Chapter 37: Caring for Clients with Central and Peripheral Nervous System Disorders

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

Altered respiratory patterns

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 nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? Inform the care team and assess for further signs of possible increased ICP. Administer bronchodilators as prescribed and monitor the client's LOC. Increase the client's bed height and reassess in 30 minutes. Administer a bolus of normal saline as prescribed.

Inform the care team and assess for further signs of possible increased 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 phenobarbital Intravenous diazepam Oral lorazepam Oral phenytoin

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 suggests onset of metabolic problems. It indicates paralysis on the right side of the body. It indicates paralysis of cranial nerve X (CN X). It indicates an injury at the midbrain level.

It indicates an injury at the midbrain level

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Restrain the client to prevent injury. Open the client's jaws to insert an oral airway. Place client in high Fowler position. Loosen the client's restrictive clothing.

Loosen the client's restrictive clothing.

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Change the client's position as indicated. Monitor serum electrolytes. Maintain NPO status. Monitor arterial blood gas (ABG) values.

Monitor serum electrolytes

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? Prednisone Dexamethasone Cafergot Phenytoin

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. Pad the client's bed rails. Administer antianxiety medications as prescribed. Reassure the client and family members.

Place the client in a side-lying position

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

Shivering

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

Supine position with the head slightly elevated

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 he client to a flat surface and turn him on his side

Which is the earliest sign of increasing intracranial pressure? Vomiting Change in level of consciousness Headache Posturing

Change in level of consciousness

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

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? Epileptic cry Confusion Urinary incontinence Body rigidity

Confusion

What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC) headache Cushing's triad coma

Decreased level of consciousness (LOC)

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to control fever. control shivering. dehydrate the brain and reduce cerebral edema. reduce cellular metabolic demand.

Dehydrate the brain and reduce cerebral edema

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? Fluid restriction Transfusion of platelets Transfusion of fresh frozen plasma (FFP) Electrolyte restriction

Fluid restriction

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? Unclassified seizure Absence seizure Generalized seizure Focal seizure

Generalized seizure

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

Lethargy and stupor

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? Baclofen Riluzole Dantrolene sodium Diazepam

Riluzole

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. Bradycardia Bradypnea Hypertension Tachycardia Pupillary constriction

Bradycardia Bradypnea Hypertension

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 is 75 years old. The client's migraines are linked to psychosocial stress. The client has angina. The client has hypertension.

The client has angina

Which client should the nurse assess for degenerative neurologic symptoms? The client with Huntington disease. The client with Paget disease. The client with osteomyelitis. The client with glioma.

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 ability of the client to follow instructions during the seizure. The success or failure of the care team to physically restrain the client. The client's ability to explain his seizure during the postictal period. The client's activities immediately prior to the seizure.

The client's activities immediately prior to the seizure

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 3 6 9 15

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? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg

70 mm Hg

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

Which signs are manifestations of the Cushing triad? Select all that apply. Bradycardia Hypertension Bradypnea Tachycardia

Bradycardia Bradypnea Hypertension

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

One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? Sensory symptoms Motor symptoms Impaired consciousness Compound forms

Impaired consciousness

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? Solid food with thin liquids Pureed food with water Semisolid food with thick liquids Thin liquids only

Semisolid food with thick liquids

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. hypothermia is indicative of severe meningitis. hypothermia is indicative of malaria. hypothermia can cause death to the client.

Shivering in hypothermia can increase ICP

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

Side-lying to facilitate drainage of oral secretions

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.

The CPP is low The normal CPP is 70 to 100 mm Hg

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: Increasing forgetfulness and confusion Tremors and muscle rigidity Visual disturbances and muscle weakness Fatigue and respiratory difficulties

Tremors and muscle rigidity

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.

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

Compliance with the prescribed medication regimen

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 Decreased pulse and respirations Projectile vomiting Loss of corneal reflex

Disorientation and restlessness

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Positioning the patient on his or her side with head flexed forward Providing for privacy Restraining the patient to avoid self injury

Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy

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

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? Place a cooling blanket on the client Administer mannitol Turn the client to the side Insert oral airway

Turn the client to the side

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? Generalized seizure Absence seizure Focal seizure Unclassified seizure

Absence seizure

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's pain becomes unbearable As soon as the client senses the onset of symptoms Twenty to 30 minutes after the onset of symptoms When the client senses his or her symptoms peaking

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? Initiate the code team response. Put a padded tongue blade into the client's mouth and restrain his extremities. Record the type of seizure and the time that it occurred. Assist the client to the floor, in a side-lying position, and protect him with linens.

Assist the client to the floor, in a side-lying position and protect him with linens

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 Exacerbation of uncontrolled hypertension Infection Increase in cerebral perfusion pressure

Increased ICP

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? Hemiplegia Dry mucous membranes Signs of internal bleeding Loss of brain stem reflexes

Loss of brain stem reflexes

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. Narcotic analgesics are ineffective against pain in head trauma. Narcotic analgesics decrease CSF pressure. Avoidance is inappropriate because narcotic analgesics are the drug of choice in treating pain associated with head trauma.

Narcotic analgesics increase CSF pressure

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? Position the client the high Fowler position as tolerated. Administer osmotic diuretics as prescribed. Participate in interventions to increase cerebral perfusion pressure (CPP). Prepare the client for craniotomy.

Participate in interventions to increase cerebral perfusion pressure (CPP)

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Computed tomography (CT) scan Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies

Lumbar puncture

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? Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) Decreased muscle spasms in the lower extremities Increased muscle strength in the upper extremities Promotion of urinary continence

Decreased muscle spasms in the lower extremities

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

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

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

High in protein and low in carbohydrate

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? Positioning to prevent complications Maintenance of a patent airway Assessment of pupillary light reflexes Determination of the cause

Maintenance of a patent airway

In the aggressive treatment for increased intracranial pressure, IV therapy can be an instrumental tool in decreasing ICP. What type of IV solution would a physician order to maintain cerebral tissue perfusion? Select all that apply. normal saline lactated Ringer's DW hypotonic saline

Normal saline Lactated Ringer's

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 Potential skin breakdown Cardiac function Cognition

Respiratory function

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Position the client supine. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position client in prone position. Maintain bed in Trendelenburg position.

Maintain head of bed (HOB) elevated at 30-45 degrees

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? Hydrochlorothiazide Furosemide Mannitol Spironlactone

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? Encephalitis CSF leak Meningitis Catheter occlusion

Meningitis

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

Restricting fluid intake and hydration

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. Designate a most responsible health care provider (MRP) early in the course of the disease. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. Ensure that witnesses are present when he provides instruction.

Prepare an advance directive.