Chapter 16: Disorders of Brain Function

The nurse is planning an inservice on hypoxia versus ischemia in brain-injured clients. The nurse should include which of the following?

Hypoxia produces a generalized depressive effect on the brain.

For seizure disorders that do not respond to anticonvulsant medications, the option for surgical treatment exists. What is removed in the most common surgery for seizure disorders?

Amygdala

The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed?

Administration of antibiotics

A nurse is teaching a client newly diagnosed with a seizure disorder. Which statement is most important for the nurse to provide regarding antiepileptic medications?

Antiepileptic medications should never be discontinued abruptly.

The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:

Lumbar puncture

The most common cause of an ischemic stroke is which of the following?

Thrombosis

The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced:

generalized seizure.

Severe head trauma from a coup-contrecoup injury may result in which type of brain injury?

cerebral hematoma

A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem?

Placement of a shunt

Which client is at least risk for rapid bleeding?

Client with a subdural hematoma

The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is:

I will come and assess the client

A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be that:

bruising on the surface of the brain occurred.

A nurse is preparing for a course in cardiopulmonary resuscitation (CPR) and realizes that ventricular fibrillation quickly disrupts blood flow to the brain that causes which result in a matter of seconds?

Global ischemia

A child has developed a benign brain tumor in the cerebellum and the floor of the third ventricle. The proper documentation for this type of tumor includes which terminology?

Pilocytic astrocytomas

A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is:

characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing.

Overstimulation of glutamate receptors is the cause of which type of brain injury?

excitotoxic

The nurse is educating parents of a child with arteriovenous malformation. The nurse determines that the parents need additional education when the parents state:

"It is a rare complication of concussions."

A client discharged from the hospital 5 days ago following a stroke has come to the emergency department with facial droop that progressed with hemiplegia and aphasia. The client's spouse is extremely upset because the physician stated that the client cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. What is the nurse's most accurate response?

"Thrombolytics may cause cerebral hemorrhage."

The spouse of a client who has been in a long-term care facility for a few months due to a brain injury that caused a vegetative state asks the nurse why the client is still being fed through the gastrostomy tube. What is the nurse's best response?

"To avoid aspiration into the lungs."

Which intracranial pressure (ICP) would the nurse consider a normal reading?

0-15 mm Hg

The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply. A. Cognition B. LOC C. Motor function D. Sensory function E. Metabolic function

A. Cognition B. LOC C. Motor function D. Sensory function

The nurse reading the results of a lumbar puncture cerebrospinal fluid analysis anticipates that the client's meningitis will be self-limiting in nature because of which findings? Select all that apply. A. Lymphocytes B. Moderately increased protein C. Polymorphonuclear neutrophils D. Reduced sugar count

A. Lymphocytes B. Moderately increased protein

Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?

Altered level of consciousness

What medication teaching should be done for a woman of childbearing age with a seizure disorder?

Antiseizure drugs increase the risk for congenital abnormalities.

The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?

Assess for other signs/symptoms of increased intracranial pressure.

A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for:

Brain death

When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present?

Brudzinski sign and Kernig sign

Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made?

CT scan

A client who has been living with Alzheimer disease and spouse are at the doctor's office and the spouse asks the nurse why the client cannot remember much of anything from the past. The best response by the nurse is that Alzheimer disease affects which part of the brain?

Cells located in the hippocampus

Which intracranial volume is most capable of compensating for increasing intracranial pressure?

Cerebrospinal fluid

The nurse is working in the emergency room. One client's presenting symptoms include the worst headache ever, nuchal rigidity, and nausea. Another client's presenting symptoms include fever, stiff back, and positive Kernig sign. Which client should the nurse assess first?

Client with the worst headache, nuchal rigidity, and nausea

A nurse on a neurology unit is assessing a client with a brain injury. The client is unresponsive to speech, with dilated pupils that do not react to light. The client is breathing regularly with a respiratory rate is 45 breaths/min. In response to a noxious stimulus, the client's arms and legs extend rigidly. What is the client's level of impairment?

Coma

Which physiologic principle can cause hydrocephalus? Select all that apply.

Decreased absorption of CSF Obstruction of CSF

A nurse caring for a client with a head injury is concerned that respirations are 30 breaths per minute. Which physiologic factor will affect cerebral blood flow?

Decreased carbon dioxide level

A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following?

Encephalitis

An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following?

Flaccid motor response

A client who is diagnosed with seizures describes feeling confused after experiencing a seizure. The family members report that the client has been smacking his lips prior to having a seizure. The client most likely experienced which type of seizure?

Focal

A family is sitting in the intensive care unit with a client who sustained significant head injuries in a motorcycle accident. They are questioning the nurse about why the client's eyes open but do not stay open for long. The nurse explains that the client is probably in which state?

In a stuporous state due to a reticular activated system (RAS) injury

Following a head injury, a client is diagnosed with intracranial epidural hematoma. During the initial assessment, the client suddenly becomes unconscious. What additional clinical manifestations correlate with this diagnosis?

Ipsilateral pupil dilation

The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition?

Muscle atrophy

The nurse is preparing a client for oculovestibular reflex assessment (cold caloric test). The nurse explains that the test is used to elicit which of the following?

Nystagmus

A parent brought her 8-year-old child to the emergent care center to be examined following a fall off a playground set, resulting in a head injury. On discharge, the nurse explains to the parent that some symptoms may continue, including the inability to remember what happened before the fall. Which term best describes the diagnosis?

Retrograde amnesia

The emergency department nurse is caring for a client who fell and has a head injury. Which assessment would be noted during the early stage of increased intracranial pressure?

Stable vital signs

What term is used to describe a level of consciousness during which a client responds only to vigorous and repeated stimuli and has minimal or no spontaneous movement?

Stupor

The nurse is explaining to a client's family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be:

The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.

A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:

Transient ischemic attack (TIA)

A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which pathophysiologic condition has contributed to this client's diagnosis?

Weakness in the muscular wall of an artery

The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should:

assess the client for additional signs/symptoms of increased intracranial pressure.

The nurse is caring for a client experiencing a seizure. During the seizure the nurse notes that the client repetitively rubs his/her clothing. When contacting the client's physician, the nurse notes that the client exhibited:

automatisms

A client suffering global cerebral ischemia a week after a suicide attempt by hanging is in the intensive care unit receiving treatment. The parent asks the nurse why it is necessary to keep the client paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies:

decrease metabolic needs and increase oxygenation.

A client has developed global ischemia of the brain. The nurse determines this is:

inadequate to meet the metabolic needs of the entire brain.

The nurse observes a new nurse performing the test for Kernig sign on a client. The new nurse performs the test by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle. The nurse should explain to the new nurse that:

resistance should be provided with the knee in a flexed position.

The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as:

rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet.