chapter 66

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? a) "All hospice clients die at home." b) "The physician coordinates all the care delivered." c) "Hospice care uses a team approach and provides complete care." d) "Clients and families are the focus of hospice care."

"Clients and families are the focus of hospice care." Correct Explanation: The most important component of hospice care is the focus that is placed on the care of the client as well as the family. Hospice does take a team approach and coordinates care through the hospice physician, but these are not the focus. Not all hospice clients wish to die at home.

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) "There is a very weak familial tendency." b) "There is a strong familial tendency." c) "No familial tendency has been demonstrated." d) "Only secondary migraine headaches show a familial tendency."

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

Which of the following values is a normal intracranial pressure in mm Hg? a) 21 b) 9 c) 5 d) 12

12 Explanation: ICP is usually measured in the lateral ventricles, with the normal pressure being 10 to 20 mm Hg. The other values are incorrect.

Cerebral edema peaks at which timeframe post intracranial surgery? a) 24 hours b) 12 hours c) 48 hours d) 72 hours

24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a) 12 b) 6 c) 3 d) 9

3 Correct Explanation: 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 (see Chapter 68).

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: a) 52 mm Hg. b) 48 mm Hg. c) 68 mm Hg. d) 88 mm Hg.

52 mm Hg. Explanation: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula: page 1943

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)? a) Elevating the head of the bed 90 degrees b) Administering a stool softener as ordered c) Encouraging oral fluid intake d) Suctioning the client once each shift

Administering a stool softener as ordered Correct Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

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) Aspiration of a brain abscess b) To assess visual acuity c) Visualization of a hemorrhage d) Access for intravenous (IV) fluids

Aspiration of a brain abscess Correct Explanation: 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.

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Keeping the head flat with use of no pillow b) Avoiding flexion of the neck with use of a cervical collar c) Rotating the neck to the far right with neck support d) Extreme hip flexion supported by pillows

Avoiding flexion of the neck with use of a cervical collar Correct Explanation: Use of a 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 unless otherwise prescribed. 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.

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

Brain tumor Explanation: The incidence of brain tumor decreases 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

Which of the following is the earliest sign of increasing ICP? a) Headache b) Posturing c) Vomiting d) Change in level of consciousness

Change in level of consciousness Explanation: The earliest sign of increasing ICP is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

Which of the following is the earliest sign of increasing ICP? a) Vomiting b) Headache c) Posturing d) Change in level of consciousness (LOC)

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

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? a) Damage to the vagal nerve b) Damage to the facial nerve c) Damage to the optic nerve d) Damage to the olfactory nerve

Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? a) Decerebrate b) Flaccid c) Decorticate d) Normal

Decerebrate Correct Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet

Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? a) Flaccid b) Decorticate c) Normal d) Decerebrate

Decorticate Correct Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone.

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

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

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) High in protein and low in carbohydrate c) Restricts protein to 10% of daily caloric intake d) At least 50% carbohydrate

High in protein and low in carbohydrate Explanation: 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 (Mosek, Natour, Neufeld, et al., 2009).

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Status epilepticus b) Shock c) Increased intracranial pressure (ICP) d) Encephalitis

Increased intracranial pressure (ICP) Correct Explanation: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A patient with epilepsy is having a seizure. Which of the following should the nurse do after the seizure? a) Place a cooling blanket beneath the patient. b) Keep the patient to one side. c) Pry the patient's mouth open to allow a patent airway. d) Help the patient sit up.

Keep the patient to one side.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? a) Labetalol b) Lamisil c) Lamictal d) Lomotil

Lamictal Correct Explanation: 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) Lethargy and stupor b) Hypertension c) Bradycardia d) A bounding pulse

Lethargy and stupor Correct Explanation: 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 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) Give the patient some mouthwash to gargle with. b) Notify the physician of a possible cerebrospinal fluid leak. c) Request an antihistamine for the postnasal drip. d) Ask the patient to cough to observe the sputum color and consistency.

Notify the physician of a possible cerebrospinal fluid leak. Correct Explanation: 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.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. 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 Correct Explanation: These drugs are commonly used in the medical management of Parkinson's disease. Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are 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 client you are caring for experiences a seizure. What would be a priority nursing action? a) Insert a tongue blade between the teeth. b) Suction the mouth during the convulsion. c) Restrain the client during the seizure. d) Protect the client from injury.

Protect the client from injury. Correct Explanation: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.

Which of the following is an inaccurate manifestation of Cushing's triad? a) Bradypnea b) Bradycardia c) Tachycardia d) Hypertension

Tachycardia Explanation: Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

A patient with increased ICP has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP? a) The CPP reading is inaccurate. b) The CPP is within normal limits. c) The CPP is low. d) The CPP is high.

The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

In your assessment of a 39-year-old victim of a motor vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure? a) Constricted response b) Unequal response c) Equal response d) Rapid response

Unequal response Correct Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated. This is not a sign of increasing ICP. In increased ICP, the pupil response is unequal.

