because of the risk of choking or compromising the airway; therefore, oral medications and suction devices should not be used.

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? a) Prevention of hemorrhage. b) Reduced serum ammonia levels. c) Stimulation of peristalsis of the bowel. d) Reduced peripheral edema and ascites.

b) Reduced serum ammonia levels. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.

Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? a. widened pulse pressure b. large amounts of very dilute urine c. bradycardia d. restlessness and confusion

d. restlessness and confusion *The earliest sign of increased ICP is a change in mental status. *Bradycardia and widened pulse pressure occur later. *The patient may void a lot of very dilute urine if his posterior pituitary is damaged.

Which of the following types of drugs might be given to regulate increased intracranial pressure, ICP ? a. carbonic anhydrase inhibitors b. barbiturates c. anticholinergics d. histamine receptor blockers

b. barbiturates *Barbiturates may be given to induce a coma in a patient with increased ICP. *This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain's need for glucose and oxygen. **Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease serum pH in a client with metabolic alkalosis. **Anticholinergics are used for many things, such as controlling GI spasms. **Histamine receptor blockers are used to decrease stomach acidity.

The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. neck in neutral position b. head turned to the side c. head of the bed elevated 30 to 45 degrees d. head midline

b. head turned to the side *The head of the client with increased cranial pressure should be positioned so the head is in a neutral midline position. *The nurse should avoid flexing or extending the client's neck, or turning the head side to side. *The head of the bed should be raised to 30 to 45 degrees. **Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure balanced.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Status epilepticus b) Shock c) Increased intracranial pressure (ICP) d) Encephalitis

c) Increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves the decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises, and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? a) Coma b) High blood pressure c) Infection d) Apnea

c) Infection The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication? a) Postnatal asphyxia b) Facial nerve paralysis c) Intracranial hemorrhage d) Skull fracture

c) Intracranial hemorrhage When the nurse cannot elicit the Moro reflex of a 4-day-old preterm infant and the Moro reflex was present at birth, intracranial hemorrhage or cerebral edema should be suspected. Other symptoms include lethargy, bulging fontanels, and seizure activity. Confirmation can be made by ultrasound. Postnatal asphyxia is suggested by respiratory distress, grunting, nasal flaring, and cyanosis. A skull fracture can be confirmed by radiography. However, it is unlikely to occur in a preterm neonate. Rather, it is more common in the large-for-gestational-age neonate. Facial nerve paralysis is indicated when there is no movement on one side of the face. This condition is more common in the large-for-gestational-age neonate.

A nurse is working with a client who is on the rehabilitation unit after a cerebrovascular accident (or brain attack). To support the client in developing independence with activities of daily living, which of the following is the most important action for the nurse to take? a) Provide feedback by identifying the client's weaknesses. b) Establish daily goals for the client to achieve. c) Reinforce participation and success in tasks accomplished. d) Demonstrate ways to regain independence in activities.

c) Reinforce participation and success in tasks accomplished. It is important to involve the client in the care and to encourage participation. As the client accomplishes relearning different tasks, it is important to commend the client for success. Small steps in progress serve to reinforce motivation. The other options either do not involve the client in regaining independence or establishing goals, or the focus is on the client's weaknesses, rather than the successes.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Coldwater is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by rapid nystagmus toward the right. The nurse understands that this indicates the client has: a. a temporal lesion b. brain death c. an intact brain stem d. a cerebral lesion

c. an intact brain stem *Caloric testing provides information about differentiating between cerebellar and brain stem lesions. *After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates the intact function of cranial nerves III, IV, and VIII are conjugate eye movements toward the side being irrigated, followed by rapid nystagmus toward the opposite side. **Absence of dye conjugate eye movements indicates brain stem damage.

The nurse is caring for a client with increased intracranial pressure, ICP. The nurse would note which of the following trends in vital signs if the ICP is rising? a. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure b. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure c. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

c. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure **A change in vital signs may be a late sign of increased ICP. *Trends include increasing temperature and blood pressure and decreased pulse and respirations. Respiratory irregularities may also arise.

Problems with memory and learning would relate to which of the following lobes? a. Parietal b. Frontal c. Temporal d. Occipital

c. temporal **The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. **The frontal lobe primarily functions to regulate thinking, planning, and judgment. **The occipital lobe functions to regulate vision. **The parietal lobe functions with sensory functions.

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client complains of a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate? a) "Maybe the physician will prescribe aspirin for the head pain." b) "Opioid medications may lead to vomiting, which increases the intracranial pressure (ICP)." c) "Pain medication is avoided after a head injury to avoid hiding a worsening condition." d) "Your child has a mild concussion; acetaminophen (Tylenol) can be given."

d) "Your child has a mild concussion; acetaminophen (Tylenol) can be given." Following an MRI of the brain, it is confirmed that there is no bleeding on the brain; thus, pain medication may be administered. The mother asks for medication for a headache. The most appropriate response is that acetaminophen (Tylenol) may be given. Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP); therefore, it should not be given. Aspirin is contraindicated in conditions that may involve bleeding, such as traumatic injuries, and for children or young adults with viral illnesses due to the danger of Reye's syndrome.

An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: a) Increased myelination b) Intracranial hypotension c) A slightly thicker cranium d) Cerebral hyperemia

d) Cerebral hyperemia Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension — not hypotension — places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable than an adult's, causing the child to receive a more severe injury.

