AH- Exam 4 - EAQ's

Occipital lobe Rationale An abscess in the occipital lobe may lead to visual impairment and hallucinations. Abscesses in the frontal and parietal lobes may result in a local or systemic infection. A temporal lobe abscess can cause psychomotor seizures. p. 1511

In which lobe of the brain would a CT scan indicate the presence of an abscess when a patient experiences visual impairment and hallucinations? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Impaired blood flow to the brain Rationale A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the ICP from the mean arterial pressure (MAP).MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm Hg + 2[60 mm Hg])/3 = (120 mm Hg + 120 mm Hg)/3 = 240/3 = 80 mm Hg.MAP - ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg.The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is elevated, preventing perfusion of the brain, and it requires treatment. pp. 1484-1485

A patient's blood pressure (BP) is 120/60 mm Hg and the intracranial pressure (ICP) is 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? High blood flow to the brain Normal ICP Impaired blood flow to the brain Adequate autoregulation of blood flow

Cerebral abscess Rationale Weakness of the left upper limb and lower limb (hemiparesis), blurred speech (dysphasia), and reduced vision (hemianopsia) are symptoms that typically resolve after meningitis treatment. If these symptoms persist, suspect a cerebral abscess. After receiving treatment for meningitis, acute cerebral edema, neurologic dysfunction, and increased intracranial pressure do not persist and are symptoms of a cerebral abscess.

After treatment for meningitis, which disorder would the nurse associate with a patient's unresolved clinical manifestations of left upper and lower limb weakness, reduced vision, and slurred speech? Cerebral abscess Acute cerebral edema Neurologic dysfunction Increased intracranial pressure

Atonic seizure Rationale A drop attack is a sudden fall without loss of consciousness. In atonic seizures, the patient suddenly falls to the ground due to paroxysmal loss of muscle tone. In tonic and clonic seizures, there may be loss of consciousness and the patient may fall. In a myoclonic seizure, the patient may fall to the ground due to excessive jerking of the extremities. p. 1546

Drop attacks are a characteristic of which type of seizure? Tonic seizure Clonic seizure Atonic seizure Myoclonic seizure

Reduced risk of aspiration Rationale: Reducing the risk of aspiration from deteriorating muscle function can help to prevent respiratory infections that are a common cause of death in ALS. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injuries related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients. p. 1569

For patients with amyotrophic lateral sclerosis (ALS), which treatment goal focuses on preventing a common cause of death in patients with ALS? Reduced fat intake Reduced risk of aspiration Decreased injuries related to falls Decreased pain secondary to muscle weakness

PaO of the patient is 110 mm Hg. 2 PaCO of the patient is 40 mm Hg. 2 Rationale The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO of the patient greater than or equal to 100 mm Hg with PaCO in the range of 35 to 45 mm Hg. Therefore the PaO value of 110 mm Hg and PaCO value of 40 mm Hg indicate effective treatment. A PaO of less than 100 and PaCO of less than 35 mm Hg indicate ineffective treatment. p. 1491

For the patient with an increased intracranial pressure who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcome indicates an effective intervention? Select all that apply. One, some, or all responses may be correct. PaO of the patient is 80 mm Hg. 2 PaO of the patient is 90 mm Hg. 2 PaO of the patient is 110 mm Hg. 2 PaCO of the patient is 40 mm Hg. 2 PaCO of the patient is 30 mm Hg. 2

"We need to monitor your liver function." "Implement and maintain practices to avoid pregnancy." Rationale Teriflunomide is an immunomodulatory agent with antiinflammatory properties. The exact mechanism of action is unknown but may involve a reduction in the number of activated lymphocytes in the central nervous system. The specific indication for prescribing teriflunomide is the treatment of relapsing forms of multiple sclerosis. The drug may cause serious liver disease; therefore it is important to monitor liver function tests. Women should avoid getting pregnant when taking this drug because teratogenicity may occur. Avoiding driving, restricting salt intake, and monitoring blood pressure may not be important interventions related to this drug. p. 1559

For the patient with multiple sclerosis, which intervention would the nurse teach about the new prescription for teriflunomide? Select all that apply. One, some, or all responses may be correct. "Be sure to restrict your daily salt intake." "We need to monitor your liver function." "Avoid driving until you adjust to the medication." "Monitor and record your blood pressure levels daily." "Implement and maintain practices to avoid pregnancy."

Hirsutism Gingival hyperplasia Rationale Gingival hyperplasia and hirsutism are the most common side effects of phenytoin. Good dental hygiene, including regular tooth brushing and flossing, can limit gingival hyperplasia. The drug is not associated with neuropathy, memory loss, or weight gain. p. 1553

Hirsutism Neuropathy Weight gain Memory loss Gingival hyperplasia

Known causes of seizure disorder include birth injury, infection, trauma, or genetic factor. Rationale: Known causes of seizure disorder include hypoxic birth injury, cerebral infection, traumatic brain injury, or genetic factor. Most epilepsy cases are idiopathic, meaning the cause of the seizure disorder is unknown. New-onset epilepsy cases are more common in males and in people of African American descent. p. 1545

Regarding a young adult driver with epilepsy who sustained trauma from a motor vehicle accident, which response would the nurse use when family members inquire about the incidence of epilepsy? Very few epilepsy cases are not attributable to a specific cause. Females are more likely to develop epilepsy than males. New cases of epilepsy are most common in Hispanic patients. Known causes of seizure disorder include birth injury, infection, trauma, or genetic factor.

Brain abscess Rationale The absence of glucose in cerebrospinal fluid indicates a brain abscess. The glucose would be normal in encephalitis, would be normal or low (>40 mg/dL) in viral meningitis, and would be decreased (5 to 40 mg/dL) in bacterial meningitis. p. 1509

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition? Encephalitis Brain abscess Viral meningitis Bacterial meningitis

80 mm Hg Rationale Patients with elevated ICP are at risk for lower CPP during suctioning. When suctioning, the nurse maintains the patient's CPP above 60 mm Hg to preserve cerebral perfusion. Normal CPP is 60 to 100 mm Hg. A CPP of less than 50 mm Hg is associated with ischemia and neuron death. A CPP of less than 30 mm Hg results in ischemia. It is incompatible with life. p. 1484

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient? 20 mm Hg 40 mm Hg 50 mm Hg 80 mm Hg

Phenytoin Lamotrigine Phenobarbital Rationale Phenytoin, lamotrigine, and phenobarbital are the drugs with a long half-life used in treating status epilepticus. Diazepam and lorazepam are the rapid-acting drugs used in the treatment of status epilepticus. They have a short half-life. p. 1550

When admitted with status epilepticus, which long-acting antiseizure medication would the nurse associate with the treatment of a patient's seizure disorder? Select all that apply. One, some, or all responses may be correct. Phenytoin Diazepam Lorazepam Lamotrigine Phenobarbital

Pregnancy Sleep deprivation Iron deficiency Rationale: The nurse should include information about the conditions that cause restless legs syndrome (RLS). The conditions associated with RLS include pregnancy, sleep deprivation, and iron deficiency. Pregnancy and anemia (iron deficiency) can worsen the symptoms. Liver failure and gastrointestinal reflux have not been associated with RLS. p. 1554

When teaching a community group, which condition would the nurse discuss as precipitating the development or intensity of restless legs syndrome (RLS)? Select all that apply. One, some, or all responses may be correct. Pregnancy Liver failure Sleep deprivation Iron deficiency Gastrointestinal reflux

Bradycardia Systolic hypertension Widening pulse pressure Rationale Cushing triad is a neurologic emergency characterized by bradycardia, systolic hypertension, and a widening pulse pressure. The heart rate slows, so Cushing triad does not include tachycardia. Systolic BP increases, so hypotension is not present. Pulse pressure widens, not narrows, with Cushing triad. p. 1487

Which clinical manifestation is characteristic of Cushing triad? Select all that apply. One, some, or all responses may be correct. Tachycardia Bradycardia Systolic hypotension Systolic hypertension Widening pulse pressure Narrowing pulse pressure

Bladder contractions are unchecked. The bladder has a small capacity for urine. The patient experiences incontinence and dribbling. Rationale A patient with spastic bladder may experience unchecked bladder contraction, and the bladder may have a small capacity for urine. Both factors may result in urine urgency and frequency and cause incontinence and dribbling. Sensation of an urge to void is present in patients with spastic bladder but absent in patients with flaccid bladder, who may have urinary retention due to a large bladder capacity for urine. p. 1557

Which clinical manifestation would the nurse expect to identify when assessing a patient with a spastic bladder secondary to multiple sclerosis? Select all that apply. One, some, or all responses may be correct. Bladder contractions are unchecked. The patient experiences urinary retention. The bladder has a small capacity for urine. The patient experiences incontinence and dribbling. There is no sensation of urge to void or no desire to void.

Prevention of seizures Rationale Phenytoin is used to control seizures, for which this patient is at risk. Mannitol is used to help decrease ICP. Phenytoin will not affect systolic pressure. Histamine (H receptor antagonists), not phenytoin, are used to prevent GI ulcers. p. 1510

Which expected outcome would the nurse anticipate after administering phenytoin to a patient with bacterial meningitis? Lowered intracranial pressure (ICP) readings Prevention of seizures Decreased systolic pressures Prevention of gastrointestinal (GI) ulcers

Loosen restrictive clothes. Ensure the presence of a patent airway. Rationale Hypoxia is a metabolic disturbance that can cause seizures. In this case, the nurse treats the underlying cause first to control the seizure. The nurse manages hypoxia by ensuring a patent airway and loosening or removing tight clothes. The nurse administers dextrose in patients with hypoglycemia. The nurse administers phenytoin after treating the underlying cause. The nurse should never force the airway between the patient's clenched teeth. p. 1548

Which intervention would the nurse implement immediately for the patient experiencing generalized tonic-clonic seizures due to hypoxia? Select all that apply. One, some, or all responses may be correct. Loosen restrictive clothes. Ensure the presence of a patent airway. Administer IV dextrose. Force the airway between clenched teeth. Administer IV phenytoin

Yoga Rationale Lifestyle changes may help those with mild to moderate RLS. Examples include decreasing the use of alcohol or tobacco, maintaining regular sleep habits, exercising, and massaging and stretching the legs. Yoga includes exercising and stretching of the legs. Research indicates that yoga improves mood, sleep, and function in patients with RLS. Walking, rocking, and kicking can help to relieve any pain at night that disrupts sleep. pp. 1554-1555

Which intervention would the nurse suggest for the patient with restless leg syndrome (RLS) to improve mood, sleep, and function? Walking Rocking Yoga Kicking

Lorazepam IV Rationale Treatment of status epilepticus requires a rapid-acting antiseizure drug. The drugs most often used are benzodiazepines. If a patient has an IV, then IV lorazepam is preferred. Because these are short-acting drugs, their administration is followed with long-acting drugs, such as fosphenytoin. Vecuronium is a paralyzing agent and is not used to treat status epilepticus. Phenytoin is a long-acting anticonvulsant medication commonly administered after a rapid-acting benzodiazepine (such as diazepam) to help to stop a seizure and prevent further seizures. A patient experiencing extended episodes of status epilepticus may be at risk for dehydration, but prescribers do not consider lactated Ringer IV fluids as an immediate intervention for rehydration. p. 1550

Which prescribed IV injection would the nurse administer first for the patient experiencing status epilepticus? Lorazepam IV Phenytoin IV Vecuronium IV Lactated Ringer IV

Rationale A seizure progresses through several phases. The prodromal phase involves signs that precede a seizure. The aural phase has a sensory warning for the seizure. The ictal phase includes a full seizure. The postictal phase is the recovery period after the seizure. p. 1545

In which order would the nurse anticipate a patient's seizure activity to occur? Picture has correct order

39 MM HG Rationale The CPP is calculated by subtracting the ICP from the MAP; 64 - 25 = 39. Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As CPP decreases, autoregulation fails and cerebral blood flow is decreased. p. 1484

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and blood pressure (BP) of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number.

