Ch 66 PrepU: Management of Patients With Neurologic Dysfunction

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

"My children are at greater risk to develop this disease." There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.

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 mg

Cerebral edema peaks during what time frame after intracranial surgery?

24-36 hours

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 9 B. 3 C. 12 D. 6

3 LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive

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: 48 mm Hg. 52 mm Hg. 68 mm Hg. 88 mm Hg.

52 mm Hg MAP-ICP=CPP The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP)

A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication?

70 58 kg X 2 = 116 mcg/min. 116 mcg X 60 minutes = 6,960 mcg per hour. 6,960 mcg/1000 = 6.96 mg, rounded to 7 mg/hour. (7 mg/50 mg) X 500 mL = 70 mL/hour.

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? A. 60 mm Hg B. 80 mm Hg C. 70 mm Hg D. 50 mm Hg

70 mm Hg Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 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 g

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? A. Assess for s/s of infection. B. Provide ventriculostomy care. C. Inspect the ICP monitor to ensure it is working properly. D. Administer acetaminophen per orders.

Administer acetaminophen per orders The nurse needs to control the fever by administering the ordered acetaminophen as the priority action. An increase in the client's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the client has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.

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

Administer corticosteroids as ordered. Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.

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

Administer medications at exact intervals ordered.

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? Encourage coughing and deep breathing. Position the client with the head turned toward the side of the brain tumor. Administer stool softeners. Provide sensory stimulation.

Administer stool softeners Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

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

Altered respiratory patterns Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

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? A. A tonic-clonic seizure B. A myoclonic seizure C. A partial seizure D. An absence seizure

An absence seizure Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? A. Access for intravenous (IV) fluids B. Visualization of a hemorrhage C. To assess visual acuity D. Aspiration of a brain abscess

Aspiration of brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? A. Assess for a patent airway B. Assess Glasgow coma scale C. Assess VS D. Assess pupils

Assess for a patent airway A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.

A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client? A. Time, distance, and shielding against radiation B. Assessing skull dressing for excess drainage C. Maintain airway via artificial ventilation. D. Assess neurological findings.

Assess neurological findings Gamma-knife radiosurgery is a non-invasive alternative for treating tumors within the brain. The nurse would be responsible for completing a neurological assessment on the client and providing comfort measures as needed. There is no incision on the skull, and no risk for radiation exposure to the nurse. The procedure eliminates surgical and anesthesia complications and does not result in use of a ventilator or artificial airway maintenance.

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. Hypertension B. Bradycardia C. Pupillary constriction D. Bradypnea D. Tachycardia

Bradycardia Bradypnea HTN At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? A. Epilepsy B. Trigeminal neuralgia C. Hypostatic pneumonia D. Brain tumor

Brain tumor The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.

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 high. The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate.

CPP is low normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low

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

Cerebrovascular disease Metabolic and toxic conditions Hyponatremia Brain tumor Drug and alcohol withdrawal The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (e.g., renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies.

Which is the earliest sign of increasing intracranial pressure? A. Change in LOC B. Posturing C. Headache D. Vomiting

Change in LOC The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

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. Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective.

Check the equipment A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

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

Chewing

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. Cloudy cerebral spinal fluid Pain and stiffness of the extremities Purpura of hands and feet Low white blood cell (WBC) count Low red blood cell (RBC) count Low antidiuretic hormone (ADH) levels

Cloudy cerebral spinal fluid Purpura of hands and feet

While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of 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 person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; rather he or she paces or thrashes about.

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? A. Recent weight gain and loss B. The type of anticonvulsant prescribed to manage the epileptic condition C. Recent stress level D. Compliance with the prescribed medication regimen

Compliance with the prescribed medication regimen

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

D. Avoiding flexion of the neck with use of a cervical collar

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 Insomnia Seizures

Death Permanent neurologic dysfunction Impaired cellular activity Seizures

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 normal. flaccid. decorticate. decerebrate

Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.

