Chapter 16: Disorders of Brain Function

The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom?

Stupor

What term is used to describe a level of consciousness that sees a client responding only to vigorous and repeated stimuli and has minimal or no spontaneous movement?

Stupor

Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors?

Brain edema and disturbances in blood flow

The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?

CT scan

The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be:

"Because the skull sutures are not fused there may be no brain damage."

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."

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

0 to 15 mm Hg

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

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 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 teenager has been in a car accident and experienced an acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication?

Brain contusions and hematomas

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

The nurse is conducting a community education program on concussions. The nurse evaluates that the participants understand the education when they state that which of these offers the brain protection from external forces?

Cerebrospinal fluid

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

The nurse knows that which treatment plan listed below is most likely to be prescribed after a computerized tomography (CT) scan of the head reveals a new-onset aneurysmal subarachnoid hemorrhage?

Craniotomy and clipping of the affected vessel

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

The nurse planning a community education class on brain tumors and their prevention should include which risk factors in the presentation? Select all that apply.

High dose irradiation exposure Acquired immune suppression

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.

Generalized convulsive status epilepticus is a medical emergency caused by a tonic-clonic seizure that does not spontaneously end, or recurs in succession without recovery. What is the first-line drug of choice to treat status epilepticus?

Intravenous lorazepam

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

Lumbar puncture

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

As a client explains to the nurse what occurred prior to the onset of seizure activity, the client describes perceiving a feeling or warning that the seizure would occur. The nurse documents the perceived warning as which of the following?

Prodrome

Following a car accident in which the driver did not have his seatbelt on, the client is diagnosed with a traumatic brain injury requiring emergent craniotomy for severe cerebral edema. Which assessments should the nurse report immediately since they correspond to a supratentorial herniation progressing to midbrain involvement? Select all that apply.

Pupils fixed at ~ 5 mm in diameter Respiration rate of 40 breaths/min Decerebrate posturing following painful stimulation of the sternum

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

A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose?

Thrombolysis

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.

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.

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.

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

Brudzinski sign and Kernig sign

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'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

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

Antiseizure drugs increase the risk for congenital abnormalities.

A client's emergency room report includes the presence of a contrecoup injury. The nurse plans care for a client with which of the following?

Closed head injury opposite the area of impact

The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.

Cognition Level of consciousness Motor function Sensory function

The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be:

Decreased level of oxygen

A high school student sustained a concussion during a football game. The school nurse will educate the family about postconcussion syndrome and ask them to watch for and report which manifestations of its presence?

Headaches and poor concentation

A family brings a client to the emergency department with increasing lethargy and disorientation. They think the client had a seizure on the drive over to the hospital. The client has been sick with a "cold virus" for the last few days. On admission, the client's temperature is 102°F (38.9°C). Which other clinical manifestations may lead to the diagnosis of encephalitis?

Impaired neck flexion resulting from muscle spasm

While lecturing to a group of physiology students, the instructor asks, "What metabolic factors cause vasodilation of cerebral vessels, thereby increasing cerebral blood flow to the brain?" The best student response would be:

Increased carbon dioxide level

A client's emergency magnetic resonance imaging (MRI) has been examined by the physician and tissue plasminogen activator (tPA) has been administered to the client. What was this client's most likely diagnosis?

Ischemic stroke

A client has developed hydrocephalus and asks the nurse what may have caused this to occur. The best response would be:

Overproduction of cerebrospinal fluid

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

Thrombosis

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 is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:

administer IV tissue plasminogen activator (tPA).