Hypernatremia Rationale Hypernatremia is a symptom of diabetes insipidus, so the nurse must monitor this patient's urine output carefully. Urine output is increased, not decreased, in the setting of diabetes insipidus because of decreased antidiuretic hormone. Dilutional hyponatremia is a symptom of syndrome of inappropriate antidiuretic hormone (SIADH), not diabetes insipidus. Elevated blood glucose levels are not measured via urine output but rather with blood tests, and diabetes insipidus is not associated with alterations in glucose level. p. 1494

For which potential disorder would the nurse monitor the urine output of a patient with an increased intracranial pressure and diabetes insipidus? Hypernatremia Decreased urine output Dilutional hyponatremia Elevated blood glucose level

Rationale: During a generalized tonic-clonic seizure, the patient loses consciousness and falls to the ground. Stiffening of the body for 10 to 20 seconds follows. There is a subsequent jerking of the extremities for another 30 to 40 seconds. The patient may then feel tired and sleep for many hours. p. 1545

In which order would the nurse anticipate the various phases of a generalized tonic-clonic seizure? The order in the picture is correct

Rationale The primary neuropathologic condition is an autoimmune process orchestrated by activated T cells. An environmental factor or virus in genetically susceptible individuals may initially trigger this process. The activated T cells in the systemic circulation migrate to the CNS, disrupting the blood-brain barrier. Subsequent antigen-antibody reaction within the CNS activates the inflammatory response and leads to the demyelination of axons. Initially, attacks on the myelin sheaths of the neurons in the brain and the spinal cord result in damage to the myelin sheath. However, attacks do not affect the nerve fiber. As ongoing inflammation occurs, affecting the nearby oligodendrocytes, the myelin loses the ability to regenerate. Eventually damage occurs to the underlying axon. Disruption of the nerve impulse transmission occurs, resulting in the permanent loss of nerve function. As inflammation subsides, glial scar tissue replaces the damaged tissue, leading to the formation of hard, sclerotic plaques. p. 1555

In which order would the nurse explain the neuropathologic changes occurring in patients with multiple sclerosis? The order in the picture is correct

The patient with an upper respiratory tract infection Rationale A patient with an upper respiratory tract infection is at high risk for developing bacterial meningitis. A skull fracture, prior brain trauma or surgery, and bacterial endocarditis place the patient at risk for developing a brain abscess. p. 1508

Of the four assigned patients on an acute care unit, which patient has the highest risk for developing bacterial meningitis? The patient with a skull fracture The patient with prior brain trauma The patient with an upper respiratory tract infection The patient with bacterial endocarditis

Papilledema Rationale When the optic nerve (CN II) is compressed by increased ICP, it may cause papilledema. Facial paresis would result from irritation of cranial nerve VII. Ptosis can indicate involvement of cranial nerve III. Loss of corneal reflex can occur with irritation or compression of cranial nerve V. p. 1509

The nurse suspects that a patient with increased intracranial pressure is experiencing cranial nerve II (CN II) irritation based on which assessment finding? Facial paresis Papilledema Ptosis Loss of corneal reflex

Obstruction Rationale Snoring sounds in a patient who has increased ICP is indicative of an obstruction, and this is an emergency. Snoring in a patient with increased ICP is not an indication of oversedation. Snoring is not a normal finding with increased ICP. The ICP will not decrease with snoring. p. 1494

Upon hearing a patient with an increased intracranial pressure (ICP) begin to snore, the nurse would relate the sound to which potential finding upon assessment? Obstruction Oversedation Normal finding Decreasing ICP

Oxycodone Rationale A patient with RLS may have severe symptoms not relieved by gabapentin. In such cases, health care providers prescribe low doses of opioids like oxycodone. Carbidopa, a dopamine precursor, is used to increase the amount of dopamine in the brain. This drug may not relieve the severe symptoms of RLS. Pramipexole, a dopamine agonist, is also used to increase the dopamine amount. Like carbidopa, this drug also may not relieve the severe symptoms of RLS. Health care providers do not use phenobarbital to treat RLS. p. 1555

When a patient with restless legs syndrome (RLS) failed to respond to gabapentin, the nurse would anticipate administering a low-dose of which medication? Pramipexole Oxycodone Phenobarbital Carbidopa/levodopa

Hearing restored prior to discharge Rationale Hearing loss caused by irritation of cranial nerve VIII (vestibulocochlear nerve) may be permanent after the treatment; thus the outcome is not realistic. Control of pain after the treatment, restored facial movement after facial paresis, and neck stiffness caused by cranial nerve irritation and neurologic dysfunction are possible.

When an experienced nurse is reviewing the plan of care for a patient with meningitis developed by a new registered nurse, which treatment outcome would the experienced nurse question? Pain controlled prior to discharge Hearing restored prior to discharge Facial movements restored prior to discharge Neck stiffness resolved prior to discharge

Resistance to flexion of the neck Rationale Nuchal rigidity (neck stiffness) is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation. p. 1509

When the nurse is assessing a patient who presents with clinical manifestations of meningeal irritation and nuchal rigidity, which description would the nurse use to explain nuchal rigidity to the patient? Tonic spasms of the legs Curling into a fetal position Arching of the neck and back Resistance to flexion of the neck

Serum sodium BP Rationale Hypertonic saline solutions can be used to treat increased ICP. Hypertonic saline infusions increase the intravascular fluid volume, which may alter the serum sodium levels and BP in the body. Monitoring blood glucose levels would be necessary if administering corticosteroids to a patient. Monitoring sedation levels would be required if administering barbiturates to the patient. Monitoring gastrointestinal disturbances would be necessary if administering corticosteroids to the patient.

When the nurse is preparing to administer a hypertonic saline infusion to a patient with an increased intracranial pressure (ICP), which parameter would the nurse monitor frequently? Select all that apply. One, some, or all responses may be correct. Blood glucose Serum sodium BP Level of sedation Gastrointestinal disturbances

Altered level of consciousness Ipsilateral pupil dilation Contralateral hemiparesis Rationale The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Patients experiencing increased intracranial pressure will present with varying degrees of altered levels of consciousness, depending on the degree of pressure. Compression of cranial nerve (CN) II (optic) results in dilation of the pupil on the same side (ipsilateral), not the opposite side (contralateral). As ICP continues to rise, the patient will experience changes in motor response on the opposite side of the lesion (contralateral), not the same side (ipsilateral). p. 1487

Which assessment finding would the nurse document regarding a patient diagnosed with a right-sided brain tumor resulting in a significantly increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. Altered level of consciousness Contralateral pupil dilation Ipsilateral pupil dilation Ipsilateral hemiparesis Contralateral hemiparesis

Turning the patient to the side Loosening the patient's tight clothing Easing the patient to the floor, if seated Rationale: The caregiver should turn the patient to the side to protect the patient from injury. Loosening any restrictive clothing of the patient will ensure a patent airway. Similarly, if seated, easing the patient to the floor will help to protect the patient from injuries. It is not necessary to send a patient immediately to the hospital after a seizure, unless the seizure is prolonged or another seizure immediately follows. Soft restraints are not applied to the patient's extremities during a seizure. The caregiver should clear the immediate area to prevent encountering objects that may cause harm or bruising. p. 1552

Which caregiver's action, implemented during the patient's acute seizure episode, indicates understanding of the home care measures taught prior to discharge? Select all that apply.One, some, or all responses may be correct. Turning the patient to the side Loosening the patient's tight clothing Easing the patient to the floor, if seated Applying soft restraints to the patient's extremities Immediately sending the patient to hospital after a single seizure

Ptosis Unequal pupils Diplopia Rationale A complication of meningitis is residual neurological dysfunction affecting many of the cranial nerves (CNs). When CN III, CN IV, and CN VI are irritated, ocular movements are affected. Ptosis, unequal pupils, and diplopia are signs that the nurse would monitor in a patient to assess for these cranial nerve irritations. Fever and neck stiffness are common symptoms associated with bacterial meningitis and are not complications. p. 1509

Which clinical manifestation would the nurse monitor to identify potential complications in a patient with bacterial meningitis who has a severe headache? Select all that apply. One, some, or all responses may be correct. Ptosis Unequal pupils Fever Neck stiffness Diplopia

Responding to stimuli Speaking Following verbal commands Rationale The GCS assesses a patient's ability to respond to stimuli, speak, and follow verbal commands. Swallowing and pupillary response are not components of the GCS. p. 1492

Which component would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. Responding to stimuli Swallowing Speaking Pupillary response Following verbal commands

CN V Rationale CN V is the trigeminal nerve; irritation of this nerve will lead to the loss of the corneal reflex. CN II (optic nerve) irritation leads to blindness. CN IV (trochlear nerve) irritation affects ocular movements. CN VII (facial nerve) irritation causes facial paresis. p. 1509

Which cranial nerve (CN) irritation, secondary to bacterial meningitis, results in the patient's loss of corneal reflexes? CN II CN V CN IV CN VII

Huntington disease Rationale Huntington disease is a genetically transmitted, autosomal dominant disorder. The offspring of a person with this disease have a 50% risk of inheriting it. Multiple sclerosis is a chronic progressive degenerative disorder of the central nervous system, not an autosomal dominant disorder. Demyelination of the nerve fibers of the brain and spinal cord is the principal characteristic of the disease. Myasthenia gravis is an autoimmune disease of the neuromuscular junction and is not an autosomal dominant disorder. Lou Gehrig disease is a rare, progressive neurologic disorder involving the degeneration of motor neurons in the brain and spinal cord. This is not an autosomal dominant disorder. p. 1569

Which degenerative neurologic disorder is an example of a genetically transmitted, autosomal dominant disorder? Multiple sclerosis Myasthenia gravis Lou Gehrig disease Huntington disease

Hypertension Rationale Hypertension is an extracranial condition associated with seizures. Migraines, brain tumors, and meningitis are all intracranial conditions that can be associated with seizures. p. 1545

Which extracranial condition would the nurse associate with a patient's seizures? Migraine Meningitis Brain tumor Hypertension

Decreases spasticity Increases coordination Retrains unaffected muscles to substitute for impaired ones Rationale Exercise improves daily function for patients with multiple sclerosis not having an exacerbation. Exercise decreases spasticity, increases coordination, and retrains unaffected muscles to act for impaired ones. Water exercise is especially beneficial. Water, which gives buoyancy to the body, allows the patient to have more control and perform activities that would otherwise be impossible. Exercise does not help to regain bladder control or delay the demyelination process. p. 1559

Which information would the nurse include when teaching a patient with multiple sclerosis about the advantages of exercise during remission? Select all that apply. One, some, or all responses may be correct. Decreases spasticity Increases coordination Helps to regain bladder control Delays the demyelination process Retrains unaffected muscles to substitute for impaired ones

Rotate injection sites with each dose. Know that flu-like symptoms are common. Wear sunscreen while exposed to sunlight. Rationale Patients on β-interferon should wear sunscreen when exposed to sunlight because the drug may cause photosensitivity. Patients should rotate the injection sites with each dose to prevent lipodystrophy. The nurse should let the patient know that flu-like symptoms are common with β-interferon. These symptoms usually subside on their own; if they do not, they should be treated with nonsteroidal antiinflammatory drugs (NSAIDs). The drug does not interact with grape juice; therefore consuming grape juice and grapes is permissible. Monitoring vital signs is not a specific teaching related to the drug. pp. 1558-1559

Which information would the nurse provide a patient with multiple sclerosis who begins treatment with β-interferon? Select all that apply. One, some, or all responses may be correct. Monitor vital signs on a regular basis. Rotate injection sites with each dose. Do not drink grape juice or eat grapes. Know that flu-like symptoms are common. Wear sunscreen while exposed to sunlight.

Do not stop using the medication abruptly. Do not consume grapefruit juice while on this medication. Notify the health care provider about any vision problems Rationale Carbamazepine is an antiseizure drug. The drug has adverse interactions with grapefruit juice. Grapefruit juice tends to potentiate the action of the drug and may cause overdose; therefore the nurse instructs the patient not to consume grapefruit juice when on treatment with carbamazepine. Vision problems are one of the most common side effects of the drug, so the patient should notify the health care provider if they occur. The nurse instructs the patient to not discontinue the drug abruptly because doing so can precipitate seizures. Carbamazepine does not cause photosensitivity; therefore there is no need to avoid sun exposure. The drug is not known to cause flu-like symptoms.

