CH 66 Management of Patients With Neurologic Dysfunction

Three primary complications of increased ICP are:

Brain stem herniation, diabetes insipidus, SIADH

The earliest sign of increased ICP is

a change in LOC

What is the optimal way to determine the level of a patient's alertness?

Alertness is measured by the patient's ability to open the eyes spontaneously or in response to a vocal or noxious stimulus (pressure or pain).

Three major potential complications in a patient with a depressed level of consciousness are:

pneumonia, aspiration, respiratory failure

Nursing intervention for impaired cough reflex

Elevate HOB 30 degrees

Nursing intervention for keratitis

Place the patient in a lateral position

What is meant by an altered level of consciousness

An altered LOC is present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum, with a normal state of alertness and full cognition on one end and coma on the other end.

Nursing intervention for paralyzed extremity

Assist with daily active or passive range of motion

If a patient with an altered LOC requires suctioning, what intervention is a priority for the nurse to provide?

Before and after suctioning, the patient is adequately ventilated to prevent hypoxia

Nursing intervention for paralyzed diaphragm

Elevate HOB 30 degrees

Nursing intervention for incontinence

Institute a bowel-training program

Nursing intervention for footdrop

Maintain dorsiflexion to affected areas and Assist with daily active or passive range of motion

List five potential collaborative problems for a patient with an altered LOC

Respiratory distress, pneumonia, aspiration, pressure ulcer, DVT, and contractures

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 6 c. 9 d. 12

a. 3

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognize as the symptoms associated with Cushing triad? (Select all that apply.) a. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction

a. Bradycardia b. Bradypnea c. Hypertension

A patient has a lesion affecting the pons, resulting in paralysis and the inability to speak, but has vertical eye movements and lid elevation. This patient is suffering from:

locked-in syndrome

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patinet? a. 8 to 15 mmHg b. 0 to 10 mmHg c. 20 to 30 mmHg d. 25 to 40 mmHg

b. 0 to 10 mmHg

The primary, lethal complication of increased ICP is:

brain herniation resulting in death

A patient is admitted to the hospital with an ICP reading of 20 mmHg and a mean arterial pressure of 90 mmHg. What would the nurse calculate the CPP to be? a. 50 mmHg b. 60 mmHg c. 70 mmHg d. 80 mmHg

c. 70 mmHg

The leading cause of seizures in the older adult is:

cerebrovascular disease

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? a. Assessment of the pupillary light reflexes b. Determination of the cause c. Positioning to prevent complications d. Maintenance of a patent airway

d. Maintenance of a patent airway

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a. 50 to 100 mL/h b. 100 to 150 mL/h c. 150 to 200 mL/h d. More than 200 mL/h

d. More than 200 mL/h

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairments? a. Decerebrate b. Decorticate c. Flaccid d. Rigid

c. Flaccid

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? (Select all that apply.) a. Loosening constrictive clothing b. Opening the patient's jaw and inserting a mouth gag c. Positioning the patient on their side with head flexed forward d. Providing for privacy e. Restraining the patient to avoid self-injury

a. Loosening constrictive clothing c. Positioning the patient on their side with head flexed forward d. Providing for privacy

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

c. High in protein and low in carbohydrate

Nursing postoperative management includes detecting and reducing ________, relieving ________, preventing __________, and monitoring ________ and _______.

cerebral edema, pain, seizures, increased ICP and neurologic status

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

d. Notify the physician of a possible cerebrospinal fluid leak

When educating a patient about the use of anticonvulsant medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a. Anemia b. Osteoarthritis c. Osteoporosis d. Obesity

c. Osteoporosis

When the nurse performs a neurologic examination, what should be included?

A neurologic exam should include evaluation of mental status, reflexes, and motor and sensory function, as well as the score of the Glasgow Coma Scale

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure

a. Increased ICP

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? a. Glycerin b. Isosorbide c. Mannitol d. Urea

c. Mannitol

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

c. Vasopressin

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

d. Lethargy and stupor

A major potential complication of epilepsy is:

status epilepticus