MS II Prep U Ch. 66 Management of Patients With Neurologic Dysfunction

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

Cloudy cerebral spinal fluid Purpura of hands and feet The CSF will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts . Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor." A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.

Cerebral edema peaks at which time point after intracranial surgery? 12 hours 24 hours 48 hours 72 hours

24 hours Cerebral edema tends to peak 24 to 36 hours after surgery

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3 Each criterion in the Glasgow Coma Scale (eye opening, verbal response, and motor response) is rated on a scale from 3 to 15. A total 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.

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number ONLY.

97.5 143 lbs/2.2 = 65 kg. 65 kg x 1.5 = 97.5 grams.

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

Altered respiratory patterns 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.

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?

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. A patient with transient ischemic attacks is advised to maintain the hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the patient cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the patient's body.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? Excessive urine output and serum hypo-osmolarity Excessive urine output and decreased urine osmolality Oliguria and serum hyperosmolarity Oliguria and decreased urine osmolality

Excessive urine output and decreased urine osmolality Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolatity, and serum hyperosmolarity.

Excessive levels of which neurotransmitter has been implicated in ALS?

Glutamate Excessive levels of the neuro-excitatory neurotransmitter glutamate have been implicated in the neurodegenrative diseases such as ALS, Huntington's disease, and the sequelae of strokes.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate 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).

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside?

Intubation tray and suction apparatus Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.

You are taking care of a client who is taking an anticonvulsant. Why should you advise the client not to stop taking the drug abruptly? It may cause alopecia. It may cause severe and ugly skin rashes. It may trigger status epilepticus. It may cause loss in appetite.

It may trigger status epilepticus. Abrupt withdrawal of any anticonvulsant may cause status epilepticus or continuous seizure activity. Therefore, the drug should be withdrawn gradually and not abruptly. Abrupt withdrawal of any anticonvulsant does not cause loss of appetite, alopecia, or rashes.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

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? Attains desired fluid balance Displays no signs or symptoms of infection Maintains a patent airway Demonstrates optimal cerebral tissue perfusion

Maintains a patent airway 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.

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 mL/h For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? Excessive urine output and serum hyponatremia Oliguria and serum hyponatremia Oliguria and serum hyperosmolarity Excessive urine output and decreased urine osmolality

Oliguria and serum hyponatremia SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

Which of the following is an inaccurate manifestation of Cushing's triad

Tachycardia Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following reasons?

To dehydrate the brain and reduce cerebral edema 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 patient with IICP. Chlorpromazine (Thorazine) may be prescribed to control shivering in the patient with IICP. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

Which of the following are used to help reduce ICP?

Using a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

A patient with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

low The normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

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)?

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. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

The nurse is caring for a client hospitalized with a severe exacerbation of Myasthenia Gravis. When administering medications to this client what is a priority nursing action? Document medication given and dose. Administer medications at exact intervals ordered. Assess client's reaction to new medication schedule. Give client plenty of fluids with medications.

Administer medications at exact intervals ordered. He or she must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP

Which of the following positions are employed to help reduce intracranial pressure (ICP)?

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. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.

Death Permanent neurologic dysfunction Impaired cellular activity As increased ICP progresses, the consequences include impaired cellular activity, temporary or permanent neurologic dysfunction, or death.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

Decorticate An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? Optimizing nutrition Offering family support groups Explaining hospice care and services Managing muscle weakness

Explaining hospice care and services The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.

A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?

Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Elevating the head of his bed Performing a lumbar puncture Giving him a barbiturate Placing him on mechanical ventilation

Performing a lumbar puncture The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?

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

When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as decerebrate. normal. flaccid. decorticate.

decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The client has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?

"Treatment aims at keeping you independent as long as possible." Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.

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

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

Which of the following medication classifications is utilized preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants 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 ICP.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3 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 nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Hashimoto's disease Dawn phenomenon Monro-Kellie Cushing's

Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hasimoto's disease is related to the thyroid gland.

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? "Cases of epilepsy are often associated intellectual level." "For many people with epilepsy, the disorder is synonymous with mental illnes." "In most people, epilepsy is usually synonymous with intellectual disability." "Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or illness

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "I need to remain active for as long as possible." "I will lose strength in my arms." "My children are at greater risk to develop this disease." "I will have progressive muscle weakness."

"My children are at greater risk to develop this disease." There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care?

Ineffective airway clearance related to altered LOC The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?