Which instruction would the nurse provide the patient prescribed carbamazepine for seizures? Select all that apply. One, some, or all responses may be correct. Do not stop using the medication abruptly. Wear protective clothing while exposed to sunlight. Do not consume grapefruit juice while on this medication. Notify the health care provider about any vision problems. Notify the health care provider if flu-like symptoms occur.

Decrease in glucose level Rationale There is a decrease in glucose levels in the cerebrospinal fluid in a patient with bacterial meningitis. An increase, not decrease, in neutrophils, lymphocytes, and protein levels would be related to bacterial meningitis. p. 1509

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis? Decrease in neutrophils Decrease in lymphocytes Decrease in glucose level Decrease in protein level

Propofol Rationale Propofol has a rapid-onset and short half-life and is used for anxiety and agitation in the intensive care unit (ICU). Avoid benzodiazepines such as lorazepam in the patient with increased intracranial pressure unless used with neuromuscular blocking agents. Use analgesics such as opioids, including morphine sulphate, for pain, not anxiety and agitation. A nondepolarizing neuromuscular blocking agent is a paralytic, such as cisatracurium besylate. p. 1494

Which medication has a rapid onset and short half-life and is administered to treat a patient's anxiety and agitation secondary to increased intracranial pressure? Propofol Lorazepam Morphine sulphate Cisatracurium besylate

Mannitol Rationale Mannitol is an osmotic diuretic given via IV to decrease ICP. Cimetidine is a histamine (H ) receptor blocker given to a patient receiving corticosteroids to prevent gastrointestinal ulcers and bleeding. Dexamethasone is a corticosteroid used to treat vasogenic edema. Hypertonic saline is an IV solution used to help reduce cerebral swelling. p. 1491

Which medication is an osmotic diuretic that the nurse would prepare to administer to lower a patient's intracranial pressure (ICP)? Mannitol Cimetidine Dexamethasone Hypertonic saline

IV dextrose solution Rationale: The cause of this patient's seizure is low blood glucose, so the nurse administers IV dextrose solution first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would treat seizures from other causes, such as head trauma, drugs, and infections. p. 1548

Which medication would the nurse anticipate administering the patient with type 1 diabetes mellitus who experiences a hypoglycemic event and begins to seize? V diazepam IV phenytoin Oral carbamazepine IV dextrose solution

Acyclovir Rationale Acyclovir is used to treat encephalitis caused by HSV infection. Its use reduces mortality rates, although neurologic complications may still occur. Use ampicillin and vancomycin to treat bacterial meningitis. Use dexamethasone to treat meningitis. pp. 1509,1512

Which medication would the nurse prepare to administer to a patient admitted to the hospital with a diagnosis of herpes simplex virus (HSV) encephalitis? Acyclovir Ampicillin Vancomycin Dexamethasone

Barbiturates decrease the level of cerebral metabolism. Rationale High doses of barbiturates decrease cerebral metabolism levels in patients with increased ICP and helps to reduce ICP. Corticosteroids are used to reduce vasogenic edema. Mannitol acts to decrease ICP through plasma expansion and osmotic effect. Hypertonic saline solution causes massive movement of water out of the brain cells into the blood vessels.

Which outcome would the nurse anticipate after administering a high dose of prescribed barbiturates to the patient with an increased intracranial pressure (ICP)? The medication reduces the vasogenic edema. Barbiturates decrease the level of cerebral metabolism. The drug facilitates plasma expansion and an osmotic effect. The therapy promotes massive movement of water out of brain cells.

Decreased cerebral blood flow (CBF) Rationale A MAP below 70 mm Hg results in a decreased CBF. The decreased MAP does not indicate a normal or increased ICP. The CPP decreases as a result of the diminished MAP. A MAP below 70 mm Hg does not necessarily guarantee a normal ICP. The normal range of a MAP is between 70 and 100 mm Hg. A MAP of at least 60 mm Hg is vital to provide enough blood to the coronary arteries, kidneys, and brain. p. 1484

Which physiologic effect is associated with a patient's calculated mean arterial pressure (MAP) below 70 mm Hg? Normal intracranial pressure (ICP) Increased ICP Decreased cerebral blood flow (CBF) Increased cerebral perfusion pressure (CPP)

An increase in the cerebral extracellular fluid volume occurred. Rationale Vasogenic cerebral edema mainly occurs in the white matter of the brain. In this type of cerebral edema, there is an increase in the permeability of the blood-brain barrier, which causes an increase in extracellular fluid volume. An intact blood-brain barrier is seen in cytotoxic cerebral edema. Cerebral hypoxia or decreased oxygen supply is seen in cytotoxic cerebral edema. Hydrocephalus or abnormal accumulation of cerebrospinal fluid in the brain is seen in interstitial cerebral edema. Test-Taking Tip: Recall the types of cerebral edema and changes associated with them to answer this question correctly. p. 1486

Which physiologic result would the nurse associate with a patient reporting a headache, who has disturbed consciousness, and whose imaging studies indicate cerebral edema in the white matter? An intact blood-brain barrier is present. A decreased oxygen supply to the brain exists. An increase in the cerebral extracellular fluid volume occurred. Something caused abnormal accumulations of cerebrospinal fluid in the brain.

Reduced ICP Rationale Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules to increase the uptake of water and diuresis by the kidneys, which specifically helps to relieve cerebral edema, thereby decreasing ICP, which is the priority outcome. Increased urine output, decreased BP, and increased intracranial perfusion are secondary outcomes of administration of mannitol. Of these, increased intracranial perfusion is most desirable because it reduces ICP. The nurse monitors BP closely because an extreme decrease in BP may occur, resulting in decreased intracranial perfusion. p. 1491

Which priority outcome would the nurse expect after administration of IV mannitol prescribed for a patient experiencing an increased intracranial pressure (ICP)? Increased urine output Decreased blood pressure (BP) Reduced ICP Increased intracranial perfusion

Size Shape Reactivity Movement Rationale When performing a neurologic assessment, compare the pupils for size, shape, reactivity, and movement. A visual acuity assessment determines the smallest letters viewed by the patient, but this does not provide information about neurologic functioning. Eliciting a corneal reflex provides information about cranial nerves V and VII, not neurologic functioning. p. 1493

Which pupil comparison would the nurse perform when completing a neurologic assessment of the eyes in a patient admitted with encephalitis? Select all that apply. One, some, or all responses may be correct. Size Shape Reactivity Movement Visual acuity Corneal reflex

"The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available." Rationale Patients suspected of having meningococcal meningitis should be placed in respiratory isolation until the spinal fluid cultures are negative or effective antibiotic therapy has been in place for 24 to 48 hours. Even if the patient has a diagnosis of meningococcal meningitis, discontinuing respiratory isolation occurs once effective antibiotic therapy has been in place for a specified period. The earliest release of culture reports is 24 hours. The patient will be on isolation precautions until the cultures are negative, not until discharge. There is no need to contact the health care provider because infection control policies dictate the necessity of isolation. p. 1326 p. 1511

Which response would the nurse use to reply to the family of a patient admitted 12 hours ago with suspected meningitis who states, "We do not understand. We thought the spinal tap 'looked good,' according to the health care provider. Why is everyone still wearing gowns and masks?" "I apologize. The isolation should have been discontinued." "These precautions need to be continued as long as the patient is in the hospital." "I will check with the health care provider and see whether we can get the isolation discontinued." "The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."

Decorticate posturing Rationale Decorticate posturing—described as flexion of the arms, wrists, and fingers—and adduction of the upper extremities indicate damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The described assessment findings do not specifically relate to describing a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. A nurse would describe decerebrate posturing as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing results from disruption of motor fibers in the midbrain and brainstem and indicates serious tissue damage. p. 1487

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? Stroke Epileptic seizure Decorticate posturing Decerebrate posturing

The patient will return to maximal neurologic function. Rationale The expected treatment outcome for the patient is to return to his or her maximal neurologic function after receiving treatment for meningitis. Relief of muscle aches after the treatment is an expected outcome. Recurrence of the infection after the treatment is not an expectation. The patient should not experience any discomfort while performing daily activities. p. 1510

Which treatment outcome would the nurse expect when administering antibiotic therapy and symptomatic treatment to a patient with bacterial meningitis? The patient will experience muscle aches. The patient will return to maximal neurologic function. The patient will have a chance of recurrence of infection. The patient will experience some discomfort while performing daily activities.

Ensure that the patient has a patent airway. During a tonic-clonic seizure, the patient becomes unconscious, has generalized stiffening (tonic phase), and then jerking (clonic phase). The most important nursing intervention is to maintain the patient's patent airway. Suctioning equipment should be available. Nurses do not restrain the patient but do protect the patient from injury. There are not any indications of hypoglycemia, so the nurse does not administer IV dextrose. Reorientation of the patient unconscious during the seizure is not possible. p. 1548

After receiving a local anesthesia during surgery, which intervention would the nurse implement for the patient with a history of epilepsy who experiences a tonic-clonic seizure lasting 2 minutes in the postanesthesia care unit (PACU)? Restrain the patient to prevent injury. Reorient the patient to place and time. Ensure that the patient has a patent airway. Administer 50 grams of IV dextrose.

Apomorphine and ondansetron Rationale The DA receptor agonist apomorphine can improve movement in hypomobility ("off") episodes. Patients must take it with an antiemetic drug because it causes severe nausea and vomiting when taken alone. It cannot be taken with antiemetics in the serotonin (5-HT3) receptor antagonist class (e.g., ondansetron). This combination can lead to very low BP and loss of consciousness. Amantadine does not have any drug-drug interactions with antiemetics such as ondansetron. Amantadine would not cause any side effects such as nausea and vomiting; therefore there is not a need for coadministration with an antiemetic such as trimethobenzamide. Trimethobenzamide is the preferred antiemetic coadministered with apomorphine because apomorphine causes nausea and vomiting when taken alone. p. 1563

After receiving an IV antiemetic for reported nausea and vomiting, a patient with Parkinson disease who takes a dopamine (DA) agonist medication loses consciousness from a sudden drop in blood pressure (BP). Which dopamine agonist and antiemetic medication combination would the nurse associate with the patient's response? Amantadine and ondansetron Apomorphine and ondansetron Amantadine and trimethobenzamide Apomorphine and trimethobenzamide

Seizures can be caused by an electrolyte imbalance." "Seizures can be caused by an increase in pH of the blood." "Seizures can be caused by a decrease in pH of the blood." "Seizures can be caused by a decrease in blood glucose levels. Rationale Common metabolic causes of seizures include very low glucose levels, abnormal serum electrolytes (sodium, magnesium, calcium), and acidosis (decreased pH) or alkalosis (increased pH). Hyperglycemia, which is an increase in blood glucose levels, is not associated with seizures either.

After receiving information as to how metabolic disturbances cause seizures, which statement indicates effective learning? Select all that apply. One, some, or all responses may be correct. "Seizures can be caused by an electrolyte imbalance." "Seizures can be caused by an increase in pH of the blood." "Seizures can be caused by a decrease in pH of the blood." "Seizures can be caused by a decrease in blood glucose levels." "Seizures can be caused by an increase in blood glucose levels."

"It will directly measure the pressure within the ventricles of my brain." Rationale Ventriculostomy is a gold-standard procedure for monitoring the intracranial pressure (ICP). In this procedure, the health care provider positions the catheter to measure the pressure within the ventricles. The ventriculostomy transducer is external and permits intraventricular drug administration. The procedure facilitates sampling of cerebrospinal fluid. p. 1488

After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy? "I will have an internal transducer inserted into my head." "I won't be able to have drugs instilled through this procedure." "It will directly measure the pressure within the ventricles of my brain." "The health care provider won't be able to get samples of my cerebrospinal fluid."