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 Loss of gag reflex and mental confusion Complaints of headache and lack of pupillary response Mental confusion and pupillary changes

Decerebrate posturing and loss of corneal reflex Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood pressure and temperature, widened pulse pressure, Cheyne-Stokes breathing, projectile vomiting, hemiplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).

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? A. Irregular breathing pattern B. Declining LOC C. Involuntary posturing D. Pupillary asymmetry

Declining LOC With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

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? Picture A: Plantar flexed Thighs internally rotated Elbows flexed Hands flexed over chest Arms adducted A. Flaccidity B. Decerebrate C. Decorticate D. Tonic clonic

Decorticate

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. Sensitivity to bright light B. SOB C. Muscle spasms D. Drooping eyelids

Drooping eyelids Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. SOB and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in MS

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? A. Elevated no more than 10 degrees B. Turned onto the operative side C. Flat D. Elevated 30 degrees

Elevate 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Administer Percocet as ordered. B. Complete a head-to-toe assessment. C. Elevate the head of the bed. D. Administer morning dose of anticonvulsant.

Elevate HOB The first action would be to elevate the HOB to promote venous drainage of blood CSF Then, a neurological assessment would be completed to determine if any other assessment findings are significant of IICP The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

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

Ensure access to a language board when communicating with the client. Establish a voiding time schedule. Encourage the client to walk with feet wide apart.

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? Excessive urine output and decreased urine osmolality Oliguria and decreased urine osmolality Oliguria and serum hyperosmolarity Excessive urine output and serum hypo-osmolarity

Excessive urine output and decreased urine osmolality Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.

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. Decorticate B. Flaccid C. Rigid D. Decerebrate

Flaccid

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? A. Absence B. Generalized C. Sensory D. Jacksonian

Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. -A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. -Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. -Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor

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

Herniation

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. Low in fat B. At least 50% carbohydrate C. Restricts protein to 10% of daily caloric intake D. High in protein and low in carbohydrate

High in protein and low in carb A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control

Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition? Hypocortisolism Hypoglycemia Hyperglycemia Hypercalcemia

Hypocortisolism

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? A. Increased ICP B. Exacerbation of uncontrolled hypertension C. Increase in cerebral perfusion pressure D. Infection

Increased ICP Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? Fluid volume deficit Risk for infection Ineffective cerebral tissue perfusion Risk for injury

Ineffective cerebral tissue perfusion The brain must be adequately perfused to maintain fxn and prevent long-term disability due to lack of oxygenation. The client is at risk for injury, fluid volume deficit due to a possible fluid restriction to maintain normovolemia, and infection due to the placement of the intraventricular catheter, but these are not the priority.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? A. Lamictal B. Labetalol C. Lomotil D. Lamisil

Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A. Hypertension B. Bradycardia C. A bounding pulse D. Lethargy and stupor

Lethargy and stupor As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

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? A. Determination of the cause B. Assessment of pupillary light reflexes C. Positioning to prevent complications D. Maintenance of a patent airway

Maintenance of a patent airway The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? Glycerin Isosorbide Mannitol Urea

Mannitol

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Half-normal saline (0.45% NSS) B. Dextrose 5% in water (D5W) C. One-third normal saline (0.33% NSS) D. Mannitol

Mannitol With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

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. More than 200 mL/h C. 150 to 200 mL/h D. 100 to 150 mL/h

More than 200mL/h For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus

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? A. Request an antihistamine for the postnasal drip. B. Give the patient some mouthwash to gargle with. C. Ask the patient to cough to observe the sputum color and consistency. D. Notify the physician of a possible cerebrospinal fluid leak.

Notify physician of possible cerebrospinal fluid leak Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.

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? A. Osteoporosis B. Obesity C. Anemia D. Osteoarthritis

Osteoporosis Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of 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: A. seizure disorder. B. multiple sclerosis. C. Parkinson's disease. D. Huntington's disease.

Parkinson's disease Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are most commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.

