Ch. 61 Management of Patients with Nuero dysfunctions

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply? A) Are you exposed to any toxins or chemicals at work? B) How would you describe your ability to cope with stress? C) What medications are you currently taking? D) When was the last time you were hospitalized? E) Does anyone else in your family struggle with headaches?

A) Are you exposed to any toxins or chemicals at work? B) How would you describe your ability to cope with stress? C) What medications are you currently taking? E) Does anyone else in your family struggle with headaches

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

A) Disorientation and restlessness Later signs include decreased pulse and vomiting

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. A) Ensure access to a language board when communicating with the client. B) Obtain daily weights to monitor weight gain. C) Establish a voiding time schedule. D) Encourage the client to walk with feet wide apart.

A) Ensure access to a language board when communicating with the client. C) Establish a voiding time schedule

Apatient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding? A) Recognize that this may represent the peak of post-surgical cerebral edema. B) Alert the surgeon to the possibility of an intracranial hemorrhage. C) Understand that the surgery may have been unsuccessful. D) Recognize the need to refer the patient to the palliative care team.

A) Recognize that this may represent the peak of post-surgical cerebral edema Post-op cerebral edema is normal after surgery, goes away after 24 - 36 hours

Aschool nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space,according to the playground supervisor. How would the nurse document the girls activity in her chart at school? A) Generalized seizure B) Absence seizure C) Focal seizure D) Unclassified seizure

B) Absence seizure all other seizures involved involuntary movement

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. Tachycardia Pupillary constriction Bradycardia Hypertension Bradypnea

Bradycardia Hypertension Bradypnea

Aneurologic nurse is reviewing seizures with a group of staff nurses. Howshould this nurse best describe the cause of aseizure? A) Sudden electrolyte changes throughout the brain B) A dysrhythmiain the peripheral nervous system C) A dysrhythmia in the nerve cells in one section of the brain D) Sudden disruptions in the blood flowthroughout the brain

C) A dysrhythmia in the nerve cells in one section of the brain

The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Furosemide

C) Dexamethasone

A patient 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? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure

C) Generalized seizure Generalized tonic clonic seizure, involves both parts of the brain

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

Isotonic solutions such as Lactated ringers , NS 0.9%

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?

Vasodilation Hypotension and hypoxia lead to vasodilation which leads to increased ICP

ALS has no known Genetic factors

true

Apatient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

C) Mannitol ( Osmitrol ) Mannitol is a osmolarity diuretic and reduces the available amount of fluids present in the brain tissue which then reduces CSF draining

Apatient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is nowexhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A) Encephalitis B) CSF leak C) Meningitis D) Catheter occlusion

C) Meningitis

Apatient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? A) Cerebellum B) Hypothalamus C) Pituitary gland D) Pineal gland

C) Pituitary gland Through the mouth and nose route

What should the nurse suspect when hourly assessment of urine output on a patient post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A) Cushing syndrome B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Adrenal crisis D) Diabetes insipidus

D) Diabetes insipidus DI can be caused by brain tumors, brain trauma or brain surgery complication

Apatient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patients jaws to insert an oral airway. C) Place patient in high Fowlers position. D) Loosen the patients restrictive clothing.

D) Loosen the patients restrictive clothing place on their side to allow saliva draining and avoid aspiration

Apatient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes

D) Loss of brain stem reflexes pupils fixed and dilated, doesn't blink

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

Diminished responsiveness

Cerebral edema peaks at which time point after intracranial surgery?

between 24 - 36 hours

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

chewing Trigeminal nerve ( Teeth ) , Nerve V,

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

herniation