Lamotrigine Gabapentin rationale: Older adult patients experience age-related changes in their liver enzymes, which decrease the ability of the liver to metabolize medications. Lamotrigine and gabapentin are newer antiseizure medications that have fewer interactions with other drugs. Hence these are safe for administration to older adults. The liver metabolizes phenytoin, so an older adult's impaired liver function may not metabolize the drug completely. Primidone and carbamazepine have significant drug interactions and should be avoided when the patient is an older adult. p. 1551

For the older adult patient with impaired liver functions who is suspected of sustaining a recent seizure, which antiseizure medication would the nurse anticipate administering? Select all that apply. One, some, or all responses may be correct. Phenytoin Primidone Lamotrigine Gabapentin Carbamazepine

Prevent the complication of pressure injuries. Prevent the complication of urinary tract infections. Rationale A patient experiencing an acute exacerbation of multiple sclerosis may be immobile and confined to bed. The first nursing interventions in this phase target the prevention of major complications associated with immobility. Pressure injuries may occur due to the immobility of the patient while confined to the bed. The nurse implements immediate care to prevent this. Urinary tract infections are also common due to the stagnation of urine. Assisting the patient with the grieving process is an important intervention during the diagnostic phase of multiple sclerosis but is not applicable to a patient with an acute exacerbation of the disease. Teaching the patient to build general resistance to illness is a general intervention for a patient suffering from multiple sclerosis. Teaching the patient to maintain a good balance between exercise and rest is a general intervention for a patient with multiple sclerosis but is not applicable for patients who are immobile. p. 1560

During an acute exacerbation of the patient's multiple sclerosis, which intervention would the nurse implement? Select all that apply. One, some, or all responses may be correct. Assist the patient with the grieving process. Prevent the complication of pressure injuries. Prevent the complication of urinary tract infections. Teach the patient to build a general resistance to illness. Teach the patient to maintain a good balance between exercise and rest.

There is no cure for Huntington disease. The onset of disease usually occurs between 30 and 55 years of age. The son will develop a progressive, degenerative brain disorder. Rationale Huntington disease is an autosomal dominant disorder caused by a mutation in the HTT gene located on chromosome 4. Genetic testing, or DNA testing, is useful in diagnosing the disease but is not helpful in predicting the onset of symptoms. There is no cure for the disease. The onset of disease usually occurs between 30 and 55 years of age. Huntington disease is a progressive, degenerative brain disorder. The symptoms of behavioral problems and movement disorder can be controlled with drugs. Negative test results would indicate that the person does not carry the mutated gene and will not develop the disease. p. 1569

For the family members of a patient with Huntington disease (HD), which inference would the nurse associate with a positive genetic test result for the patient's son? Select all that apply. One, some, or all responses may be correct. There is no cure for Huntington disease. Drugs are not available to control the movement and behavioral problems. The onset of disease usually occurs between 30 and 55 years of age. The son will develop a progressive, degenerative brain disorder. The son will be a carrier of the mutated gene but will not develop the disease.

Fluid intake Rationale Because high fever increases the metabolic rate and insensible fluid loss, the nurse would assess the patient for dehydration and adequacy of fluid intake. Elevated temperatures may alter a patient's urine output, BP, and respiratory rate, but monitoring these parameters would not help to prevent any complications in a patient with meningitis. p. 1511

For the febrile patient diagnosed with meningitis, which parameter would the nurse monitor to prevent development of potential complications? Fluid intake Urine output BP Respiratory rate

Gabapentin Levetiracetam Oxcarbazepine Rationale Brain tumors can cause tonic-clonic seizures. Headaches, confusion, and altered consciousness are the clinical signs of tonic-clonic seizures. Gabapentin, levetiracetam, and oxcarbazepine are the safest medications for older adults because these drugs have fewer effects on cognitive function when compared to others. Primidone and carbamazepine potentially affect cognitive function; therefore these medications are contraindicated for older adults. p. 1551

For the older adult with a brain tumor, which medication would the nurse anticipate for the treatment of associated headache symptoms, confusion, and altered levels of consciousness reported by the family? Select all that apply. One, some, or all responses may be correct. Primidone Gabapentin Levetiracetam Oxcarbazepine Carbamazepine

Plan activities with periods of rest. Eat a balanced diet, promoting easily chewed items. Schedule medications so their peak effect is at mealtime. Rationale The discharge teaching should focus on neurologic deficits and their effect on daily living. The nurse teaches the patient about a balanced diet composed of easily chewed and swallowed items. The nurse helps the patient to plan activities of daily living to avoid fatigue. Scheduling doses of drugs so peak action occurs at mealtime may make eating less difficult. Semisolid foods may be easier to eat than solids or liquids. Diversional activities that require little physical effort and match the patient's interests should be arranged. Playing golf may be too exhausting.

For the patient diagnosed with myasthenia gravis, which instruction would the nurse include in the patient's discharge teaching plan? Select all that apply. One, some, or all responses may be correct. Plan activities with periods of rest. Practice hobbies such as playing golf. Include liquid rather than solid foods in the diet. Eat a balanced diet, promoting easily chewed items. Schedule medications so their peak effect is at mealtime.

Phenytoin Carbamazepine Divalproex Rationale Characteristics of tonic-clonic seizures include continuous muscle contractions and loss of consciousness. The main drugs to treat tonic-clonic seizures are phenytoin, carbamazepine, and divalproex. Ethosuximide, clonazepam, and divalproex are used to treat generalized onset nonmotor and myoclonic seizures. p. 1548

For the patient receiving emergency treatment for continuous muscle contractions and loss of consciousness secondary to head trauma, which medication would the nurse anticipate administering? Select all that apply. One, some, or all responses may be correct. Phenytoin Carbamazepine Ethosuximide Divalproex Clonazepam

Improved muscle contractibility during an edrophonium test Decreased response to repeated stimulation of hand muscles during electromyography (EMG) test Rationale Patients with myasthenia gravis experience improved muscle contractibility after IV administration of the anticholinesterase agent edrophonium chloride. This test aids in diagnosis of myasthenia gravis. EMG testing may show a decreased response to repeated stimulation of muscles in the hands, which would indicate muscle fatigue. Single-fiber EMG is a confirmative test for myasthenia gravis. The alteration of one copy of a gene in a DNA test is a diagnostic test for Huntington disease, a genetically transmitted autosomal dominant disorder. The presence of TRAP is classic of Parkinson's disease and includes tremor, rigidity, akinesia, and postural instability; it is a confirmed diagnostic test for Parkinson disease. Increased immunoglobulin G levels in the cerebrospinal fluid during CSF analysis test confirms multiple sclerosis, not myasthenia gravis.

For the patient reporting difficulty with eye and eyelid movement, chewing, swallowing, speaking, and breathing, which diagnostic finding would the nurse associate with myasthenia gravis? Select all that apply. One, some, or all responses may be correct. Alteration of one copy of gene in DNA testing Improved muscle contractibility during an edrophonium test Presence of TRAP: tremor, rigidity, akinesia, and postural instability Decreased response to repeated stimulation of hand muscles during electromyography (EMG) test Increased immunoglobulin G levels in the cerebrospinal fluid (CSF) during CSF analysis test

Nystagmus or confusion Rationale Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, and palpitations are not associated with phenytoin toxicity. Test-Taking Tip: Be aware that information from previously asked questions may help you to respond to other examination questions. p. 1551

For the patient who receives scheduled doses of phenytoin and begins to experience diplopia, the nurse would immediately determine the presence of which clinical manifestation? An aura or focal seizure Nystagmus or confusion Abdominal pain or cramping Irregular pulse or palpitations

Subclinical seizure Rationale : Subclinical seizures are a form of status epilepticus in which a sedated patient seizes but there are no external signs because of sedative use. In atonic seizures, the external signs like paroxysmal loss of muscle tone are visible. In myoclonic seizures, the patient may have sudden and excessive jerks of the body. In tonic-clonic seizures, the skin feels warm and has visible symptoms of cyanosis.

For the patient who sustained a head trauma and is sedated and on a ventilator, which type of seizure might this patient experience? Atonic seizure Myoclonic seizure Subclinical seizure Tonic-clonic seizure

CN III Rationale Compression of CN III, the oculomotor nerve, is a result of the brain shifting from midline, compressing the trunk of CN III and paralyzing the muscles controlling pupillary size and shape. Irritation of CN V results in sensory losses and loss of the corneal reflex. Irritation of CN VII results in facial paresis. Irritation of CN VIII causes tinnitus, vertigo, and deafness. p. 1509

For the patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression? CN III CN V CN VII CN VIII

Cut food into bite-size pieces. Serve foods the patient finds appetizing. Include whole grains and fruits in the diet Rationale A well-balanced diet is important for patients with PD. Malnutrition and constipation can result from poor nutrition. Patients who have dysphagia and bradykinesia need appetizing foods that are easy to chew and swallow. Food should be cut into bite-sized pieces. The diet should have adequate fiber, such as grains and fruit, to reduce constipation. Protein ingestion can impair the absorption of levodopa, the most common drug used in the treatment of PD. Limiting protein intake to the evening meal can decrease this problem. Eating six small meals a day may be less tiring than eating three large meals a day. p. 1566

For the patient with Parkinson disease (PD), which dietary adjustment would the nurse include in the plan of care to prevent malnutrition and constipation? Select all that apply. One, some, or all responses may be correct. Cut food into bite-size pieces. Serve foods the patient finds appetizing. Include whole grains and fruits in the diet. Include plenty of food items high in protein. Provide three large meals rather than six small meals

"I will refrain from drinking alcohol." "I will wear a helmet while riding a bike." "I will maintain adequate sleep and rest schedules." Rationale Good general health habits are helpful for patients who have a seizure disorder. Patients with a seizure disorder should exercise regularly. Loss of sleep is one of the factors that may aggravate the condition of the patient with a seizure disorder. Therefore adequate sleep is very important for these patients. Alcohol consumption can cause liver damage. Patients with a seizure disorder should refrain from drinking alcohol to prevent aggravation of this condition. Patients with seizure disorders are more prone to accidents. Therefore wearing a helmet will reduce the risk of head injury. Driving laws for patient with seizure disorders vary between states. Some require a three-month seizure-free period, while others require up to one year before issuing or reissuing a driver's license, but never being able to drive again is not an absolute in this situation.

For the patient with a seizure disorder and a history of diabetes mellitus, which statements indicate understanding of safety measures taught by the nurse? Select all that apply. One, some, or all responses may be correct. "I will refrain from drinking alcohol." "I will wear a helmet while riding a bike." "I will refrain from doing physical exercises." "I will not be able to drive a motorized vehicle anymore." "I will maintain adequate sleep and rest schedules."

Keep suction equipment readily available at the patient's bedside. Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first 7 days after injury. Rationale Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Using padded side rails helps to prevent injury from falling. Prophylactic antiseizure therapy is used during the first 7 days after injury to prevent seizures. Providing stimulation to the patient may aggravate the condition; therefore the environment should be quiet. Seizure treatment should be used prophylactically. The patient with increased ICP and decreased level of consciousness (LOC) needs protection from self-injury, so placing the patient on seizure precautions instead of waiting for the confirmation of diagnosis or the seizures to occur is appropriate. p. 1495

For the patient with an increased intracranial pressure (ICP), which precaution would the nurse implement to protect the patient from potential seizure activity? Select all that apply. One, some, or all responses may be correct. Keep suction equipment readily available at the patient's bedside. Provide sufficient stimulation of the patient to avoid comatose behaviors. Place the patient on seizure precautions after confirming the seizure diagnosis. Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first 7 days after injury.

