Chapter 37: Caring for Clients with Central and Peripheral Nervous System Disorders

While caring for a client with a seizure disorder, the nurse observes a sudden, brief jerking of the client's left arm. Most likely, the client has which type of seizure disorder? a. myoclonic seizure b. tonic-clonic seizure c. partial seizure d. absence seizure

a Myoclonic seizures are characterized by sudden, excessive jerking of the arms, legs, or entire body. The seizures are brief.

Which of the following medication classifications is utilized preoperatively to decrease risk of postop seizures? a. Anticonvulsants b. Diuretics c. Corticosteroids d. Antianxiety

a Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the patient with increased intracranial pressure.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? a. Position the client supine. b. Maintain head of bed (HOB) elevated at 30 to 45 degrees. c. Position client in prone position. d. Maintain bed in Trendelenburg position.

b The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Maintaining adequate hydration b. Administering prescribed antipyretics c. Restricting fluid intake and hydration d. Hyperoxygenation before and after tracheal suctioning

c Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

A client fell at home and sustained a head injury. The client exhibits signs and symptoms of head trauma with indications of increased ICP. What is the normal ventricular ICP? a. 5 to 15 mm Hg b. 16 to 20 mm Hg c. 21 to 30 mm Hg d. 31 to 40 mm Hg

a Normal ICP is 5 to 15 mm Hg.

Which is a late sign of increased intracranial pressure (ICP)? a. Irritability b. Slow speech c. Altered respiratory patterns d. Headache

c Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? a. It suggests onset of metabolic problems. b. It indicates paralysis on the right side of the body. c. It indicates paralysis of cranial nerve X (CN X). d. It indicates an injury at the midbrain level.

d Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

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. Recent weight gain and loss d. Compliance with the prescribed medication regimen

d The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A client with an inoperable brain tumor says to the nurse, "I'm so afraid that I'm going to die alone." What is the nurse's best response? a. "You sound frightened." b. "You are not going to die." c. "There is nothing to be afraid of." d. "It won't be as bad as you think."

a In this scenario, the nurse stating "You sound frightened" is an example of reflective technique; it focuses on the client's feelings and encourages verbalization. The other statements deny the client's feelings.

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. Rising blood pressure and bradycardia b. Hypotension and bradycardia c. Hypotension and tachycardia d. Hypertension and narrowing pulse pressure

a 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.

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? a. The patient should perform frequent physical activity but avoid becoming fatigued. b. The patient should perform exercises that are brief but high-intensity. c. The patient should prioritize energy conservation and remain on bed rest if possible. d. The patient should attempt to maintain prediagnosis levels of activity and mobility.

a The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.

Which activity should be avoided in clients with increased intracranial pressure (ICP)? a. Suctioning b. Enemas c. Position changes d. Minimal environmental stimuli

b Enemas should be avoided in clients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the client increases the ICP, rotating beds, turning sheets, and holding the client's head during turning may minimize the stimuli that cause increased ICP.

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? a. IV phenobarbital b. IV diazepam c. IV lidocaine d. Oral phenytoin

b Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a. pupillary changes. b. diminished responsiveness. d. decreasing blood pressure. d. elevated temperature.

b Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

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 A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).

One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? a. Sensory symptoms b. Motor symptoms c. Impaired consciousness d. Compound forms

c A complex partial seizure is characterized by complex symptoms with the impairment of consciousness. A simple partial seizure generally occurs without impairment of consciousness.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to a. control fever. b. control shivering. c. dehydrate the brain and reduce cerebral edema. d. reduce cellular metabolic demand.

c Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? a. unequal response b. equal response c. rapid response d. constricted response

a In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client? a. 5 to 15 mm Hg b. 10 to 20 mm Hg c. 15 to 25 mm Hg d. 20 to 30 mm Hg

a Intracranial pressure (ICP) is usually measured in the lateral ventricles. Normal pressure is 5 to 15 mm Hg. Early signs of increased ICP include decreased level of consciousness, headache, and vomiting without nausea.

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 his or her side with head flexed forward d. Providing for privacy e. Restraining the patient to avoid self injury

a, c, d During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? a. Computed tomography (CT) scan b. Lumbar puncture c. Magnetic resonance imaging (MRI) d. Venous Doppler studies

b A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? a. The ability of the client to follow instructions during the seizure. b. The success or failure of the care team to physically restrain the client. c. The client's ability to explain his seizure during the postictal period. d. The client's activities immediately prior to the seizure.

d Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure is not clinically relevant.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? a. Place the client in a side-lying position. b. Pad the client's bed rails. c. Administer antianxiety medications as prescribed. d. Reassure the client and family members.

a To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

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 and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? a. Encephalitis b. CSF leak c. Meningitis d. Catheter occlusion

c Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter.

