115 PrepU Chapter 61: Management of Patients with Neurologic Dysfunction
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 in tenths.
97.5
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure?
Keep the client on one side.
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Lactated Ringer's
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
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?
Verapamil (Calan)
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
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
decerebrate
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise.
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?
Airway clearance
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 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.
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
Phenobarbital
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."
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?
"There is a strong familial tendency."
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.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?
Apply warm or cool cloths to the forehead or back of the neck.
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar
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.
Bradycardia Bradypnea Hypertension
Which is the earliest sign of increasing intracranial pressure?
Change in level of consciousness
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
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
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor
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?
Maintains a patent airway
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?
Maintenance of a patent airway
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.
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
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
generalized
A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?
safety
The Monro-Kellie hypothesis explains
the dynamic equilibrium of cranial contents.
A client the nurse is caring for experiences a seizure. What would be a priority nursing action?
Protect the client from injury.
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
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move the client to a flat surface and turn him on his side.
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 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
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
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
Lamictal
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.
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy
A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply.
Medication regimen Appointments for chemotherapy or radiotherapy Adverse effects of chemotherapy or radiation and techniques for managing them Nutritional support
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?
Monro-Kellie
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
shivering