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? a) Seizures b) Vomiting c) Vector bites d) Change in level of consciousness

Vector bites Explanation: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in LOC, vomiting, and seizures are all symptoms of increased ICP and due not assist in the differentiating of cause, diagnosis, or establishing nursing care.

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

diminished responsiveness. Explanation: 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.

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

promote carbon dioxide elimination. Explanation: 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 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? a) "I will lose strength in my arms." b) "I need to remain active for as long as possible." c) "I will have progressive muscle weakness." d) "My children are at greater risk to develop this disease."

"My children are at greater risk to develop this disease." Correct Explanation: 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 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) 70 mm Hg b) 80 mm Hg c) 60 mm Hg d) 50 mm Hg

70 mm Hg Correct Explanation: 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 (Hickey, 2009).

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. How many grams will the nurse administer to the client? Enter the correct number ONLY. ____grams

97.5

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)? a) Encouraging oral fluid intake b) Administering a stool softener as ordered c) Elevating the head of the bed 90 degrees d) Suctioning the client once each shift

Administering a stool softener as ordered Correct Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

Which of the following is a late sign of increased ICP? a) Altered respiratory patterns b) Slowing of speech c) Irritability d) Headache

Altered respiratory patterns Correct Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache is an early sign of increased ICP. Irritability and any change in LOC are early signs of increased ICP. Speech changes, such as slowing or slurring, are early signs of increased ICP.

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child? a) A partial seizure b) A complex seizure c) An absence seizure d) A tonic-clonic seizure

An absence seizure Correct Explanation: 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. A generalized seizure involves the whole brain.

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? a) Decerebrate b) Flaccidity c) Tonic clonic d) Decorticate

Decerebrate Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures

Which of the following is one of the earliest signs of increased ICP? a) Coma b) Cushing's triad c) Decreased level of consciousness (LOC) d) Headache

Decreased level of consciousness (LOC) Correct Explanation: Decreasing LOC is one of the earliest signs of increased ICP. Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. Decreasing LOC is one of the earliest signs of increased ICP. If untreated, increasing ICP will lead to coma. Decreasing LOC is one of the earliest signs of increased ICP.

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) Flat c) Turned onto the operative side d) Elevated 30 degrees

Elevated 30 degrees Correct Explanation: 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.

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? a) Managing muscle weakness b) Explaining hospice care and services c) Offering family support groups d) Optimizing nutrition

Explaining hospice care and services Correct Explanation: 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.

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. a) Bradykinesia b) Muscle fasciculations c) Hallucinations and delusions d) Depression

Hallucinations and delusions Explanation: 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.

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

Maintains a patent airway Explanation: 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 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) Assessment of pupillary light reflexes b) Positioning to prevent complications c) Maintenance of a patent airway d) Determination of the cause

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

To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do? a) Promote an active range of motion. b) Avoid physical contact with family members. c) Minimize exposure to bright lights and noise. d) Increase environmental stimuli.

Minimize exposure to bright lights and noise. Correct Explanation: 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. Environmental stimuli may worsen symptoms; therefore, environmental stimuli 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 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) Cushing's b) Monro-Kellie c) Dawn phenomenon d) Hashimoto's disease

Monro-Kellie Correct Explanation: 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 cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hasimoto's disease is related to the thyroid gland.

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) Osteoarthritis b) Anemia c) Osteoporosis d) Obesity

Osteoporosis Correct Explanation: 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 (AANN, 2009).

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________. a) Multiple sclerosis b) Huntington's disease c) Parkinson's disease d) Seizure disorder

Parkinson's disease Correct Explanation: These drugs are commonly used in the medical management of Parkinson's disease. Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are 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.

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) Esophageal carcinoma b) Colorectal carcinoma c) Laryngeal carcinoma d) Pituitary carcinoma

Pituitary carcinoma Correct Explanation: 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. Surgery to treat esophageal carcinoma usually is palliative and involves esophagogastrectomy with jejunostomy. Laryngeal carcinoma may necessitate a laryngectomy. To treat colorectal cancer, the surgeon removes the tumor and any adjacent tissues and lymph nodes that contain cancer cells.

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in supine position with head slightly elevated. b) Place patient in the dorsal recumbent position. c) Place patient in prone position with head turned to unaffected side. d) Place patient in the Trendelenburg position.

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

A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention? a) Shivering b) Capillary refill of 2 seconds c) Cool, dry skin d) Urine output of 100 mL/hr

Shivering Explanation: 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

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

Suicidal ideations Correct Explanation: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate but not as important as assessing for suicidal ideations.

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in supine position with head slightly elevated. b) Place patient in the Trendelenburg position. c) Place patient in the dorsal recumbent position. d) Place patient in prone position with head turned to unaffected side.

Supine position with head slightly elevated Correct Explanation: After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. Bed rest with a firm mattress and bed board is used for patients with a lumbar herniated disk. Sitting position and body and head aligned are the correct positions to place the patient after the surgery.

