Neuro pt1

client w/subdural hematoma become restless and confused, with dilation of ipsilateral pupil. the physical orders mannitol for which of the following reasons?

to promote osmotic diuresis to decrease ICP

the nurse is positioning client w/ increased ICP which of the following positions would the nurse avoid?

turn head to side

for client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

using a picture board

nurse is assessing client who is experiencing seizure activity. the nurse understands that it is unnecessary to determine info about which of the following items as part of routine assessment of seizures?

what the client ate in 2hrs preceding seizure activity

which of the following signs and symptoms of increase ICP after head trauma would appear first?

restlessness and confusion

nurse caring for client who begins to experience seizure activity while in bed, which of the following action by nurse could be contraindicated?

restraining clients limbs

nurse is caring for male client who begins to experience seizure activity while in bed. which of the following actions by the nurse would be contraindicated?

restraining the client's limbs

male client having lumbar puncture performed. the nurse would plan to place the client in which position?

side lying w/legs pulled up and head bent down into chest

nurse is assessing child diagnosed w/brain tumor, which of the following s/s would nurse expect child to demonstrate ? select all that apply

A. head tilt B vomiting D lethargy

nurse explains that the neural synapse refers to the

space between the axons of one neuron and the dendrites of the next

when preparing to teach a client about phenytoin sodium(Dilantin) therapy, the nurse should urge the client not to stop the drugs suddenly because?

status epileptics may develop

which of the following should the nurse include in the teaching plan for a client w/seizures who is going home w/ a prescription for gabapentin(Neurontin)?

Notify the physical if vision changes occur

pt w/severe head injury begins to assume a posture of flexed upper extremities w/plantar flexed lower extremities. these assessments indicates?

ICP w/ decorticate posturing

most reliable indicator of neuro status is?

LOC

which of the following will nurse observe in client in the ictal phase of a generalized tonic-clonic seizure?

LOC, body stiffening, and violent muscle contractions

male client having a tonic-clonic seizures. What should the nurse do first?

take measures to prevent injury

pt w/migraine headaches has a seizure. After the seizure which action can you delegate to CNA?

take pts vital signs

pt w/generalized convulsive disorder has a nursing diagnosis of deficient knowledge, related to lack of info about side effects of phenytoin(Dilantin). which goal and outcome criteria would be most appropriate?

absence of GI complaint; take meds w/food

priority nursing diagnosis for pt experiencing migraine headache.

acute pain related to biologic and chemical factors

pt should be left with a ny permanent paralysis. in which of the following regions would it be apt to most severe?

arm

nurse witnesses pt w/seizure disorder as the pt suddenly jerks the arms and legs, falls to the floor and regains consciousness immediately. it will be most important for nurse to?

asses pt for possible head injury

Emt transports 27 yr old iron worker to the ER. he fell from 2 story building. has large contusion on left chest and a hematoma in left parietal area. has compound fracture of his left femur and he's comatose. we intubated him and hes maintaining an arterial o2 sat of 92% by pulse ox w/ manual resuscitation bag. which intervention by the nurse has the highest priority?

assessing LOC

nurse explains that the 3 symptoms characteristic of Cushing triad associated w/ ICP are

bradycardia,HTN and widening pulse pressure

nurse is assigned to care for female client w/complete rt sided hemiparesis. nurse plans care knowing that this condition:

the client has weakness on rt side of body including face and tongue

assessing a pt w/head injury, the nurse recognizes that the earliest indication of ICP is?

changes in LOC

female client who's paralyzed on left side has been receiving physical therapy and attending teaching sessions about safety. which behavior indicates that the client accurately understands safety measures rerated to paralysis?

client uses a mirror to inspect skin

when pt falls to floor in a generalized seizure, the nurse should?

cradle the head to prevent injury

neurologic finding that would be considered abnormal in an 88yrold pt would be?

dizziness and problems w/balance

nurse has completed discharged instructions for client w/applications of a halo device. nurse determines that client needs further clarification of instructions if the client stated to

drive during the daytime

pt in ER states that she fell and hit her head and blacked out for a while but became alert again. Suspecting an epidural hematoma, the nurse will be diligent in the assessment of:

drowziness

client w/nursing diagnosis impaired swallowing related to neuro impairment, the nurse should

elevate the HOB 90 degrees during meals

during immediate minutes of trauma your first goal is to

establish an open airway

in caring for unconscious pt who suffered head injury 10 days ago the nurse positions the pt to prevent limbs from

flexion deformities

problems with memory and learning would relate to which of the following lobes?

frontal

20yr old who hit his head while playing football has tonic clonic seizures. upon awakening from the seizure, the client asks the nurse what caused me to have a seizure? I've never had one before. which cause should the nurse include in the response as a primary cause of tonic clonic seizures in adults older than age 20?

head trauma

nurse positioning female client w/ICP which position would nurse avoid?

head turned to the side

nurse is caring for the client with increased ICP. the nurse would note which of the following trends in vital signs if the ICP is rising?

increased temp, decreased pulse, decreasing resp, increase BP

nursing student is teaching pt and family about epilepsy prior to pts discharge, for which statement should you intervene?

its ok to take over the counter meds

to prevent headache after lumbar puncture, the nurse instructs the pt to

lie flat

pt begin to mutter book pointing at water. behavior indicated

motor aphasia

nurse assessing motor function of unconscious male client. nurse would plan to use which plan to use which of the following to test peripheral response to pain?

nail bed pressure

pt with right sided weakness that started 1 hr ago is admitted to ER and all these are diagnostic tests are ordered. which order should the nurse act on first?

non contrast computed tomography (CT) scan

while cooking, your client couldn't feel the temp of a hot oven. Which lobe could be dysfunctional?

parietal

after striking head on tree while falling from ladder a young man age 18 is admitted to emergency dpt. hes unconscious and his pupils are nonreactive. which intervention would be most dangerous for the client?

perform a lumbar puncture

male clientw/suspected ICP most appropriate resp goal is to?

promote carbon dioxide elimination

priority nursing goal of a pt w/sensory alteration is

providing safe environment

when caring for pt who has head injury which assessment info is of most concern to nurse?

pt is more difficult to arouse

most sensitive indicator of unconscious pt w/head injury is the

pupillary changes