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? a. Hydrochlorothiazide b. Furosemide c. Mannitol d. Spironlactone

c The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spironlactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches? a. The client leads a sedentary lifestyle. b. The client takes vitamin D and calcium supplements. c. The client takes vasodilators for the treatment of angina. d. The client has a pattern of weight loss followed by weight gain.

c Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way? a. Ascending paralysis b. Numbness and tingling in the lower extremities c. Weakness starting in the muscles supplied by the cranial nerves d. Jerky, uncontrolled movements in the extremities

c The chief symptoms are fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and incoordination. In about 25% of patients, weakness starts in the muscles supplied by the cranial nerves, and difficulty in talking, swallowing, and ultimately breathing occurs.

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? a. The CPP is high. b. The CPP is low. c. The CPP is within normal limits. d. The CPP reading is inaccurate.

b The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? a. Solid food with thin liquids b. Pureed food with water c. Semisolid food with thick liquids d. Thin liquids only

c A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? a. Monitoring of pulse oximetry b. Administration of a low-protein diet c. Administration of thorough oral hygiene d. Fluid restriction as prescribed

c Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? a. Chronic confusion b. Impaired urinary elimination c. Impaired verbal communication d. Bowel incontinence

c Impaired communication is an appropriate nursing diagnosis; the voice in clients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in clients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? a. Attains desired fluid balance b. Displays no signs or symptoms of infection c. Maintains a patent airway d. Demonstrates optimal cerebral tissue perfusion

c Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? a. Copes with sensory deprivation. b. Registers normal body temperature. c. Pays attention to grooming. d. Obeys commands with appropriate motor responses.

d An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of "disturbed sensory perception." The outcome of "registers normal body temperature" relates to the diagnosis of "potential for ineffective thermoregulation." Body image disturbance would have a potential outcome of "pays attention to grooming."

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? a. Hemiplegia b. Dry mucous membranes c. Signs of internal bleeding d. Loss of brain stem reflexes

d Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses? a. Prepare an advance directive. b. Designate a most responsible health care provider (MRP) early in the course of the disease. c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. d. Ensure that witnesses are present when he provides instruction.

a Clients with ALS are encouraged to complete an advance directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

What is one of the earliest signs of increased ICP? a. decreased level of consciousness (LOC) b. headache c. Cushing's triad d. coma

a Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? a. Inform the care team and assess for further signs of possible increased ICP. b. Administer bronchodilators as prescribed and monitor the client's LOC. c. Increase the client's bed height and reassess in 30 minutes. d. Administer a bolus of normal saline as prescribed.

a Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the client and administering bronchodilators are insufficient responses, even though these actions may later be prescribed.

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 LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case? a. Narcotic analgesics increase CSF pressure. b. Narcotic analgesics are ineffective against pain in head trauma. c. Narcotic analgesics decrease CSF pressure. d. Avoidance is inappropriate because narcotic analgesics are the drug of choice in treating pain associated with head trauma.

a Narcotic analgesics depress the respiratory center and raise CSF pressure. Their use is contraindicated in clients with head trauma or increased ICP, unless administration is an absolute necessity.

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a. chewing b. swallowing c. smelling d. tasting

a Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.

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

a, b, c At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. a. Ensure access to a language board when communicating with the client. b. Obtain daily weights to monitor weight gain. c. Establish a voiding time schedule. d. Encourage the client to walk with feet wide apart.

a, c, d Language assistive devices may be needed if communication is severely affected. Occasional bladder incontinence may lead to total incontinence. A voiding time schedule will allow the client greater independence. If motor dysfunction causes problems of incoordination and clumsiness, the patient is at risk for falling. As the disease progresses, nutritional deficiencies may develop. Weight should be assessed to ensure that there is no significant weight loss. Weight gain should not be an issue.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the a. dorsal recumbent position. b. supine position with the head slightly elevated. c. prone position with the head turned to the unaffected side. d. Trendelenburg position.

b After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? a. Epileptic cry b. Confusion c. Urinary incontinence d. Body rigidity

b In the postictal state (after the seizure), the client is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately? a. Intravenous phenobarbital b. Intravenous diazepam c. Oral lorazepam d. Oral phenytoin

b Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? a. Generalized seizure b. Absence seizure c. Focal seizure d. Unclassified seizure

b Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? a. Baclofen b. Riluzole c. Dantrolene sodium d. Diazepam

b Riluzole, a glutamate antagonist, has been shown to prolong survival for persons with ALS for 3 to 6 months.

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? a. Alopecia b. Gingival hyperplasia c. Diplopia d. Ataxia

b Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

Which is the earliest sign of increasing intracranial pressure? a. Vomiting b. Change in level of consciousness c. Headache d. Posturing

b The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? a. Change the client's position as indicated. b. Monitor serum electrolytes. c. Maintain NPO status. d. Monitor arterial blood gas (ABG) values.

b The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in clients with cerebral edema. Changing the client's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume.

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Maintaining adequate hydration b. Administering prescribed antipyretics c. Restricting fluid intake and hydration d. Hyperoxygenation before and after tracheal suctioning

c Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? a. Solumedrol b. Dextromethorphan c. Dexamethasone d. Furosemide

c If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

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 Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.