PP RNSG 1538 Intracranial Regulation Mastery Quiz

Administer prescribed IV mannitol.

A 10-year-old with a severe head injury is unconscious and has coarse breath sounds, a temperature of 39° C (102.2° F), a heart rate of 70 bpm, a blood pressure of 130/60 mm Hg, and an intracranial pressure (ICP) of 36 mm Hg. Which action should the nurse perform first?

4 hours

A 16-year-old adolescent sustains a severe head injury in a motor vehicle accident. He's admitted to the neurologic unit and subsequently develops neurogenic diabetes insipidus. The physician orders vasopressin, 5 units subcutaneously (subQ) twice per day. How long will the effects of the vasopressin last?

Move the family to an area where an assessment can be completed and call for a physician.

A 4-month-old infant has been carried into the emergency department after falling off his parents' bed and hitting his head on the floor. What should the nurse do next?

"Your child has a mild concussion; acetaminophen can be given."

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate?

crebrovascular accident.

A client has atrial fibrillation. The nurse should monitor the client for:

Meningitis

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which of the following?

expressive aphasia.

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for:

unequal pupil size

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

15

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

Intracranial pressure of 10 mm Hg

A client is receiving intravenous mannitol for treatment of a brain tumor. The client's intracranial pressure before administration of the mannitol was 14 mm Hg. Which assessment finding indicates that the medication is attaining a therapeutic effect?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Contacting the physician

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which of the following is the appropriate nursing intervention?

Risk for injury

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?

diminished responsiveness.

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

dysfunction in the brain stem.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

seizures

After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:

Notify the healthcare provider

An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which of the following is the nurse's best action?

Seizures

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?

Reduced serum ammonia levels.

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?

Liver

The nurse administers phenytoin 125 mg by mouth twice daily to a 6 year old child who is diagnosed with complex partial seizures. The nurse is most concerned about phenytoin toxicity when the child also has a disorder of which of the following organs?

decrease in level of consciousness (LOC)

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

Cortisol levels before and after the system is challenged with a synthetic steroid

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test?

impulsive acts of aggression

The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have?

Pain Coughing Agitation

The nurse is caring for an 8-year-old child with a head injury. Which of the following symptoms are important for the nurse to control to prevent an increase in intracranial pressure? Select all that apply.

notify the health care provider (HCP).

The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back. The nurse should:

Protecting the visitor's head with a pad to prevent injury

The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. Which of the following is the nurse's appropriate intervention when caring for the visitor?

Can be roused with stimulation

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness?

Maintaining stable intracranial pressure

When caring for an adolescent who is at risk for injury related to intracranial pathology following a motor vehicle collision, which of the following nursing actions is the priority?

Increased intracranial pressure (ICP)

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?

They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.

Which effects do most antipsychotic medications exert on the central nervous system (CNS)?

loss of consciousness, body stiffening, and violent muscle contractions

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

bulging fontanels

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?

Tell the client to march in place.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement?

Abnormalities in brain neurotransmitters, and the caudate nucleus, and genetics

While teaching a group of parents whose children have Tourette syndrome, a nurse is asked about factors associated with its development. Which factor should the nurse include in her response?