PUCH61 NEUROLOGIC DYSFUNCTION PART 2

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

A

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered A. high. B. low. C. within normal limits. D. inaccurate.

B

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? A. Coma B. Infection C. High blood pressure D. Apnea

B

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

C

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? a. Diencephalon b. Medulla c. Midbrain d. Cortex

C

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? A. Mannitol B. Furosemide (Lasix) C. Vasopressin D. Phenobarbital

C

A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: A. unknown. B. muscular. C. vasodilating agents. D. endocrine.

A

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? A. vasodilation B. vasoconstriction C. hypertension D. increased PaO

A

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? a. Decerebrate posturing and loss of corneal reflex b. Loss of gag reflex and mental confusion c. Complaints of headache and lack of pupillary response d. Mental confusion and pupillary changes

A

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? A. Herniation B. Autoregulation C. Cushing response D. Monro-Kellie hypothesis

A

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. A. Keep a food diary. B. Maintain a headache diary. C. Sleep no more than 5 hours at a time. D. Exercise in a dark room. E. Use St. John's Wort.

A B

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

The nurse recognizes that causes of acquired seizures include what? Select all that apply. A. Cerebrovascular disease B. Metabolic and toxic conditions C. Hyponatremia D. Brain tumor E. Drug and alcohol withdrawal

A B C D

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? A. Blood pressure 100/60 mm Hg B. Lethargy C. Nausea D. Periorbital edema

B

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? A. Cerebellar function B. Glasgow Coma Scale C. Cranial nerve function D. Mental status evaluation

B

Cerebral edema peaks at which time point after intracranial surgery? A. 12 hours B. 24 hours C. 48 hours D. 72 hours

B

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

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? A. "There is a very weak familial tendency." B. "No familial tendency has been demonstrated." C. "There is a strong familial tendency." D. "Only secondary migraine headaches show a familial tendency."

C

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? A. Decerebrate B. Decorticate C. Flaccid D. Rigid

C

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? A. Giving him a barbiturate B. Placing him on mechanical ventilation C. Performing a lumbar puncture D. Elevating the head of his bed

C

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

C

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

C

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

C

While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? A. Migraine B. Tension C. Cluster D. Sinus

C

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

D

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? A. 50 to 100 mL/h B. 100 to 150 mL/h C. 150 to 200 mL/h D. More than 200 mL/h

D

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

A

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

B

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

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

A

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

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

B

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

D

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

A

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

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? A. Verapamil (Calan) B. Metoprolol (Lopressor) C. Amiodarone (Cordarone) D. Carvedilol (Coreg)

A

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? A. Monro-Kellie B. Cushing's C. Dawn phenomenon D. Hashimoto's disease

A

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: A. 48 mm Hg. B. 52 mm Hg. C. 68 mm Hg. D. 88 mm Hg.

B

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? A. Shortness of breath B. Sensitivity to bright light C. Muscle spasms D. Drooping eyelids

D