prepU ch. 61 Management of Patients with Neurologic Dysfunction

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? "My children are at greater risk to develop this disease." "I will lose strength in my arms." "I need to remain active for as long as possible." "I will have progressive muscle weakness."

"My children are at greater risk to develop this disease."

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: 88 mm Hg. 48 mm Hg. 52 mm Hg. 68 mm Hg.

52 mm Hg.

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

Administer corticosteroids as ordered.

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? Administer medications at exact intervals ordered. Assess client's reaction to new medication schedule. Give client plenty of fluids with medications. Document medication given and dose.

Administer medications at exact intervals ordered.

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

Altered respiratory patterns

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? Assess pupils. Assess for a patent airway. Assess vital signs. Assess Glasgow Coma Scale.

Assess for a patent airway.

Which phase of a migraine headache usually lasts less than an hour? Headache Premonitory Aura Postdrome

Aura

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

Bradycardia Hypertension Bradypnea

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? Brain tumor Trigeminal neuralgia Hypostatic pneumonia Epilepsy

Brain tumor

Which is the earliest sign of increasing intracranial pressure? Vomiting Change in level of consciousness Posturing Headache

Change in level of consciousness

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? Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective. Contact the physician to review the care plan. Check the equipment.

Check the equipment.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? Damage to the facial nerve Damage to the olfactory nerve Damage to the vagal nerve Damage to the optic nerve

Damage to the optic nerve

A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) Promotion of urinary continence Decreased muscle spasms in the lower extremities Increased muscle strength in the upper extremities

Decreased muscle spasms in the lower extremities

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? Sensitivity to bright light Shortness of breath Muscle spasms Drooping eyelids

Drooping eyelids

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

Elevate the head of the bed.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? Restricts protein to 10% of daily caloric intake At least 50% carbohydrate High in protein and low in carbohydrate Low in fat

High in protein and low in carbohydrate

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

Increased ICP is 12 mm Hg.

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

Lamictal

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? Determination of the cause Positioning to prevent complications Assessment of pupillary light reflexes Maintenance of a patent airway

Maintenance of a patent airway

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 decreased urine osmolality Excessive urine output and serum hyponatremia Oliguria and serum hyponatremia Oliguria and serum hyperosmolarity

Oliguria and serum hyponatremia

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? Obesity Anemia Osteoarthritis Osteoporosis

Osteoporosis

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

Phenobarbital

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? Esophageal carcinoma Pituitary carcinoma Laryngeal carcinoma Colorectal carcinoma

Pituitary carcinoma

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. Administer lorazepam per orders. Reorient the client while gently holding their arms. Place the client in wrist restraints.

Reorient the client while gently holding their arms.

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? Cardiac function Cognition Respiratory function Potential skin breakdown

Respiratory function

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

The CPP is low.

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? Phenobarbital Vasopressin Mannitol Furosemide (Lasix)

Vasopressin

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? Diet containing extra sodium Fluid restriction Vasopressin therapy Hypertonic saline solution

Vasopressin therapy

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

chewing

What is one of the earliest signs of increased ICP? coma headache Cushing triad decreased level of consciousness (LOC)

decreased level of consciousness (LOC)

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

supine position with the head slightly elevated.

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 with intellectual level." "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." "In most people, epilepsy is usually synonymous with intellectual disability." "For many people with epilepsy, the disorder is synonymous with mental illness."

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

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)? Encouraging oral fluid intake Suctioning the client once each shift Elevating the head of the bed 90 degrees Administering a stool softener as ordered

Administering a stool softener as ordered

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? An absence seizure A partial seizure A myoclonic seizure A tonic-clonic seizure

An absence seizure

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? Flaccidity Decerebrate Tonic clonic Decorticate

Decorticate

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Decerebrate Flaccid Normal Decorticate

Decorticate

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? Turned onto the operative side Elevated no more than 10 degrees Elevated 30 degrees Flat

Elevated 30 degrees

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. Opening the patient's jaw and inserting a mouth gag Restraining the patient to avoid self injury Positioning the patient on his or her side with head flexed forward Loosening constrictive clothing Providing for privacy

Positioning the patient on his or her side with head flexed forward Loosening constrictive clothing Providing for privacy

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

dehydrate the brain and reduce cerebral edema.

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

diminished responsiveness.

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? Blood pressure 100/60 mm Hg Periorbital edema Lethargy Nausea

Lethargy

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? Lethargy and stupor Bradycardia Hypertension A bounding pulse

Lethargy and stupor

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 one for which no organic cause can be identified." "A migraine headache is an example of a secondary headache." "A secondary headache is located in the frontal area."

"A secondary headache is associated with an organic cause, such as a brain tumor."

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 Mental confusion and pupillary changes Complaints of headache and lack of pupillary response

Decerebrate posturing and loss of corneal reflex

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: Huntington disease. seizure disorder. multiple sclerosis. Parkinson disease.

Parkinson disease.

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? The patient should attempt to maintain prediagnosis levels of activity and mobility. The patient should perform frequent physical activity but avoid becoming fatigued. The patient should prioritize energy conservation and remain on bed rest if possible. The patient should perform exercises that are brief but high-intensity.

The patient should perform frequent physical activity but avoid becoming fatigued.

Which method is used to help reduce intracranial pressure? Keeping the head of bed flat Using a cervical collar Extreme hip flexion, with the hip supported by pillows Rotating the neck to the far right with neck support

Using a cervical collar

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

24 hours

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Shivering Urine output of 100 mL/hr Capillary refill of 2 seconds Cool, dry skin

Shivering

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? constricted response unequal response rapid response equal response

unequal response

The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. Pain and stiffness of the extremities Low red blood cell (RBC) count Low white blood cell (WBC) count Purpura of hands and feet Low antidiuretic hormone (ADH) levels Cloudy cerebral spinal fluid

Cloudy cerebral spinal fluid Purpura of hands and feet