Neuro

Which of the following positions are employed to help reduce intracranial pressure (ICP)? 1. Keeping the head flat with use of no pillow 2. Extreme hip flexion supported by pillows 3. Avoiding flexion of the neck with use of a cervical collar 4. Rotating the neck to the far right with neck support

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

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

3 Explanation: 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 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect: 1. Acute attacks with full recovery or residual deficit upon recovery. 2. Progression with clear relapses with or without recovery. 3. Progressive disability from onset. 4. Acute attacks followed by progression at a variable rate.

Acute attacks with full recovery or residual deficit upon recovery. Explanation: With relapsing-remitting multiple sclerosis, recovery is usually complete with each relapse. Residual deficits may occur and accumulate over time, contributing to a functional decline.

female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option. 1. Because shivering in hypothermia can increase ICP 2. Because hypothermia is indicative of malaria 3. Because hypothermia can cause death to the client 4. Because hypothermia is indicative of severe meningitis

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

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? 1. Damage to the vagal nerve 2. Damage to the facial nerve 3. Damage to the olfactory nerve 4. Damage to the optic nerve

Damage to the optic nerve Explanation: 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.

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

Mannitol If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents.

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mm Hg Explanation: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).

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? 1. "A migraine headache is an example of a secondary headache." 2. "A secondary headache is located in the frontal area." 3. "A secondary headache is associated with an organic cause, such as a brain tumor." 4. "A secondary headache is one for which no organic cause can be identified."

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.

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child? 1. A tonic-clonic seizure 2. A complex seizure 3. An absence seizure 4. A partial seizure

Absence Seizure

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? 1. Administer stool softeners. 2. Encourage coughing and deep breathing. 3. Position the client with the head turned toward the side of the brain tumor. 4. Provide sensory stimulation.

Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return.

Which of the following is the earliest sign of increasing ICP?

Change of LOC

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? 1. Bradycardia 2. A bounding pulse 3. Hypertension 4. Lethargy and stupor

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

To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do? 1. Minimize exposure to bright lights and noise. 2. Promote an active range of motion. 3. Avoid physical contact with family members. 4. Increase environmental stimuli.

Minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli.

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

Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? 1. Choreiform movements 2. Emotional apathy 3. Loss of bowel and bladder control 4. Suicidal ideations

Suicidal ideations Explanation: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's 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 symptoms is appropriate, but not as important as assessing for suicidal ideations.

Which of the following medication classifications is utilized preoperatively to decrease the risk of postoperative seizures? Diuretics Anticonvulsants Antianxiety Corticosteroids

Anticonvulsants

In your assessment of a 39-year-old victim of a motor vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure? 1. Unequal response 2. Constricted response 3. Equal response 4. Rapid response

Unequal response

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: 1. place an oral airway in the client's mouth to maintain an open airway. 2. hold the client's arm still to keep him from hitting anything. 3. carefully move the client to a flat surface and turn him on his side. 4. allow the client to remain in the chair but move all objects out of his way.

carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated 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.

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? Generalized Absence Sensory Jacksonian

Generalized