Parkinson's disease Early signs include stiffness, referred to as rigidity, and tremors of one or both hands, described as pill-rolling (a rhythmic motion of the thumb against the fingers). The hand tremor is obvious at rest and typically decreases when movement is voluntary, such as picking up an object. Bradykinesia, slowness in performing spontaneous movements, develops. Clients have a masklike expression, stooped posture, hypophonia (low volume of speech), and difficulty swallowing saliva. Weight loss occurs. A shuffling gait is apparent, and the client has difficulty turning or redirecting forward motion. Arms are rigid while walking. These symptoms are not indicative of MS, Myesthenia gravis, or Huntington's.

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate?

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

To meet the sensory needs of a client with viral meningitis, the nurse should:

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. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis?

poor An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice 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. Hospice does take a team approach and coordinates care through the hospice physician, but these are not the focus. Not all hospice clients wish to die at home.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? Give acetaminophen per orders. Assess for weight loss. Document signs and symptoms of inflammation. Administer corticosteroids as ordered.

Administer corticosteroids as ordered. Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.

Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

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. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Elevate the head of the bed. Administer morning dose of anticonvulsant. Administer Percocet as ordered. Complete a head-to-toe assessment.

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 cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

Which signs are manifestations of the Cushing triad? Select all that apply. Hypertension Bradycardia Bradypnea Tachycardia

Hypertension Bradycardia Bradypnea Cushing triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

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? Mannitol Phenobarbital Vasopressin Furosemide (Lasix)

Vasopressin Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.

The initial sign of increasing ICP includes

decreased level of consciousness. The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may be herniated through the tentorium, causing pressure on the brain stem. Vomiting and headache are not initial signs of increasing ICP.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Contact the physician to review the care plan. Check the equipment. Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective.

Check the equipment. A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? Use ophthalmic lubricant and protect the eye. Avoid stimuli that trigger pain. Complete the course of antibiotics as prescribed. 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. Avoiding stimuli that can trigger pain is specific to tic douloureux(cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsybecause it is thought to be caused by a virus.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?

Explaining hospice care and services The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate, but not as important as assessing for suicidal ideations.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness. 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.

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?

Increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity. Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. Keep a food diary. Maintain a headache diary. Sleep no more than 5 hours at a time. Exercise in a dark room. Use St. John's Wort.

Keep a food diary. Maintain a headache diary. The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.

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? The type of anticonvulsant prescribed to manage the epileptic condition Compliance with the prescribed medication regimen Recent stress level Recent weight gain and loss

Compliance with the prescribed medication regimen 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 a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? Decerebrate posturing and loss of corneal reflex Loss of gag reflex and mental confusion Complaints of headache and lack of pupillary response Mental confusion and pupillary changes

Decerebrate posturing and loss of corneal reflex Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood presure and temperature, widened pulse pressure, Chenyne-Stokes breathing, projectile vomiting, heimplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? Cerebral perfusion pressure (CPP) is 21 mm Hg. The pupils are dilated and fixed. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). Increased ICP is 12 mm Hg.

Increased ICP is 12 mm Hg. A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? "You must restrict your fluid intake." "You must lie flat for 24 hours after surgery." "You must report ringing in your ears immediately." "You must avoid coughing, sneezing, and blowing your nose."

"You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

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?

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. A generalized seizure involves the whole brain.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?

Aspiration of a brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction? A B both demonstrate severe dysfunction neither is considered severe

B An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing (B) indicates deeper and more severe dysfunction than does decorticate posturing (A). Decerebrate implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of the forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.

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?

Increased ICP 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.

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?

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 (AANN, 2009).

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol(Osmitrol) With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Parkinson's disease. Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are most commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.

Which of the following drugs may be used after a seizure to maintain a seizure-free state? Ativan Phenobarbital Cerebyx Valium

Phenobarbital IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. Inspect the oral cavity and teeth. Provide verbal reassurance. Turn the client to the side. Physically restrain the client's movements.

Provide verbal reassurance. Turn the client to the side. Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? Apply oxygen via nasal cannula. Place the client in wrist restraints. Reorient the client while gently holding their arms. Administer lorazepam per orders.

Reorient the client while gently holding their arms. Some clients during the postictal phase will become confused and agitated. This reaction is not intentional and most clients do not remember becoming agitated. The nurse should attempt to calm and reorient the client, but also should gently hold the arms to prevent the client from hitting. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease.

hallucinations and delusions As Huntington's disease progresses, hallucinations, delusions, and impaired judgment develop due to degeneration of the cerebral cortex. Depression is a likely symptom for clients with both Parkinson's disease and Huntington's disease. Bradykinesia, slowness in performing spontaneous movement, is commonly associated with Parkinson's disease. Muscle fasciculations, or twitching, are commonly associated with ALS.