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? Feet are plantar flexed Wrists are flexed at sides Arm is adducted, extended, and probated

Poor This is decerebrate

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? A. Administering prescribed antipyretics B. Restricting fluid intake and hydration C. Hyperoxygenation before and after tracheal suctioning D. Maintaining adequate hydration

Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

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 Hypotension and bradycardia Hypotension and tachycardia Hypertension and narrowing pulse pressure

Rising blood pressure and bradycardia Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure began at 1300 hours. The client cried out before the seizure began. Seizure was 1 minute in duration including tonic-clonic activity. Sleeping quietly after the seizure

Seizure was 1 minute in duration including tonic-clonic activity. Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? A. Urine output of 100 mL/hr B. Capillary refill of 2 seconds C. Cool, dry skin D. Shivering

Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? A. High Fowler's, to prevent aspiration B. Supine, to rest the muscles of the extremities C. Side-lying, to facilitate drainage of oral secretions D. Semi-Fowler's, to promote breathing

Side-lying to facilitate drainage or oral secretions To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? A. Loss of bowel and bladder control B. Emotional apathy C. Suicidal ideations D. Choreiform movements

Suicidal ideations

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the A. supine position with the head slightly elevated. B. dorsal recumbent position. C. prone position with the head turned to the unaffected side. D. Trendelenburg position.

Supine position with head slightly elevated After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.

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? A. equal response B. constricted response C. unequal response D. rapid response

Unequal response

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

Vasopressin Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.

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) Metoprolol (Lopressor) Amiodarone (Cordarone) Carvedilol (Coreg)

Verapamil (Calan) Ca channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to tx migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: hold the client's arm still to keep him from hitting anything. carefully move the client to a flat surface and turn him on his side. allow the client to remain in the chair but move all objects out of his way. place an oral airway in the client's mouth to maintain an open airway.

carefully move the client to a flat surface and turn him on his side.

A nurse is caring for client diagnosed with Huntington disease. The client's plan of care includes interventions to address the client's potential for injury. Which would be included as a cause for this risk? choreiform movements shuffling gait uncontrolled movements rigidity

choreiform movements

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 Damage to the vagal nerve Damage to the olfactory nerve Damage to the facial nerve

damage to optic nerve

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of: Dysphoria. Facial muscle weakness. Diplopia. Generalized fatigue.

diplopia

Which activity should be avoided in clients with increased intracranial pressure (ICP)? Suctioning Enemas Position changes Minimal environmental stimuli

enemas Enemas should be avoided in clients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the client increases the ICP, rotating beds, turning sheets, and holding the client's head during turning may minimize the stimuli that cause increased ICP.

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? Alopecia Gingival hyperplasia Diplopia Ataxia

gingival hyperplasia SE of dilantin: visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: increase the frequency of the catheterizations. insert an indwelling urinary catheter. place the client on fluid restrictions. use a condom catheter instead of an invasive one.

increase the frequency of the catheterizations. As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.

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

infection The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: prevent respiratory alkalosis. lower arterial pH. promote carbon dioxide elimination. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

promote carbon dioxide elimination. The goal of treatment for ICP is to prevent acidemia by eliminating carbon dioxide because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this client. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

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 lie flat for 24 hours after surgery." "You must avoid coughing, sneezing, and blowing your nose." "You must restrict your fluid intake." "You must report ringing in your ears immediately."

"You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? A. Use pressure-relieving pads or a similar type of mattress B. Perform the Heimlich maneuver C. Apply warm or cool cloths to the forehead or back of the neck D. Maintain hydration by drinking eight glasses of fluid a day

Apply warm or cool cloths to the forehead or back of the neck Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink 8 glasses of fluid a day. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.

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

Diminished responsiveness Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

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

Increased ICP is 12 mm Hg.

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? A. "For many people with epilepsy, the disorder is synonymous with mental illness." B. "In most people, epilepsy is usually synonymous with intellectual disability." C. "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." D. "Cases of epilepsy are often associated with intellectual level."