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? a) Dilated, fixed pupils b) Decrease in the pulse rate c) Widening pulse pressure d) Decrease in the level of consciousness (LOC)

d) Decrease in level of consciousness (LOC) A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

Which respiratory pattern indicates increasing intracranial pressure in the brain stem? a) Nasal flaring b) Rapid, shallow respirations c) Asymmetric chest excursion d) Slow, irregular respirations

d) Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations. Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

While in the emergency department, an adolescent who has been in a motorcycle accident less than 1 hour earlier remains conscious but is agitated and anxious. The nurse observes that his pulse and respirations are increasing and his blood pressure is decreasing. The nurse should initiate interventions to manage which of the following? a) Autonomic dysreflexia. b) Increased intracranial pressure. c) Metabolic alkalosis. d) Spinal shock.

d) Spinal shock Spinal shock occurs 30 to 60 minutes after a spinal cord injury owing to the sudden disruption of central and autonomic pathways. This disruption causes flaccid paralysis, loss of reflexes, vasodilation, hypotension, and increased pulse and respiratory rates. Autonomic dysreflexia occurs only after the return of spinal reflexes and is characterized by hypertension. Increased intracranial pressure is associated with widened pulse pressure and decreased pulse and respiratory rates. Metabolic alkalosis, manifested by vomiting, elevated plasma and urine pH, and elevated plasma bicarbonate levels, does not occur with spinal shock. Rather, hydrogen ion loss leading to metabolic alkalosis would occur with pyloric stenosis, diuretic therapy, and potassium depletion.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? a) VI b) IV c) IX d) XII

d) XII Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements.

A nurse is teaching family members of a client with a concussion about the early signs of increased cranial pressure, ICP. Which of the following would the nurse cite as early signs of ICP? a. decreased systolic blood pressure b. inability to wake the patient with noxious stimuli c. dilated pupils that don't react to light d. headache and vomiting

d. headache and vomiting *Headache and vomiting are early signs of increased ICP. *Decreases systolic blood pressure, inability to wake a patient with noxious stimuli, and dilated pupils that don't react to light are late signs of increased ICP.

Whether Mr. Synder's tumor is benign or malignant, it will eventually cause an increase in intracranial pressure (ICP). Signs and symptoms of increasing ICP include ALL of the following EXCEPT: a. papilledema, dizziness, mental status changes b. headache, nausea, vomiting c. obvious motor deficits d. increased pulse rate, drop in blood pressure

d. increased pulse rate, drop in blood pressure **As ICP increases, pulse rate decreases, and blood pressure increases. **As ICP continues to increase, vital signs vary considerably.

For an adult client with a suspected increased intracranial pressure (ICP), a most appropriate respiratory goal would be: a. lower arterial pH b. maintain partial pressure of arterial oxygen, PaO2, above 80 mm/Hg c. prevent respiratory alkalosis d. promote CO2 elimination

d. promote CO2 elimination *The goal of treatment would be to prevent acidemia by eliminating CO2. *That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. *Preventing respiratory alkalosis and lowering arterial pH could raise acid levels. *A minimum 60 mm/hg can oxygenate most clients.

Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information should the nurse include in a preprocedural teaching plan? Select all that apply. a) The CT scan is considered an invasive procedure, but not dangerous. b) The test requires standing alone without assistance. c) Throat irritation and facial flushing may occur if contrast dye is used. d) All medications must be withheld for 12 hours prior to the procedure. e) It is necessary to report any known allergies to iodine or seafood prior to the procedure. f) A contrast dye may be given before the test.

• Throat irritation and facial flushing may occur if contrast dye is used. • It is necessary to report any known allergies to iodine or seafood prior to the procedure. • A contrast dye may be given before the test. The nurse should inform the client who is scheduled to undergo a CT scan that a contrast medium may be administered before the procedure and that the dye can cause throat irritation and facial flushing. Because the dye is iodine based, it is essential for the client to report any known allergies to iodine or seafood before testing begins. The CT scan is not invasive or dangerous. The client will need to lie still (not stand) during the procedure and will not be able to take routine medications for 24 hours beforehand.

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness? a) Can be roused with stimulation b) Limited spontaneous movement; sluggish speech c) Remains in a deep sleep; responsive only to vigorous and repeated stimulation d) No motor or verbal response to noxious (painful) stimuli

a) Can be roused with stimulation The child is obtunded if he can be aroused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? a) Check vital signs and level of consciousness; then place the client in a quiet area with a family member. b) Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. c) Notify the emergency physician and request a telephone order for sedation. Administer the medication and place the client in a quiet place for monitoring. d) Monitor the level of agitation, and when the client calms down, refer to the community addiction team.

b) Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity ( inability to flex the neck forward due to rigidity of the neck muscles), and projectile vomiting. The nurse knows that lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a. the client needs mechanical ventilation b. vomiting continues c. intracranial pressure, ICP, is increased d. blood is anticipated in the cerebral spinal fluid (CSF)

c. intracranial pressure is increased **Sudden removal of CSF results in pressures lower in the lumbar region than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. **Vomiting may be caused by reasons other than ICP, so LP is not strictly contraindicated. **LP may be performed on a client needing mechanical ventilation.**Blood in the CSF is diagnostic for subarachnoid hemorrhage, and was obtained before signs and symptoms of increased ICP.

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The physician orders lab work and a dexamethasone suppression test. Which parameter is measured with the dexamethasone suppression test? a) The amount of dexamethasone in the system. b) Cortisol levels after the system is challenged. c) Changes in certain body chemicals, which are altered in depression. d) Cortisol levels before and after the system is challenged with a synthetic steroid.

d) Cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test measures cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test does not measure dexamethasone or body chemicals altered in depression. Dexamethasone is used to challenge the cortisol level.