Administer IV 0.9% sodium chloride and 5% glucose (dextrose) Rationale Hypoglycemia can cause tonic-clonic seizures in some patients. In such cases, nurses treat the underlying cause of the seizure first, followed by the administration of antiseizure drugs if necessary. Therefore the nurse would administer dextrose immediately to reverse the hypoglycemia. IV administration of saline corrects fluid and electrolyte imbalance in patients with fluid volume deficits. Nurses administer IV diazepam to patients with status epilepticus. If the symptoms do not subside after treating the underlying cause of a seizure, oral administration of gabapentin may be necessary. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly because there usually is no pattern to the answers. p. 1548

For the patient with hypoglycemia who has experienced a suspected seizure, which IV intervention would the nurse implement immediately? Administer IV push (IVP) of diazepam Administer IV push (IVP) of gabapentin Administer IV 0.9% sodium chloride injection (normal saline) Administer IV 0.9% sodium chloride and 5% glucose (dextrose)

Attended the funeral of a family member earlier in week Took an antibiotic prescribed for a urinary tract infection Was diagnosed with urinary tract infection the previous week Omitted pyridostigmine on the previous day rationale Myasthenia gravis is an autoimmune disease in which destruction of acetylcholine receptors occurs at the neuromuscular junction. Patients experience muscular weakness that improves with rest. A myasthenia crisis is an acute exacerbation of muscle weakness that often involves the respiratory muscles. Precipitation of exacerbations and crises occurs from many factors, including infection (patient's urinary tract infection), emotional stress (funeral of family member), reaction to medications (antibiotic prescribed for urinary tract infection), and inadequate anticholinesterase medications. Pyridostigmine is an anticholinesterase medication that prolongs acetylcholine present in the neuromuscular junction to improve muscle strength. Taking corticosteroid medications as prescribed suppresses immunity to decrease the myasthenic effect of muscular weakness. Lying

For the patient with myasthenia gravis, which factor experienced in the patient's current life likely led to the development of a myasthenic crisis and respiratory failure that required admission to the hospital? Select all that apply. One, some, or all responses may be correct. Attended the funeral of a family member earlier in week Took an antibiotic prescribed for a urinary tract infection Was diagnosed with urinary tract infection the previous week Omitted pyridostigmine on the previous day Consistently took prescribed corticosteroid every other day Laid down for a nap in a personal recliner after the noon meal each day

Patient C Rationale Patient C, who sustains no jerking and a sudden loss of muscle tone, may have atonic seizures. Because atonic seizure onset is sudden, patients are at a greater risk of sustaining a head injury. Patient A, who experiences excessive jerking of the extremities and increased muscle tone, may have myoclonic seizures. Clonic seizures may occur in patient B, who experiences a sudden loss of muscle tone, followed by limb jerking. Patient D, who has increased muscle tone and no jerks, may have tonic seizures. p. 1546

From the data provided on four patients with a history of seizures, which patient has the highest risk for sustaining a head injury? Patient A Patient B Patient C Patient D

The patient diagnosed with encephalitis Rationale Encephalitis is a cerebral viral infection that can cause cerebral edema. A thrombosis is a blood clot in the circulatory system. A contusion is bruising. Hydrocephalus is the buildup of cerebrospinal fluid (CSF) in the brain. A thrombosis, a contusion, and hydrocephalus are not related to an infection. pp. 1485,1512

Of the four assigned patients in the intensive care unit (ICU), which patient with an infection has the highest risk for developing cerebral edema? The patient diagnosed with encephalitis The patient experiencing cerebral thrombosis The patient who sustained a contusion from a fall The patient with hydrocephalus from a malfunctioning shunt

Pregabalin Rationale Pregabalin is an added treatment for focal aware or impaired awareness seizures not successfully controlled with one medication. Divalproex, lamotrigine, and levetiracetam are common antiseizure drugs also used to treat focal seizures but not as an additional medication paired with carbamazepine. p. 1548

When determining that the prescribed carbamazepine for focal seizures is ineffective, which medication, in addition to the carbamazepine, would the nurse anticipate the health care provider will add to the patient's medication list? Divalproex Pregabalin Lamotrigine Levetiracetam

BP of 148/58 mm Hg and pulse 48 beats/min Rationale The nurse would associate a BP with a widening pulse pressure, bradycardia, and irregular respirations with an increasing intracranial pressure (ICP) known as the Cushing triad, which should be reported immediately. Presence of a gag reflex, urine output of 50 mL over an hour, and a temperature of 99.8°F (37.6°C) and pulse of 96 beats/min are acceptable assessment findings in a postoperative patient. p. 1487

The initial assessment of a patient in the postanesthesia care unit recovering from a brain tumor resection included a temperature of 100°F (37.7°C), blood pressure (BP) of 130/76 mm Hg, pulse of 64 beats/min, a urinary catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One hour later, which assessment finding would the nurse immediately report to the health care provider? Presence of a gag reflex Urine output of 50 mL during the past hour BP of 148/58 mm Hg and pulse 48 beats/min Temperature of 99.8°F (37.6°C) and pulse of 96 beats/min

Rationale In order, tissue edema occurs and causes reduced blood flow in the cerebellum. The increased cranial pressure leads to decreased oxygen delivery and death of brain cells. The compression of ventricles and blood vessels ultimately causes compression of the brainstem and respiratory center. p. 1485

When explaining neurologic pathophysiology to a group of nursing students, the nurse describes the progression of increased intracranial pressure in which chronologic order? order is correct

BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are irregular. Rationale Late signs of increased intracranial pressure include an increased systolic BP and decreasing diastolic BP (widening pulse pressure), bradycardia, and irregular respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing triad and require immediate intervention. A sleeping patient who awakens in response to painful stimuli; not remembering what happened; and a BP of 110/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min do not necessarily indicate deterioration in the patient's condition. p. 1487

The patient admitted with a closed head injury is awake but lethargic, and the baseline vital signs include a blood pressure (BP) of 120/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min. Which finding indicates deterioration of the patient's condition 2 hours later? The patient is sleeping but awakens in response to painful stimuli. The patient does not remember what happened during the 6 hours prior to the injury. BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are 20 breaths/min. BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are irregular.

Allow adequate time for the patient to eat six small meals a day. Rationale Eating six small meals a day may be less tiring than eating three large meals a day and improve overall intake. Plan ample time for eating to avoid frustration. Foods should be easily chewable and dissected into small bites to increase the overall intake. Protein impairs the absorption of levodopa, so the best practice is to avoid large amounts of protein when administering carbidopa/levodopa. Eating every 2 hours would exhaust the patient. pp. 1565-1566

The patient with Parkinson disease lost 35 pounds (15.9 kg) over the last 2 months, and a swallow study indicates ability to swallow without aspiration. Which intervention would the nurse discuss with the patient and spouse to improve nutritional intake? Include chewy foods so that the patient builds up the jaw muscles. Administer prescribed carbidopa/levodopa with a protein drink. Allow adequate time for the patient to eat six small meals a day. Encourage the patient to eat at least every 2 hours while awake.

Have the patient wear slip-on shoes. Provide the patient with an elevated toilet seat. Encourage the patient to elevate the legs on an ottoman when sitting. Rationale To promote self-care and independence of the patient, family members should identify potential changes in the home environment. The patient should use slip-on shoes because the patient can easily put them on or taken them off. Elevated toilet seats help with getting on and off the toilet easily. Patients should elevate legs on an ottoman prevents ankle edema. Family members should remove rugs because they can cause the patient to fall. Hooks and buttons as clothing fasteners may be difficult for the patient to use; instead, use clothing with hook-and-loop (Velcro) fasteners or zippers. p. 1566

To promote self-care and independence in patients with Parkinson disease, which intervention would the nurse provide family members? Select all that apply. One, some, or all responses may be correct Have the patient wear slip-on shoes. Provide the patient with an elevated toilet seat. Use rugs on the floor to keep the patient's feet warm. Examine the patients clothing and use items with buttons and hooks. Encourage the patient to elevate the legs on an ottoman when sitting.

Impaired facial mobility Difficulty in swallowing food Voice fading after a long conversation Rationale Myasthenia gravis characteristics include a fluctuating weakness of skeletal muscles. The patient may have impaired facial mobility and expressions. Chewing and swallowing food may become difficult. The disease may affect the patient's speech as the voice fades after a long conversation. Apart from the muscle weakness, there is no other dysfunction such as muscle atrophy or abnormal reflexes. p. 1566

When performing a physical assessment of a patient with myasthenia gravis, which clinical manifestation would the nurse likely identify? Select all that apply. One, some, or all responses may be correct. Muscle atrophy Abnormal reflexes Impaired facial mobility Difficulty in swallowing food Voice fading after a long conversation

"Are you able to sleep well and feel rested?" Rationale RLS is a condition in which patients experience paresthesias, including numbness, tingling, pain, and restlessness in one or both legs. The condition occurs commonly at night, interferes with the patient's ability to sleep, and contributes to daytime fatigue. The nurse would ask if the patient sleeps well and feels rested. The professional term for calf pain occurring with walking is intermittent claudication and is a symptom of peripheral vascular disease. A temporary episode of paralysis describes a transient ischemic attack (TIA), a precursor to a stroke. Raynaud disease occurs in persons with connective tissue conditions and involves vasospasms in response to cold. The legs become pale, then cyanotic, and often reddened post vasospasm. The episodes are painful. p. 1554

Upon review of a patient's medical history, which question would the nurse ask the patient with a history of restless legs syndrome (RLS)? "Are you able to sleep well and feel rested?" "Do you experience calf pain after walking a block?" "Do you experience episodes where you are unable to move one leg?" "When exposed to cold, do your legs turn pale, then blue, and become painful?"

Pain and agitation may elevate the patient's ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return. Rationale Pain and agitation cause rapid movements, which may increase the ICP. Extreme hip flexion may raise the intraabdominal pressure, which increases the ICP. Increased intrathoracic pressure may increase ICP by impeding venous return. Elevation of the head of the bed promotes drainage from the head, decreases vascular congestion, and therefore decreases ICP. Slow and gentle movements will provide comfort to the patient and will not increase the ICP. Test-Taking Tip: Be alert for details about what you asked to do. In this question type, the request was to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1495

When a plan of care is developed for a patient with an elevated intracranial pressure (ICP), which factor guides the nursing interventions? Select all that apply. One, some, or all responses may be correct. Pain and agitation may elevate the patient's ICPs. Elevating the head of the patient's bed increases ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return. Slow and gentle movements exhaust the patient's energy reserve.

A brief staring spell Rationale: The patient experiencing an absence seizure displays a sudden onset of a brief staring spell that resembles daydreaming and sudden recovery. It often goes unnoticed because it lasts less than 10 to 20 seconds. Usually, the patient is unresponsive when spoken to during the seizure. Dizziness and intense anxiety are not commonly associated with absence seizures. Stiffening of the body is the tonic phase associated with a tonicclonic seizure, not an absence seizure. p. 1546

When assessing a patient for the presence of an absence seizure, which classic sign would the nurse associate with this disorder? Dizziness Intense anxiety Stiffening of the body A brief staring spell

5 to 15 mm Hg Rationale A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 20 mm Hg is abnormal. p. 1484

When assessing a patient's intracranial pressure (ICP) after sustaining a head trauma, which normative value would the nurse utilize to compare the assessment data? 5 to 15 mm Hg 25 to 35 mm Hg 45 to 60 mm Hg 80 to 120 mm Hg

Limb weakness Difficulty swallowing Slurred speech Rationale ALS is a rare, progressive neurologic disorder characterized by loss of motor neurons. Progressive muscle weakness and atrophy are the classic sign of ALS. Early symptoms of weakness vary. Some have "limb-onset ALS," initially affecting the arms or legs. People may have trouble with tasks requiring fine motor skills (e.g., writing, typing) or notice they are tripping, dropping things, or stumbling more often. Those who first have problems with slurred speech or swallowing have "bulbar onset" ALS. Muscle wasting and involuntary contractions and twitching result from the denervation of the muscles and lack of stimulation and use. Other symptoms include pain, sleep disorders, spasticity and hyperreflexia, drooling, emotional lability, constipation, and esophageal reflux. Eventually the patient may not be able to communicate. As the ability to move decreases, swallowing is impaired, leading to aspiration. ALS does not affect intelligence but affected people may have problems with decision making and memory. Death often results from compromised respiratory function due to muscle weakness and paralysis. Twisting movements of the face and involuntary movements of the body do not occur in ALS.

