PrepU Chapter 66: Neurologic Dysfunction

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? a. Mannitol b. Vasopressin c. Furosemide (Lasix) d. Phenobarbital

b. Vasopressin Rationale: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.

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 avoid coughing, sneezing, and blowing your nose." b. "You must report ringing in your ears immediately." c. "You must restrict your fluid intake." d. "You must lie flat for 24 hours after surgery."

a. "You must avoid coughing, sneezing, and blowing your nose." Rationale: 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 nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? a. Administer medications at exact intervals ordered. b. Give client plenty of fluids with medications. c. Assess client's reaction to new medication schedule. d. Document medication given and dose.

a. Administer medications at exact intervals ordered. Rationale: The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? a. Decerebrate posturing and loss of corneal reflex b. Complaints of headache and lack of pupillary response c. Mental confusion and pupillary changes d. Loss of gag reflex and mental confusion

a. Decerebrate posturing and loss of corneal reflex Rationale: Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood pressure and temperature, widened pulse pressure, Cheyne-Stokes breathing, projectile vomiting, hemiplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? a. Maintenance of a patent airway b. Assessment of pupillary light reflexes c. Positioning to prevent complications d. Determination of the cause

a. Maintenance of a patent airway Rationale: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a. Rising blood pressure and bradycardia b. Hypotension and tachycardia c. Hypertension and narrowing pulse pressure d. Hypotension and bradycardia

a. Rising blood pressure and bradycardia Rationale: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? a. Safety b. Skin care c. Self-care d. Activity

a. Safety Rationale: Clients who have seizures are carefully monitored and protected from injury. Therefore, safety is the priority.

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. a. Turn the client to the side. b. Physically restrain the client's movements. c. Inspect the oral cavity and teeth. d. Provide verbal reassurance.

a. Turn the client to the side. d. Provide verbal reassurance. Rationale: Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? a. Verapamil (Calan) b. Metoprolol (Lopressor) c. Carvedilol (Coreg) d. Amiodarone (Cordarone)

a. Verapamil (Calan) Rationale: Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.

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

b. "A secondary headache is associated with an organic cause, such as a brain tumor." Rationale: 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.

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 Rationale: Cerebral edema tends to peak 24 to 36 hours after surgery.

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

b. Administer corticosteroids as ordered. Rationale: 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 nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a. swallowing b. chewing c. tasting d. smelling

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

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

b. Avoiding flexion of the neck with use of a cervical collar Rationale: 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.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? a. Document the reading because it reflects that the treatment has been effective. b. Check the equipment. c. Contact the physician to review the care plan. d. Continue the assessment because no actions are indicated at this time.

b. Check the equipment. Rationale: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

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. The type of anticonvulsant prescribed to manage the epileptic condition b. Compliance with the prescribed medication regimen c. Recent weight gain and loss d. Recent stress level

b. Compliance with the prescribed medication regimen Rationale: 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 completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? a. Muscle spasms b. Drooping eyelids c. Sensitivity to bright light d. Shortness of breath

b. Drooping eyelids Rationale: Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.

Which activity should be avoided in clients with increased intracranial pressure (ICP)? a. Suctioning b. Enemas c. Minimal environmental stimuli d. Position changes

b. Enemas Rationale: Enemas should be avoided in clients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the client increases the ICP, rotating beds, turning sheets, and holding the client's head during turning may minimize the stimuli that cause increased ICP.

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 serum hypo-osmolarity b. Excessive urine output and decreased urine osmolality c. Oliguria and serum hyperosmolarity d. Oliguria and decreased urine osmolality

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

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? a. Diplopia b. Gingival hyperplasia c. Alopecia d. Ataxia

b. Gingival hyperplasia Rationale: Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a. Hypertension b. Lethargy and stupor c. Bradycardia d. A bounding pulse

b. Lethargy and stupor Rationale: 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 is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? a. One-third normal saline (0.33% NSS) b. Mannitol c. Half-normal saline (0.45% NSS) d. Dextrose 5% in water (D5W)

b. Mannitol Rationale: With increasing ICP, hypertonic solutions, like mannitol, 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.

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. Positioning the patient on his or her side with head flexed forward c. Providing for privacy d. Restraining the patient to avoid self injury e. Loosening constrictive clothing

b. Positioning the patient on his or her side with head flexed forward c. Providing for privacy e. Loosening constrictive clothing Rationale: 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.

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease. a. muscle fasciculations b. hallucinations and delusions c. bradykinesia d. depression

b. hallucinations and delusions Rationale: As Huntington's disease progresses, hallucinations, delusions, and impaired judgment develop due to degeneration of the cerebral cortex. Depression is a likely symptom for clients with both Parkinson's disease and Huntington's disease. Bradykinesia, slowness in performing spontaneous movement, is commonly associated with Parkinson's disease. Muscle fasciculations, or twitching, are commonly associated with ALS.

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because a. hypothermia is indicative of malaria. b. shivering in hypothermia can increase ICP. c. hypothermia is indicative of severe meningitis. d. hypothermia can cause death.

b. shivering in hypothermia can increase ICP. Rationale: The nurse should avoid hypothermia in a client with increased ICP because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia in a client with ICP does not indicate malaria or meningitis and is not likely to cause death.

