Ch. 66: Management of Patients with Neurologic Dysfunction
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? a) "The physician coordinates all the care delivered." b) "Clients and families are the focus of hospice care." c) "All hospice clients die at home." d) "Hospice care uses a team approach and provides complete care."
"Clients and families are the focus of hospice care." The most important component of hospice care is the focus that is placed on the care of the client as well as the family
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? a) "No familial tendency has been demonstrated." b) "Only secondary migraine headaches show a familial tendency." c) "There is a strong familial tendency." d) "There is a very weak familial tendency."
"There is a strong familial tendency." Migraine headaches have a strong familial tendency.
The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome? a) 'Antibodies that triggered the autoimmune response are removed from your blood.' b) 'Blood transfusions are the gold standard for the treatment of this syndrome ' c) ' Plasma replacement dilutes the organisms that are causing the symptoms.' d) 'The blood removal allows for replacement of cleaner blood from a healthy person.'
'Antibodies that triggered the autoimmune response are removed from your blood.' Because GBS is believed to be an autoimmune disease, plasmapheresis (not blood transfusion) has emerged as a major treatment intervention. This process removes the blood, filters out the antibodies that trigger the autoimmune disease, and then returns the blood to the client. The blood removal is only a part of the process for filtering out antibodies and is not a dilution process.
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a) 60 mm Hg b) 70 mm Hg c) 50 mm Hg d) 80 mm Hg
70 mm Hg Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? a) Encouraging oral fluid intake b) Suctioning the client once each shift c) Administering a stool softener as ordered d) Elevating the head of the bed 90 degrees
Administering a stool softener as ordered To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child? a) An absence seizure b) A tonic-clonic seizure c) A partial seizure d) A complex seizure
An absence seizure Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex.
The nurse is taking care of a patient with a history of headaches. The nurse takes measures to reduce headaches in the patient in addition to administering medications. Which of the following appropriate nursing interventions may be provided by the nurse to such a patient? a) Perform the Heimlich maneuver b) Maintain hydration by drinking eight glasses of fluid a day c) Use pressure-relieving pads or a similar type of mattress d) Apply warm or cool cloths to the forehead or back of the neck
Apply warm or cool cloths to the forehead or back of the neck Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the patient.
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a) Assess vital signs. b) Assess for a patent airway. c) Assess pupils. d) Assess Glasgow Coma Scale.
Assess for a patent airway. A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway.
Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Keeping the head flat with use of no pillow b) Rotating the neck to the far right with neck support c) Extreme hip flexion supported by pillows d) Avoiding flexion of the neck with use of a cervical collar
Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP.
A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option. a) Because hypothermia is indicative of malaria b) Because hypothermia is indicative of severe meningitis c) Because hypothermia can cause death to the client d) Because shivering in hypothermia can increase ICP
Because shivering in hypothermia can increase ICP Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? a) The type of anticonvulsant prescribed to manage the epileptic condition b) Recent stress level c) Compliance with the prescribed medication regimen d) Recent weight gain and loss
Compliance with the prescribed medication regimen The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy.
Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? a) Flaccid b) Decerebrate c) Normal d) Decorticate
Decorticate Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? a) Complete a head-to-toe assessment. b) Administer morning dose of anticonvulsant. c) Administer Percocet as ordered. d) Elevate the head of the bed.
Elevate the head of the bed. The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Status epilepticus b) Increased intracranial pressure (ICP) c) Encephalitis d) Shock
Increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure.
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? a) Decreased pulse rate, abdominal breathing b) Decreased pulse rate, respirations of 20 breaths/minute c) Increased pulse rate, respirations of 16 breaths/minute d) Increased pulse rate, adventitious breath sounds
Increased pulse rate, adventitious breath sounds An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance.
A patient with epilepsy is having a seizure. Which of the following should the nurse do after the seizure? a) Place a cooling blanket beneath the patient. b) Help the patient sit up. c) Keep the patient to one side. d) Pry the patient's mouth open to allow a patent airway.
Keep the patient to one side.
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? a) Mannitol(Osmitrol) b) One-third normal saline (0.33% NSS) c) Dextrose 5% in water (D5W) d) Half-normal saline (0.45% NSS)
Mannitol(Osmitrol) With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells.
To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do? a) Minimize exposure to bright lights and noise. b) Increase environmental stimuli. c) Promote an active range of motion. d) Avoid physical contact with family members.
Minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a) Osteoarthritis b) Anemia c) Osteoporosis d) Obesity
Osteoporosis Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________. a) Seizure disorder b) Huntington's disease c) Parkinson's disease d) Multiple sclerosis
Parkinson's disease These drugs are commonly used in the medical management of Parkinson's disease.
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? a) Esophageal carcinoma b) Colorectal carcinoma c) Pituitary carcinoma d) Laryngeal carcinoma
Pituitary carcinoma Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur.
A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a) Restricting fluid intake and hydration b) Hyperoxygenation before and after tracheal suctioning c) Administering prescribed antipyretics d) Maintaining adequate hydration
Restricting fluid intake and hydration Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH.
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a) Hypotension and bradycardia b) Rising blood pressure and bradycardia c) Hypertension and narrowing pulse pressure d) Hypotension and tachycardia
Rising blood pressure and bradycardia Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? a) Choreiform movements b) Suicidal ideations c) Loss of bowel and bladder control d) Emotional apathy
Suicidal ideations Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations.
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects? a) To dehydrate the brain and reduce cerebral edema b) To increase urine output c) To reduce cellular metabolic demands d) To lower uncontrolled fevers
To dehydrate the brain and reduce cerebral edema Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? a) Use ophthalmic lubricant and protect the eye. b) Complete the course of antibiotics as prescribed. c) Avoid stimuli that trigger pain. d) Encourage semiannual dental exams.
Use ophthalmic lubricant and protect the eye. The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied.
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? a) Verapamil (Calan) b) Metoprolol (Lopressor) c) Amiodarone (Cordarone) d) Captopril (Coreg)
Verapamil (Calan) Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channels blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and captopril aren't used to treat migraines
The initial sign of increasing ICP includes a) decreased level of consciousness. b) headache. c) vomiting. d) herniation.
decreased level of consciousness. The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a) elevated temperature. b) decreasing blood pressure. c) diminished responsiveness. d) pupillary changes.
diminished responsiveness. Usually, diminished responsiveness is the first sign of increasing ICP.