When performing a physical assessment on a patient with amyotrophic lateral sclerosis (ALS), which clinical manifestation would the nurse identify? Select all that apply. One, some, or all responses may be correct. Limb weakness Difficulty swallowing Slurred speech Twisting movements of the face Involuntary movements of the body

Drooling of saliva Decreased arm swing Shuffling, propulsive gait Rationale The patient may manifest drooling of saliva; a shuffling, propulsive gait; and decreased arm swing. These symptoms are due to the combination of tremors, rigidity of muscles, and bradykinesia. Parkinson disease does not have clinical manifestations of patchy blindness (migraine headaches) or nystagmus. p. 1562

When performing a physical examination of a patient with Parkinson disease, which associated clinical manifestation would the nurse likely identify? Select all that apply. One, some, or all responses may be correct. Nystagmus Patchy blindness Drooling of saliva Decreased arm swing Shuffling, propulsive gait

Rationale The first step is determining that the ICP is above the prescribed/desired level. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. After opening the stopcock, allow CSF to drain for 2 to 3 minutes to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step. The nurse always maintains strict aseptic techniques when performing this intervention. p. 1490

When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid? Order in picture is correct

Provide the patient a quiet and calm environment. Minimize procedures that potentially produce agitation. Observe the patient for signs of agitation or irritation and intervene. Rationale When managing the patient with increased ICP, the environment should be quiet and calm to provide minimal stimulation to the patient. Procedures that can produce agitation should avoided. The nurse would observe the patient for signs of agitation or irritation. The nurse would decrease the stimulation levels and instruct the patient's family to reduce stimulation and noise, including not visiting too frequently.

When planning the care for a patient with an increased intracranial pressure (ICP), which intervention would the nurse integrate to provide comfort? Select all that apply. One, some, or all responses may be correct. Provide the patient a quiet and calm environment. Minimize procedures that potentially produce agitation. Encourage the patient's family to increase patient interactions. Facilitate an increased number of family visits to the patient. Observe the patient for signs of agitation or irritation and intervene.

Provide palliative care as the collaborative approach. Provide a fluid diet, including enteral or parenteral nutrition to meet caloric needs. Provide a comfortable environment by maintaining physical safety. Provide documents for the patient to determine personal advance directives. Rationale There is no cure for HD, so the collaborative care would be palliative. Providing a fluid diet may help the patient to swallow more easily and prevent complications such as aspiration. As the disease progresses, provide enteral or parenteral nutrition to meet caloric needs. Maintain physical safety for the patient and caregiver by providing a comfortable environment. End-of-life issues such as artificial methods of feeding, advance directives, use of antibiotics to treat infections, and guardianship need to be discussed with the patient and caregiver. Address these topics throughout the course of the disease as the patient and caregiver adapt to increasing disability. Choreic movements are the clinical manifestations of HD, and caloric requirements can be as high as 4000 to 5000 calories/day to maintain a patient's body weight. The patient is not in danger of becoming obese as the chorea demands a high-caloric requirement.

When providing care for a patient with advanced Huntington disease (HD), which intervention would the nurse implement? Select all that apply. One, some, or all responses may be correct. Provide palliative care as the collaborative approach. Provide a fluid diet, including enteral or parenteral nutrition to meet caloric needs. Provide a comfortable environment by maintaining physical safety. Provide documents for the patient to determine personal advance directives. Provide a low-calorie diet, not more than 2000 calories/day to prevent weight gain

Do not stop the drug abruptly without consulting the health care provider. Rationale: Phenytoin is an antiseizure drug. Abrupt withdrawal of the drug after long-term use may precipitate seizures; therefore the patient should not stop the drug without consulting the health care provider. Unusual hair growth and gingival hyperplasia are side effects of antiseizure drugs and are not relevant in preventing precipitation of seizures. Maintaining a healthy lifestyle is a general measure to keep healthy and may not contribute to prevention of precipitation of seizures. p. 1542

When visiting a patient prescribed phenytoin for seizures, which instruction would the nurse provide the patient to prevent precipitation of seizures? Notify the health care provider about unusual hair growth. Practice good dental hygiene to control gingival hyperplasia. Maintain a healthy lifestyle with regular exercise and nutritious diet. Do not stop the drug abruptly without consulting the health care provider.

Brush your teeth at least twice per day. Rationale To prevent gingival hyperplasia, the patient should brush twice per day with a soft-bristled toothbrush and visit the dentist twice per year. This condition does not indicate the need for an antifungal solution. p. 1553

Which action would the nurse instruct the patient to perform when prescribed phenytoin for seizures? Visit a dentist annually. Use a firm-bristle toothbrush. Brush your teeth at least twice per day. Rinse with an oral antifungal solution twice per day.

Administer codeine for head and neck pain. Collect specimens for a culture to confirm the diagnosis of bacterial meningitis. Initiate antibiotic therapy after obtaining a specimen but prior to confirming diagnosis. rationale Patients with bacterial meningitis may have severe head and neck pain. Codeine provides some pain relief without undue sedation for most patients. Collecting specimens to confirm the diagnosis and administering antibiotics after the specimens are collected are the measures that must be taken immediately because bacterial meningitis is a medical emergency. Waiting and watching until the fever reduces and the additional symptoms of meningitis appear and waiting for a confirmed diagnosis before starting antibiotics are not advisable because they may aggravate the condition and become life-threatening. pp. 1510-1511

Which action would the nurse take when caring for a patient who is diagnosed with bacterial meningitis? Select all that apply. One, some, or all responses may be correct. Administer codeine for head and neck pain. Wait and watch until the fever lowers or additional symptoms begin to appear. Collect specimens for a culture to confirm the diagnosis of bacterial meningitis. Wait for a confirmed diagnosis of bacterial meningitis before starting antibiotics. Initiate antibiotic therapy after obtaining a specimen but prior to confirming diagnosis.

Smacking of the lips Rationale: Smacking of the lips, picking at clothes, or other repetitive, purposeless actions (automatisms) are characteristic features seen only in focal-onset seizures. While jerking of the limbs and increased muscle tone can occur in focal-onset seizures, they occur in other types of seizures, too. Loss of consciousness is not associated with focal-onset seizures.

Which clinical manifestation is exclusive to a focal-onset seizure? Jerking of the limbs Smacking of the lips Loss of consciousness Increased muscle tone

Numbness and tingling in the legs Leg pain localized to the calf muscles Sensation like bugs creeping on the legs Rationale: On assessment of the patient with Willis-Ekbom disease, also known as restless leg syndrome, the nurse may find that the patient has numbness and tingling in the legs. Pain may occur in the legs, usually localized to the calf muscles. The patient may have uncomfortable and annoying sensations, such as if bugs were creeping on the legs. The discomfort occurs when the patient is sedentary and is most common in the evening or at night. p. 1554

Which clinical manifestation would the nurse expect to identify during data collection and assessment of a patient admitted to an acute care facility with Willis-Ekbom disease? Select all that apply. One, some, or all responses may be correct. Numbness and tingling in the legs Discomfort that occurs during activity Leg pain localized to the calf muscles Sensation like bugs creeping on the legs Occurrence of symptoms mostly in the morning

Blurred vision Vomiting Decreased level of consciousness Rationale Blurred vision, vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant. p. 1504

Which clinical manifestation would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt? Select all that apply. One, some, or all responses may be correct. Cough Blurred vision Gaseous distention Vomiting Decreased level of consciousness

Positive response to antiparkinsonian medications Presence of two of the four classic features: rigidity, bradykinesia, tremor, and postural instability Rationale No specific diagnostic test exists for PD. The diagnosis is based on the history and clinical features. Clinical diagnosis requires the presence of two of the four main manifestations (tremor, rigidity, bradykinesia, and postural instability) and asymmetric onset. Disease is confirmed with a positive response to antiparkinsonian drugs (levodopa or dopamine (DA) agonist). Tumors of the thymus gland are associated with myasthenia gravis, not PD. MRI and CT are usually normal in PD. The cause of PD is decreased, not increased, dopamine levels in the brain. p. 1563

Which criterion would the nurse associate with the health care provider's diagnosis of Parkinson disease (PD)? Select all that apply. One, some, or all responses may be correct. Increased dopamine levels Tumor present in the thymus gland Positive response to antiparkinsonian medications MRI showing areas of plaque on cranial nerves Presence of two of the four classic features: rigidity, bradykinesia, tremor, and postural instability

Bacterial meningitis Rationale The normal range of WBC count is 0 to 5 cells/μL, the normal range of protein is 15 to 45 mg/dL, and the normal range of glucose is 50 to 77 mg/dL in the CSF. An increased WBC count >1000 cells/μL, increased protein >500 mg/dL, and decreased glucose are signs of bacterial meningitis. A patient with a brain abscess would have an increased WBC count, normal protein levels, and a decrease or absence of glucose. In viral meningitis, the CSF reflects an increased WBC count of 25 to 500 cells/μL and protein level of 50 to 500 mg/dL, along with decreased or absent glucose. In viral encephalitis, the CSF reflects an increased WBC count, slightly increased protein level, and normal glucose levels.

Which diagnosis would the nurse associate with a patient's cerebrospinal fluid (CSF) culture findings of a white blood cell (WBC) count of 1200 cells/μL, protein 600 mg/dL, and glucose 25 mg/dL? Brain abscess Viral meningitis Viral encephalitis Bacterial meningitis

Include chicken and lean meat in your diet. Include whole grains, potatoes, and cereals in the diet. Divide your three main meals into small, frequent feedings. Rationale As a part of home care, the nurse would provide instructions regarding the importance of adequate nutrition, with an emphasis on a high-protein and high-calorie diet. Chicken and lean meats are good sources of protein and should be an important component of the meal. Whole grains, potatoes, and cereals are packed with calories and should be included in the diet. The meals should be small and given more often at frequent intervals. Peanuts and peanut butter should also be included in the diet because they are good sources of protein and are calorie dense. Alcohol and caffeinated beverages should be excluded from the diet.

Which dietary discharge instruction would the nurse provide a patient recovering from meningitis? Select all that apply. One, some, or all responses may be correct. Include chicken and lean meat in your diet. Avoid eating peanuts, peanut butter, or peanut oils. Include whole grains, potatoes, and cereals in the diet. Divide your three main meals into small, frequent feedings. Consume moderate quantities of alcohol and caffeinated beverages.

A diet with high fats and low carbohydrates Rationale A ketogenic diet is a special high-fat, low-carbohydrate diet that helps control seizures in some people. A person on this diet makes ketones that pass into the brain, where they replace glucose as an energy source. Meals are carefully planned to restrict the amount of protein and carbohydrate. A diet with low fats and low carbohydrates is not part of a ketogenic diet. A ketogenic diet also does not contain low fats and high carbohydrates. Similarly, a diet with high fats and high carbohydrates is not a ketogenic diet.

Which dietary recommendation would the nurse share as a means of controlling seizures in some patients? A diet with low fats and low carbohydrates A diet with low fats and high carbohydrates A diet with high fats and low carbohydrates A diet with high fats and high carbohydrates

Multiple sclerosis Lhermitte sign is a transient sensory symptom manifested in patients with multiple sclerosis and is described as an electric shock radiating down the spine or into the limbs with flexion of the neck. Myasthenia gravis does not manifest as sensory loss. Lou Gehrig disease, or amyotrophic lateral sclerosis, is a degenerative disorder of motor neurons and does not exhibit characteristics related to sensory loss. Characteristics of Huntington disease include motor, cognitive, and psychiatric disorders, but there is no sensory loss. p. 1557

Which disease process includes Lhermitte sign as a clinical manifestation? Multiple sclerosis Myasthenia gravis Lou Gehrig disease Huntington disease

Restless legs syndrome (RLS) Rationale: Paresthesia, tingling, and a pins-and-needles sensation and pain at night are clinical signs of RLS. The antiseizure drugs gabapentin, enacarbil, or pregabalin are first-line drugs for RLS. They may decrease the sensory sensations and nerve pain. A patient who sustains a stroke will present with one-sided weakness. This is not a symptom of RLS. Epilepsy and status epilepticus do not present with paresthesias, tingling, and pinsand-needles sensations. A patient with epilepsy may have jerking movements and muscle rigidity. A patient with status epilepticus can experience hypoxia and arrhythmias.