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? a. "No familial tendency has been demonstrated." b. "There is a very weak familial tendency." c. "There is a strong familial tendency." d. "Only secondary migraine headaches show a familial tendency."

c. "There is a strong familial tendency." Rationale: Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.

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. Suctioning the client once each shift b. Elevating the head of the bed 90 degrees c. Administering a stool softener as ordered d. Encouraging oral fluid intake

c. Administering a stool softener as ordered Rationale: 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. Slow speech b. Irritability c. Altered respiratory patterns d. Headache

c. Altered respiratory patterns Rationale: 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.

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 his progress across the playground. The school nurse suspects what in this child? a. A complex seizure b. A partial seizure c. An absence seizure d. A tonic-clonic seizure

c. An absence seizure Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain.

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? a. Antianxiety b. Diuretics c. Anticonvulsants d. Corticosteroids

c. Anticonvulsants Rationale: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.

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. Optimizing nutrition b. Managing muscle weakness c. Explaining hospice care and services d. Offering family support groups

c. Explaining hospice care and services Rationale: 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.

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

c. High in protein and low in carbohydrate Rationale: 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 (Mosek, Natour, Neufeld, et al., 2009).

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. Infection b. Exacerbation of uncontrolled hypertension c. Increased ICP d. Increase in cerebral perfusion pressure

c. Increased ICP Rationale: 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 client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? a. Place a cooling blanket beneath the client. b. Help the client sit up. c. Keep the client on one side. d. Pry the client's mouth open to allow a patent airway.

c. Keep the client on one side. Rationale: The nurse will need to keep the client on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the client to the environment. If the client is confused or wandering, guide the client gently to a bed or chair. If the client becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the client is fully aware. The client does not need a cooling blanket after a seizure. The client's temperature should not be elevated from the seizure. The nurse should not pry the client's mouth open after a seizure so that the airway remains open.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? a. Lomotil b. Lamisil c. Lamictal d. Labetalol

c. Lamictal Rationale: 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 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. Displays no signs or symptoms of infection b. Demonstrates optimal cerebral tissue perfusion c. Maintains a patent airway d. Attains desired fluid balance

c. Maintains a patent airway Rationale: 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 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. Dawn phenomenon b. Cushing's c. Monro-Kellie d. Hashimoto's disease

c. Monro-Kellie Rationale: 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 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a. Give the patient some mouthwash to gargle with. b Request an antihistamine for the postnasal drip. c. Notify the physician of a possible cerebrospinal fluid leak. d. Ask the patient to cough to observe the sputum color and consistency.

c. Notify the physician of a possible cerebrospinal fluid leak. Rationale: Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.

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? a. Anemia b. Osteoarthritis c. Osteoporosis d. Obesity

c. Osteoporosis Rationale: 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).

Which of the following drugs may be used after a seizure to maintain a seizure-free state? a. Valium b. Ativan c. Phenobarbital d. Cerebyx

c. Phenobarbital Rationale: 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.

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? a. Administer lorazepam per orders. b. Apply oxygen via nasal cannula. c. Reorient the client while gently holding their arms. d. Place the client in wrist restraints.

c. Reorient the client while gently holding their arms. Rationale: Some clients during the postictal phase will become confused and agitated. This reaction is not intentional, and most clients do not later remember becoming agitated. The nurse should attempt to calm and reorient the client, while also gently holding the arms to prevent the client from hitting, thereby preventing the client from doing injury to self or others. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.

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. Hyperoxygenation before and after tracheal suctioning b. Maintaining adequate hydration c. Restricting fluid intake and hydration d. Administering prescribed antipyretics

c. Restricting fluid intake and hydration Rationale: 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 client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? a. Capillary refill of 2 seconds b. Urine output of 100 mL/hr c. Shivering d. Cool, dry skin

c. Shivering Rationale: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? a. Use pressure-relieving pads or a similar type of mattress b. Maintain hydration by drinking eight glasses of fluid a day c. Perform the Heimlich maneuver d. Apply warm or cool cloths to the forehead or back of the neck

d. Apply warm or cool cloths to the forehead or back of the neck Rationale: Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.

Which is the earliest sign of increasing intracranial pressure? a. Posturing b. Vomiting c. Headache d. Change in level of consciousness

d. Change in level of consciousness Rationale: The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

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 Percocet as ordered. c. Administer morning dose of anticonvulsant. d. Elevate the head of the bed.

d. Elevate the head of the bed. Rationale: 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.

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. seizure disorder. b. multiple sclerosis. c. Huntington's disease. d. Parkinson's disease.

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

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. Esophageal carcinoma b. Laryngeal carcinoma c. Colorectal carcinoma d. Pituitary carcinoma

d. Pituitary carcinoma Rationale: 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 with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? a. The CPP is high. b. The CPP reading is inaccurate. c. The CPP is within normal limits. d. The CPP is low.

d. The CPP is low. Rationale: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.