Ch. 61

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 client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?

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

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 client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?

15

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

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 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

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action?

Administer acetaminophen per orders.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered.

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

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 optic nerve

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

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decerebrate

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

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining level of consciousness (LOC)

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 caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

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

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

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

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?

Lamictal

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?

Lethargy

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

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.

Maintain a headache diary. Keep a food diary.

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 disease.

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

Phenobarbital

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?

Rising blood pressure and bradycardia

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

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

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 client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

You must avoid coughing, sneezing, and blowing your nose

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:

diploplia

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson disease and Huntington disease is the development of what symptom in clients with advanced Huntington disease?

hallucinations and delusions

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

low

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.

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."

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

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 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.

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.

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?

Cluster

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 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?

Decorticate

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.

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

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Lactated Ringer's

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 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 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 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 client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?

Turn the client to the side

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

Urinary tract infection

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?

Vasopressin

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.

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

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

diminished responsiveness.

A nurse working in the neurologic intensive care unit 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 part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis?

poor

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

Which method is used to help reduce intracranial pressure?

using a cervical collar