Which disorder does the nurse suspect for a patient reporting paresthesia, tingling, and a pins-and-needles sensation and pain at night for which the health care provider prescribes gabapentin? Stroke Epilepsy Status epilepticus Restless legs syndrome (RLS)

Posture Suctioning Hypoxemia Intraabdominal pressure Rationale Posture, suctioning, hypoxemia, and intraabdominal pressure all influence ICP. Swallowing does not affect ICP. Drowsiness may be a sign of increased ICP, but it does not influence it. pp. 1494-1495

Which factor would the nurse associate with influencing a patient's intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. Posture Swallowing Drowsiness Suctioning Hypoxemia Intraabdominal pressure

Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Follow protocol standards to maintain a head-up position for the patient. Rationale The nurse should take care to prevent extreme neck flexion of the patient because it can cause venous obstruction and contribute to elevated ICP. The nurse would position the patient's body to decrease ICP and improve the cerebral perfusion pressure (CPP). Maintaining a head-up position for the patient is important because elevation of the head of the bed promotes drainage and decreases the vascular congestion that can produce cerebral edema. The patient avoids extreme hip flexion to decrease the risk for raising the intraabdominal pressure, which increases ICP. Rotating the patient to a side-lying position may further increase the ICP. Special air beds can alternate skin pressures to prevent tissue damage. pp. 1494-1495

Which factor would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. Maintain the patient's hips in flexed position while lying on the side. Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Rotate the patient to a side-lying position to prevent skin breakdown. Follow protocol standards to maintain a head-up position for the patient.

Herpes simplex virus (HSV) encephalitis Rationale HSV encephalitis is the most common cause of acute nonepidemic viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western equine cause epidemic encephalitis. p. 1511

Which inflammatory condition would the nurse associate with the common cause of acute nonepidemic viral encephalitis? St. Louis encephalitis Eastern equine encephalitis Western equine encephalitis Herpes simplex virus (HSV) encephalitis

Ease the patient to the floor. Loosen constrictive clothes. Protect the patient from any injury Rationale: During an acute seizure, the most important thing is to ease the patient to the floor, if seated, and loosen constrictive clothing. The caregiver should protect the patient from any potential injury. The chances of injury are higher if restraining the patient. It is not necessary to bring the patient to the hospital immediately. Once the seizures have stopped and the patient becomes stable, then the caregiver transports the patient to the hospital. p. 1552

Which information would the nurse provide the caregiver of a patient with acute seizures regarding actions to implement if another seizure occurs at home? Select all that apply. One, some, or all responses may be correct. Ease the patient to the floor. Loosen constrictive clothes. Restrain the patient to a bed. Protect the patient from any injury. Bring the patient to the hospital immediately.

Brief staring spells are a characteristic of the seizure. The child will be unresponsive when spoken to during the seizure. The occurrence of seizures usually subsides during adolescence. Rationale Absence seizures most often occur in children. They rarely occur beyond adolescence. A typical absence seizure is marked by a sudden onset brief staring spell that resembles daydreaming and sudden recovery. It often goes unnoticed because it lasts less than 10 to 20 seconds. Usually, the patient is unresponsive when spoken to during the seizure. The child may not have loss of postural tone and may not experience confusion after a seizure. p. 1546

Which information would the nurse provide the concerned parents of a child recently diagnosed with typical absence seizures? Select all that apply. One, some, or all responses may be correct. A seizure is associated with loss of postural tone. The child will usually seem confused after a seizure. Brief staring spells are a characteristic of the seizure. The child will be unresponsive when spoken to during the seizure. The occurrence of seizures usually subsides during adolescence.

Do not take this medication with grapefruit or grapefruit juice. Rationale Grapefruit inhibits the activity of the gastrointestinal enzyme that breaks down this medication so that more of the drug is in the body, and sometimes dangerously high amounts can enter the bloodstream. Carbamazepine is administered to treat generalized tonic-clonic and partial seizures. The nurse instructs the patient to report any type of visual abnormalities. Antiseizure drugs do not cure the condition but help to prevent seizures with a minimum of side effects. p. 1549

Which information would the nurse relay to the patient with a newly prescribed medication, carbamazepine, for treatment of a new-onset seizure disorder? This medication treats absence and myoclonic seizures. Do not take this medication with grapefruit or grapefruit juice. Do not be concerned if visual disturbances occur while taking this medication. The goal of this medication is to cure the condition and prevent seizure activity.

Regular tooth brushing can limit hyperplasia Regular flossing can control gingival tissue growth. Rationale Gingival hyperplasia is a common side effect of phenytoin. The nurse should instruct the patient to maintain good dental hygiene with regular tooth brushing and flossing. Regular flossing not only helps to maintain good dental hygiene but also helps control gingival tissue growth. Similarly, regular brushing, besides being generally good for dental health, also helps to limit gingival hyperplasia. Mild gingival hyperplasia does not require a change in medication. Required surgical intervention occurs only if the gingival hyperplasia were extensive, which is not the case with this patient.

Which instruction would the nurse provide the patient who has a history of focal seizures, which is controlled with phenytoin, and mild gingival hyperplasia? Select all that apply. One, some, or all responses may be correct. The gingival tissue requires a surgical repair. Regular tooth brushing can limit hyperplasia. Gingival hyperplasia is not related to phenytoin. Consult the health care provider to change the medication. Regular flossing can control gingival tissue growth.

Begin parenteral nutrition if oral intake is not adequate. Ensure nutrition replacement is meeting the caloric needs by at least day 5 after injury. Evaluate the patient's urine output, fluid loss, and electrolyte balance. Rationale For a patient with increased ICP, begin parenteral nutrition or enteral feedings if oral intake is not adequate. Nutrition replacement should meet caloric needs by at least day 5 after injury because early feeding after brain injury may improve patient outcomes. Monitor the patient's urine output, fluid loss, and electrolyte balance to evaluate the effectiveness of nutritional therapy. Do not keep the patient in a hypovolemic fluid state; the patient needs to be in a normovolemic state. The patient with increased ICP is in a hypermetabolic and hypercatabolic state that increases, not decreases, the need for glucose as fuel for metabolism of the injured brain. p. 1492

Which intervention would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. Keep the patient in a hypovolemic fluid state. Begin parenteral nutrition if oral intake is not adequate. Ensure nutrition replacement is meeting the caloric needs by at least day 5 after injury. Decrease the amount of glucose given to the patient to decrease ICP. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

Convey an attitude of caring Keep a familiar person at the patient's bedside. Rationale All patients with bacterial meningitis have some degree of mental distortion and hypersensitivity. They may be frightened and may misinterpret the environment. Conveying an attitude of caring is helpful. Keeping a familiar person at the bedside will help the patient to calm down. Administering pain medications would be beneficial for head and neck pain, not for mental distortion and hypersensitivity. The use of touch and a soothing voice (not commanding) to give a simple explanation of activities is helpful. p. 1510

Which intervention would the nurse implement for a patient with bacterial meningitis who develops mental distortion and hypersensitivity? Select all that apply. One, some, or all responses may be correct. Convey an attitude of caring. Administer pain medications. Refrain from touching the patient unless needed. Use a commanding voice to give explanations. Keep a familiar person at the patient's bedside.

Consider administering light sedation agents. Keep suctioning to less than 10 seconds in duration. Ensure restraints are secure enough to be effective in an agitated patient. Rationale To prevent injury to the patient, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Suctioning and coughing cause transient decreases in PaO and increase ICP. Keep suctioning to a minimum and less than 10 seconds in duration. Use restraints carefully in the agitated patient. If restraints are necessary to keep the patient from removing tubes or falling out of bed, they should be secure enough to be effective. The room should not have a stimulating environment; a calm, nonstimulating environment will help. Do not prevent family members

Which intervention would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? Select all that apply. One, some, or all responses may be correct. Consider administering light sedation agents. Keep suctioning to less than 10 seconds in duration. Use a stimulating environment in the room. Keep family members away from the patient. Ensure restraints are secure enough to be effective in an agitated patient.

Perform cooling techniques. Rationale Fever may increase cerebral edema, which may cause seizures. Therefore, any fever should be treated vigorously by performing cooling techniques. Low lighting should be provided if the patient develops hallucinations and delirium. Antibiotics are administered to treat an infection, not to prevent seizures. Elevation of the head of the bed provides relief from head and neck pain.

Which intervention would the nurse implement to prevent seizures in a patient with meningitis? Provide low lighting. Administer antibiotics. Elevate the head of the bed. Perform cooling techniques.

Monitor ICP. Elevate the head of the bed to 30 degrees. Maintain systolic arterial pressure of 100 to 160 mm Hg. Rationale ICP monitoring, elevating the head of the bed 30 degrees, and maintaining a systolic arterial pressure of 100 to 160 mm Hg are components of expected management for a patient with increased ICP. Cerebral angiography, patient history, and a physical examination are diagnostic assessment tools rather than interventions to promote a positive outcome. The PaO should be maintained at 100 mm Hg or greater. p. 1488

Which intervention would the nurse implement to promote positive outcomes for a patient experiencing increased intracranial pressures (ICPs) in the neurologic intensive care unit? Select all that apply. One, some, or all responses may be correct. Monitor ICP. Obtain consent for a cerebral angiography. Elevate the head of the bed to 30 degrees. Obtain a patient history and physical examination. Maintain a PaO of 90 mm Hg or greater. 2 Maintain systolic arterial pressure of 100 to 160 mm Hg.

Minimize environmental stimuli. Rationale A patient with mental distortion may be frightened and may misinterpret the environment. Minimizing environmental stimuli may therefore help to calm the patient. Low lighting (not bright) may decrease hallucinations. Elevating the head of the bed would be beneficial if the patient experiences head and neck pain. Applying a cool cloth over the patient's eyes would help to decrease photophobia. p. 1510

Which intervention would the nurse implement to reduce the mental distortion experienced by a patient with meningitis? Ensure bright lighting. Elevate the head of the bed. Minimize environmental stimuli. Apply a cool cloth over the eyes.

Reduce fever with the use of acetaminophen. Use a cooling blanket on the patient to reduce fever. Lower temperature by using tepid-water sponge baths. Rationale Use of acetaminophen to reduce fever, use of a cooling blanket to reduce fever, and tepid-water sponge baths may be effective in lowering temperature. Rapidly reducing temperature may result in shivering and is not advisable. Shivering should be prevented because it may cause a rebound effect and increase the temperature.

Which intervention would the nurse implement when managing a fever for a patient with acute meningitis? Select all that apply. One, some, or all responses may be correct. Reduce fever with the use of acetaminophen. Reduce body temperature rapidly to provide relief. Use a cooling blanket on the patient to reduce fever. Encourage shivering in the patient to help reduce fever. Lower temperature by using tepid-water sponge baths.

Place the patient in a comfortable position. Place the patient in a curled-up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture. Rationale In acute meningitis, the nurse would assist the patient to a comfortable position; often, having the patient curled up with the head slightly extended is best. The head of the bed should be slightly elevated when permitted after lumbar puncture. Keeping the patient supine (lying flat) may increase headaches in the patient. Making the patient walk in the room is not advisable because movement can aggravate the head and neck pain. The patient with meningitis may have delirium, and making the patient walk may increase the risk of injury. p. 1510

Which intervention would the nurse implement when providing care for a patient with a diagnosis of acute meningitis? Select all that apply. One, some, or all responses may be correct. Keep the patient in a supine position. Place the patient in a comfortable position. Instruct the patient to ambulate or walk around the room. Place the patient in a curled-up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture.