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

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? Excessive urine output and decreased urine osmolality Oliguria and serum hyponatremia Oliguria and serum hyperosmolarity Excessive urine output and serum hyponatremia

Oliguria and serum hyponatremia SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.

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. "Only secondary migraine headaches show a familial tendency." B. "There is a strong familial tendency." C. "There is a very weak familial tendency." D. "No familial tendency has been demonstrated."

There is a strong familial tendency Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.

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? Attains desired fluid balance Displays no signs or symptoms of infection Maintains a patent airway Demonstrates optimal cerebral tissue perfusion

maintain patent airway Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. Turn the client to the side. Physically restrain the client's movements. Inspect the oral cavity and teeth. Provide verbal reassurance.

turn the client to side provide verbal reassurance Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness.

normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low Using a cervical collar Keeping the head of bed flat Rotating the neck to the far right with neck support Extreme hip flexion, with the hip supported by pillows

using cervical collar cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Administering prescribed antipyretics Elevating the head of the bed to 90 degrees Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Frequent oral care

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Decerebrate Decorticate Flaccid Normal

Decorticate

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. Explaining hospice care and services B. Managing muscle weakness C. Offering family support groups D. Optimizing nutrition

Explaining hospice care and services The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.

Which of the following is an early sign of increasing intracranial pressure (ICP)? Loss of consciousness Vomiting Headache Decerebrate posturing

HA

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

Increased ICP is 12 mm Hg. A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage.

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. Medulla B. Midbrain C. Cortex D. Diencephalon

Midbrain Damage to the midbrain causes decerebrate posturing that's characterized by abnormal extension in response to painful stimuli. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

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

Monro-Kellie -The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. -Cushing's response is seen when cerebral blood flow decreases significantly. -Systolic blood pressure increases, pulse pressure widens, and heart rate slows. -The Dawn phenomenon is related to high BG levels in the morning in clients with diabetes. -Hashimoto's disease is related to the thyroid gland.

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? Giving him a barbiturate Placing him on mechanical ventilation Performing a lumbar puncture Elevating the head of his bed

Performing a lumbar puncture The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

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

Phenobarbital IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures IMMEDIATELY Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state.

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? A. Colorectal carcinoma B. Esophageal carcinoma C. Laryngeal carcinoma D. Pituitary carcinoma

Pituitary carcinoma Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur.

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease. hallucinations and delusions depression bradykinesia muscle fasciculations

hallucinations and delusions As Huntington's disease progresses, hallucinations, delusions, and impaired judgment develop due to degeneration of the cerebral cortex. Depression is a likely symptom for clients with both Parkinson's disease and Huntington's disease. Bradykinesia, slowness in performing spontaneous movement, is commonly associated with Parkinson's disease. Muscle fasciculations, or twitching, are commonly associated with ALS.

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following? Heart failure Kidney failure Pancreatitis Diabetes insipidus

heart failure It is possible for the client to have a fluid overload that creates such an increased workload for the heart that it fails.

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: increase the frequency of the catheterizations. insert an indwelling urinary catheter. place the client on fluid restrictions. use a condom catheter instead of an invasive one.

increase the frequency of the catheterizations. if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased.

Following a motorcycle accident, 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? Blood pressure 100/60 mm Hg Lethargy Nausea Periorbital edema

lethargy Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.

To meet the sensory needs of a client with viral meningitis, the nurse should: minimize exposure to bright lights and noise. promote an active range of motion. increase environmental stimuli. avoid physical contact between the client and family members.

minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? Place the client in wrist restraints. Reorient the client while gently holding their arms. Administer lorazepam per orders. Apply oxygen via nasal cannula.

reorient the client while gently holding their arms Some clients during the postictal phase will become confused and agitated. This reaction is not intentional, and most clients do not later remember becoming agitated. The nurse should attempt to calm and reorient the client, while also gently holding the arms to prevent the client from hitting, thereby preventing the client from doing injury to self or others. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.

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 vasoconstriction hypertension increased PaO

vasodilation