NUR 320: Intracranial EAQ
Mannitol is given to do what?
Decrease fluid in the brain
A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program?
Explain ways to prevent physical trauma from occurring during a seizure.
A nurse is caring for a client who is admitted to the hospital with a severe head injury. Which action is priority?
Maintain respiratory exchange and ventilation.
Which information should be included in the teaching plan for the client diagnosed with epilepsy?
People taking phenytoin must floss regularly. Rational: Gingival hyperplasia is a common side effect of phenytoin
A nurse is assessing a 3-week-old infant who has been admitted to the pediatric unit with hydrocephalus. What finding denotes a complication requiring immediate attention?
Tense anterior fontanel
A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP?
Unequal pupil size
A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?
Widening pulse pressure
What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?
Monitor the client for signs of brain injury.
A client with a head injury has been receiving dexamethasone. The health care provider plans to reduce the dosage gradually and to continue a lower maintenance dosage. Which effect associated with the gradual dosage reduction of the drug should the nurse explain to the client?
Promotes return of cortisone production by the adrenal glands
Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Why must the nurse observe the client closely during the initial days of treatment with warfarin?
Warfarin affects the metabolism of phenytoin.
A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure?
Placing the child in the side-lying position
A client has a tonic-clonic seizure. Which is the priority nursing intervention during the tonic-clonic stage of the seizure?
Protect the client from injury
A client with a seizure disorder is receiving phenytoin and phenobarbital. What client statement indicates that the instructions regarding the medications are understood?
"Stopping the drugs can cause continuous seizures and I may die."
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?
"Were you aware of anything different or unusual just before your seizure began?" Rationale: Identification of a sensation that occurs before each seizure (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure.
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.
- Irritability - High-pitched cry - Ineffective feeding behavior
When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply.
- Slowing of the hr - Bleeding from the oral cavity - Increased pulse pressure - Altered LOC (level of consciousness)
Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure?
- Vomiting - Irritability - Decreased LOC (level of consciousness)
A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs?
Suctioning the oropharynx routinely Rationale: Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure.
A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?
Teach isometric exercises Rationale: The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure.
A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately?
Bleeding from the ears
A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position?
In bed with the head of the bed elevated Rationale: With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure, which will intensify the ischemic manifestations of hemorrhage.
The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?
Increased restlessness Rationale: Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system.
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?
Lethargy
A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for?
Decrease in the level of consciousness
A nurse assesses a client for increasing intracranial pressure by monitoring the pulse pressure. What is the pulse pressure?
Difference between systolic and diastolic readings
What action should be included in the nursing care of an infant with increased intracranial pressure?
Elevating the head higher than the hips Rationale: Elevation of the head helps decrease intracranial pressure by way of gravity.