Monitor temperature. Assess for headaches. Assess the eye for sensitivity to light. Monitor for seizures. Assess level of consciousness (LOC). Rationale The key signs of meningitis include fever and severe headaches; thus the nurse would monitor for temperature and headaches. Photophobia may also be present, so sensitivity to light would be monitored in a patient with meningitis. Seizures occur in one third of all cases, so the nurse would monitor the patient for seizures. The most common acute complication of bacterial meningitis is increased intracranial pressure (ICP). Most patients have increased ICP, and it is the major cause of altered mental status; thus the nurse would monitor for LOC. p. 1509

Which intervention would the nurse include in the plan of care for a patient diagnosed with meningitis? Select all that apply. One, some, or all responses may be correct. Monitor temperature. Assess for headaches. Assess the eye for sensitivity to light. Monitor for seizures. Assess level of consciousness (LOC).

Reduce the patient's environmental stimuli as much as possible. Rationale When a patient has bacterial meningitis, the meninges are inflamed and easily irritated by sensory input. For this reason, keep environmental stimulation to a minimum to avoid causing seizures and neurologic discomfort. Patients with bacterial meningitis do not necessarily require restraints or an increase in fluid intake. The position of comfort for a patient with bacterial meningitis is supine with the head of the bed elevated 30 to 45 degrees.

Which intervention would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis? Restrain the patient in bed. Increase the patient's fluid intake. Maintain the patient in a flat, supine position. Reduce the patient's environmental stimuli as much as possible.

Phenytoin Rationale Phenytoin, gabapentin, clonazepam, valproic acid, and carbamazepine are the drugs used in treating epilepsy. Gingival enlargement is a common side effect of phenytoin; therefore a patient with epilepsy who is using phenytoin may experience gingival enlargement. Gabapentin, clonazepam, and valproic acid do not cause gingival enlargement. p. 1553

Which medication, taken by a patient with a history of epilepsy, would the nurse associate with gingival enlargement? Phenytoin Gabapentin Clonazepam Valproic acid

Ventriculostomy Rationale A ventriculostomy is the gold standard for measurement of ICP. A fiberoptic catheter and air pouch/pneumatic are other measures for monitoring ICP, but they are not considered the gold standard. A transcranial Doppler evaluates blood flow in the brain. p. 1488

Which method of measurement is the gold standard for obtaining intracranial pressures (ICPs)? Ventriculostomy Fiberoptic catheter Air pouch/pneumatic Transcranial Doppler

2nd Pic Rationale Decerebrate posture (Choice 2) is when all four extremities are in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture (Choice 1) is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers caused by interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body (Choice 3) may occur depending on the damage to the brain. Opisthotonic posturing (Choice 4) is decerebrate posture with the neck and back arched posteriorly and is potentially visualized with traumatic brain injury. p. 1487

Which position would the nurse expect a patient to display as decerebrate posturing when diagnosed with an elevated intracranial pressure (ICP) causing serious disruption of motor fibers in the midbrain and brainstem?

Petechiae Adrenal hemorrhage Disseminated intravascular coagulation (DIC) Rationale Waterhouse-Friderichsen syndrome is a complication of meningococcal meningitis and is manifested by petechiae, adrenal hemorrhage, DIC, and circulatory collapse. Waterhouse-Friderichsen syndrome does not cause diplopia or a pulmonary effusion.

Which potential finding would the nurse identify in a patient suspected of developing Waterhouse-Friderichsen syndrome secondary to meningococcal meningitis? Select all that apply. One, some, or all responses may be correct. Diplopia Petechiae Pulmonary effusion Adrenal hemorrhage Disseminated intravascular coagulation (DIC)

"Do you have kidney disease?" "Do you have a history of any seizure disorder?" Rationale Dalfampridine is a selective potassium channel blocker and improves nerve conduction in damaged nerve segments. Because the medication is a potassium channel blocker, it should not be administered to patients with a history of seizure disorders or moderate to severe kidney disease. Therefore the nurse should ask the patient about any history of seizure disorders or kidney diseases. The factors of family history of diabetes, operating machines, or taking over-the-counter drugs are not relevant to dalfampridine use or nonuse. pp. 1559-1560

Which question would the nurse ask a patient with multiple sclerosis prior to administering the newly prescribed medication dalfampridine? Select all that apply. One, some, or all responses may be correct "Do you have kidney disease?" "Does your work involve operating machinery?" "Do you have a history of any seizure disorder?" "Does any member of the family have diabetes?" "Have you been taking any over-the-counter medications?"

Patient A's laboratory results indicated elevated liver enzymes. Rationale Elevated liver enzymes may decrease the liver's ability to metabolize drugs. Because the liver metabolizes phenytoin, it should not be used in older patients with liver problems. It is not safe for patient A, who has decreased liver function. Therefore the health care provider prescribed Patient A lamotrigine, which may be safer than phenytoin. The health care provider prescribed Patient B phenytoin. Hence Patient B would not have elevated liver enzymes. Blood urea nitrogen will not affect the medication's metabolism. Therefore the health care provider may prescribe any antiseizure medication for patients with elevated blood urea nitrogen. p. 1551

Which rationale would the nurse associate with the treatment of two older patients who arrived at the hospital with similar symptoms but who were provided different medications, as indicated in the clinical data provided below? Patient A's laboratory results indicated elevated liver enzymes. Patient B's laboratory results indicated elevated liver enzymes. Patient A's laboratory results revealed an elevated blood urea nitrogen. Patient B's laboratory results revealed an elevated blood urea nitrogen.

The brain begins autoregulation functions. Rationale Autoregulation is a normal response occurring in the brain when systemic arterial pressures are altered. Intracranial pressure alterations, decreasing or increasing, are not an initial response to systemic pressure changes. Compliance is the expandability of the brain and is not an initial response to systemic arterial pressure change. p. 1484

Which response occurs in the brain when a patient's systemic arterial pressure begins to deviate from the normal range? The intracranial pressures decrease. The intracranial pressures increase. There is an increase in brain compliance. The brain begins autoregulation functions.

Decorticate posturing Rationale Decorticate posture involves internal rotation and adduction of the arms with extension of the elbows, wrists, and fingers, as illustrated in the image. This results from interruption of voluntary motor tracts in the cerebral cortex. The patient may also demonstrate an extension of the legs. A decerebrate posture may indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar extension of the feet. Sinusoidal posturing does not exist. Opisthotonic posturing consists of the head, neck, and spinal column in an arching position. p. 1487

Which response would the nurse document when a patient with a brain injury experiences the motor function changes depicted in the image? Decorticate posturing Decerebrate posturing Sinusoidal posturing Opisthotonic posturing

"Stroke is an intracranial cause of tonic-clonic seizure." "Brain tumor is an intracranial cause of tonic-clonic seizure." "Hypertensive crisis is an intracranial cause of tonic-clonic seizure." Rationale Strokes, brain tumors, and hypertensive crises are considered intracranial events that may precipitate tonicclonic seizures. Septicemia is an infectious process that can precipitate a tonic-clonic seizure. Systemic lupus erythematosus is a metabolic disorder that can precipitate a tonic-clonic seizure. p. 1548

Which response would the nurse use when a patient's caregiver inquires as to why the patient developed tonic-clonic seizures without a prior history of epilepsy? Select all that apply. One, some, or all responses may be correct. "Stroke is an intracranial cause of tonic-clonic seizure." "Septicemia is an intracranial cause of tonic-clonic seizure." "Brain tumor is an intracranial cause of tonic-clonic seizure." Hypertensive crisis is an intracranial cause of tonic-clonic seizure." "Systemic lupus erythematosus is an intracranial cause of tonic-clonic seizure."

Aural phase Rationale: Systemic lupus erythematosus can lead to tonic-clonic seizures. Warm skin and pallor are the clinical signs of the aural phase of a tonic-clonic seizure. Tonic-clonic seizures progress through several phases. Lethargy and altered level of consciousness occur in the postictal phase. In the tonic phase, continuous muscle contraction occurs. Rigidity and relaxation in rapid succession occur in the clonic phase. p. 1548

Which seizure phase would the nurse identify when a patient with systemic lupus erythematosus presents to the emergency department with warm skin, pallor, lethargy, and an altered level of consciousness? Tonic phase Clonic phase Postictal phase Aural phase

Oxygenation Oral body temperature Respiratory rate and pattern Rationale Status epilepticus may cause hypoxia, hyperthermia, and ventilatory insufficiency in a patient. Therefore the nurse should assess the patient's oxygenation level, oral body temperature, and respiratory rate and pattern. Status epilepticus is one of the complications of all types of seizures. The patient's pain level is not essential at this time. Tachycardia is the clinical sign of tonic-clonic seizures, so the nurse need not focus on the apical heart rate. However, the nurse may monitor the heart rate to check for any improvement of the patient's overall health. p. 1548

Which specific patient assessment would the nurse perform immediately after a status epilepticus event subsides? Select all that apply. One, some, or all responses may be correct. Pain Oxygenation Apical heart rate Oral body temperature Respiratory rate and patter

Resection of epileptogenic tissue Rationale Unusual feelings and sensations are the clinical signs of simple focal seizures. Resection of epileptogenic tissue is the effective surgical treatment when there is a defined site of seizure origin such as in focal seizures. Patients who have multifocal epilepsy, associated with hemiplegia have a hemispherectomy performed. When surgery is not feasible, health care providers perform a vagal nerve stimulation. Sectioning of corpus callosum is an appropriate surgical therapy for generalized seizures. pp. 1546,1551

Which surgical treatment would the health care provider discuss with the patient whose seizure activity has a defined site of origin, failed to respond to medication therapy, and who reports unusual feelings and sensations? Hemispherectomy Vagal nerve stimulation Sectioning of corpus callosum Resection of epileptogenic tissue

Vasogenic Rationale Vasogenic cerebral edema occurs mainly in the white matter and is the most common type. It is characterized by leakage of large molecules from the capillaries into the surrounding space. Interstitial cerebral edema is usually a result of hydrocephalus. Hypoxia is a lack of oxygen to the brain and does not cause cerebral edema, though the edema may cause the hypoxia. Cytotoxic cerebral edema results from disruption of the integrity of the cell membranes from lesions or trauma. p. 1486

Which type of cerebral edema would the nurse associate with a diagnostic report indicating edema of the white matter and characterized by leakage of large molecules from the capillaries into the surrounding space? Interstitial Vasogenic Hypoxic Cytotoxic

Cytomegalovirus encephalitis Rationale Commonly, cytomegalovirus encephalitis is found in patients with AIDS. La Crosse encephalitis and West Nile encephalitis are epidemic diseases transmitted by ticks and mites. Herpes simplex virus encephalitis is a nonepidemic encephalitis. p. 1509

Which type of encephalitis would be seen in a patient with acquired immunodeficiency syndrome (AIDS)? La Crosse encephalitis West Nile encephalitis Cytomegalovirus encephalitis Herpes simplex virus encephalitis

Clonic seizure Rationale: Losing consciousness and falling to the ground, followed by jerky movements of the left leg, indicate a clonic seizure. Characteristics of an atonic seizure includes atonic episode or a paroxysmal loss of muscle tone and begins suddenly with the person falling to the ground. Consciousness usually returns by the time the person hits the ground, and the person has the ability to resume normal activity immediately. In focal seizures, the person may or may not lose consciousness and experience unusual feelings and sensations. A characteristic of an absence seizure is a brief staring spell. p. 1546

Which type of seizure would the nurse suspect when family members report that the patient suddenly lost consciousness and fell, and the patient's left leg exhibited jerky movements for a few seconds? Clonic seizure Atonic seizure Focal seizure Absence seizure

Flexion withdrawal Localization of pain Obedience of command Rationale Flexion withdrawal, localization of pain, and obedience of command are terms used to record a patient's best motor response. Opening of the eyes in response to stimuli and disorganized use of words are not part of the scale's motor response. p. 1492

While utilizing the Glasgow Coma Scale (GCS) to assess a patient's level of consciousness, which potential response would the nurse document under best motor response? Select all that apply. One, some, or all responses may be correct. Flexion withdrawal Localization of pain Obedience of command Disorganized use of words Opening the eyes in response to sound