CH 37: PART 2
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
Which value indicates a normal intracranial pressure (ICP)?
5 mm Hg
A client fell at home and sustained a head injury. The client exhibits signs and symptoms of head trauma with indications of increased ICP. What is the normal ventricular ICP?
5 to 15 mm Hg
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?
70 mm Hg
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
Absence seizure
A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
Administer morphine sulfate as prescribed.
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 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)?
Administering a stool softener as ordered
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
Which of the following medication classifications is utilized preoperatively to decrease risk of postop seizures?
Anticonvulsants
A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?
As soon as the client senses the onset of symptoms
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?
Assist the client to the floor, in a side-lying position, and protect him with linens.
Which is the earliest sign of increasing intracranial pressure?
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?
Check the equipment.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?
Compliance with the prescribed medication regimen
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?
Confusion
While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
Confusion
A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.
Death Permanent neurologic dysfunction Impaired cellular activity
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?
Decreased muscle spasms in the lower extremities
The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP?
Disorientation and restlessness
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?
Dyskinesia
The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?
Fluid restriction
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 client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
Generalized seizure
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?
Glasgow Coma scale
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
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure?
IV diazepam
A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition?
Impaired verbal communication
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
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?
Increased intracranial pressure (ICP)
The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately?
Intravenous diazepam
During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding?
It indicates an injury at the midbrain level.
A client with a chronic neuromuscular disorder has dysphagia. What should the nurse do to prevent aspiration after meals? Select all that apply.
Keep the head of the bed elevated for an hour after meals. Offer liquids frequently in small amounts.
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 documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the client's restrictive clothing.
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
Loss of brain stem reflexes
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment?
Lumbar puncture
The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client?
Maintain head of bed (HOB) elevated at 30 to 45 degrees.
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
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?
Maintenance of 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
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication?
Mannitol
A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
Meningitis
A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case?
Narcotic analgesics increase CSF pressure.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?
Notify the physician of a possible cerebrospinal fluid leak.
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?
Osteoporosis
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:
Parkinson's disease.
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?
Phenytoin
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?
Place the client in a side-lying position.
A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses?
Prepare an advance directive.
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?
Respiratory function
A client with neurologic 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 patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?
Semisolid food with thick liquids
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering
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 low.
A nurse is caring for a client with recent history of migraines. What aspect of this client's current status may rule out the safe use of triptans?
The client has angina.
A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches?
The client takes vasodilators for the treatment of angina.
Which client should the nurse assess for degenerative neurologic symptoms?
The client with Huntington disease.
The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
The client's activities immediately prior to the seizure.
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 perform frequent physical activity but avoid becoming fatigued.
The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply.
Transcranial Doppler flow study Cerebral angiography MRI
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:
Tremors and muscle rigidity
A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?
Weakness starting in the muscles supplied by the cranial nerves
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 caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
What is one of the earliest signs of increased ICP?
decreased level of consciousness (LOC)
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to
dehydrate the brain and reduce cerebral edema.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise.
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
A client with a neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing action is critical for this client?
restricting fluid intake and hydration
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:
shivering in hypothermia can increase ICP.
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.
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?
unequal response