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects? a) To dehydrate the brain and reduce cerebral edema b) To increase urine output c) To lower uncontrolled fevers d) To reduce cellular metabolic demands

To dehydrate the brain and reduce cerebral edema Correct Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the patient with IICP. Although mannitol is a type of diuretic, it is not used to increase urine output. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

Which of the following are used to help reduce ICP? a) Rotating the neck to the far right with neck support b) Extreme hip flexion supported by pillows c) Using a cervical collar d) Keeping the head of bed flat

Using a cervical collar Correct Explanation: Use of a 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 unless otherwise prescribed. 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.

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) Bradycardia b) Pupillary constriction c) Hypertension d) Tachycardia e) Bradypnea

• Bradycardia • Bradypnea • Hypertension Explanation: 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.

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 illnes." b) "Cases of epilepsy are often associated intellectual level." c) "In most people, epilepsy is usually synonymous with mental retardation." d) "Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Explanation: Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with mental retardation or illness.

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 pupils. b) Assess for a patent airway. c) Assess vital signs. d) Assess Glasgow Coma Scale.

Assess for a patent airway. Correct Explanation: 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.

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Keeping the head flat with use of no pillow b) Avoiding flexion of the neck with use of a cervical collar c) Extreme hip flexion supported by pillows d) Rotating the neck to the far right with neck support

Avoiding flexion of the neck with use of a cervical collar Explanation: Use of a 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 unless otherwise prescribed. 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.

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

Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper extremities and plantar flexion of the feet. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone.

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) Rigid b) Decerebrate c) Flaccid d) Decorticate

Flaccid Explanation: 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 (see Chapter 68). An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate (Fig. 66-1; see also Chapter 65). The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been administered pharmacologic paralyzing agents (i.e., neuromuscular blocking agents).

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) More than 200 mL/h b) 50 to 100 mL/h c) 150 to 200 mL/h d) 100 to 150 mL/h

More than 200 mL/h Correct Explanation: 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 (Hickey, 2009).

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in prone position with head turned to unaffected side. b) Place patient in the Trendelenburg position. c) Place patient in supine position with head slightly elevated. d) Place patient in the dorsal recumbent position.

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

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) Muscle spasms b) Drooping eyelids c) Shortness of breath d) Sensitivity to bright light

Drooping eyelids Explanation: Ptosis is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.

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

"You must avoid coughing, sneezing, and blowing your nose." Explanation: 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

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? a) Use pressure-relieving devices when the client is in bed or in a wheelchair. b) Change body position every 2 hours. c) Use a footboard and trochanter rolls. d) Help the client perform range-of-motion (ROM) exercises every 8 hours.

Help the client perform range-of-motion (ROM) exercises every 8 hours. Explanation: Helping the client perform ROM exercises every 8 hours helps in promoting joint flexibility and muscle tone in a client with muscle weakness. Measures such as using pressure-relieving devices or changing the body positions every 2 hours prevents skin breakdown. The nurse should use a footboard and trochanter rolls to promote a neutral body position that will keep the body in good alignment.

A patient experiences a seizure while hospitalized for appendicitis. During the postictal phase, the patient is yelling and swings with a closed fist at the nurse. Which of the following is the appropriate action for the nurse to take? a) Place the patient in wrist restraints. b) Apply oxygen via nasal cannula. c) Reorient the patient while gently holding the arms. d) Administer lorazepam (Ativan) per orders.

Reorient the patient while gently holding the arms. Explanation: Some patients during the postictal phase will become confused and agitated. This reaction is not intentional and most patients do not remember becoming agitated. The nurse should attempt to calm and reorient the patient, but also should gently hold the arms to prevent the patient from hitting. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the patient before applying wrist restraints. Lorazepam (Ativan) is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this patient.

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

Suicidal ideations Correct Explanation: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate, but not as important as assessing for suicidal ideations.

A 17-year-old victim of a motor vehicle collision is admitted to the ICU. She suffered a closed head injury in the event, an ICP monitor was inserted, and you monitor according to physician's orders. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? a) Vasoconstriction b) Increased PaO c) Vasodilation d) Hypertension

Vasodilation Explanation: Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels, and this leads to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

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? a) good b) poor c) excellent d) fatal

poor Correct Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Status epilepticus b) Shock c) Increased intracranial pressure (ICP) d) Encephalitis

Increased intracranial pressure (ICP) Explanation: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option. a) Because hypothermia is indicative of severe meningitis b) Because shivering in hypothermia can increase ICP c) Because hypothermia is indicative of malaria d) Because hypothermia can cause death to the client

Because shivering in hypothermia can increase ICP Correct Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia causes shivering, and shivering, in turn, can increase intracranial pressure. Hypothermia causes shivering, and shivering, in turn, can increase intracranial pressure. Hypothermia causes shivering, and shivering, in turn, can increase intracranial pressure.

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside? a) Nebulizer and thermometer b) Incentive spirometer c) Intubation tray and suction apparatus d) Blood pressure apparatus

Intubation tray and suction apparatus Correct Explanation: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.

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

"My children are at greater risk to develop this disease." Correct Explanation: 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.

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease? a) Drugs administered may not cause the requisite therapeutic effect. b) Clients take an assortment of different drugs. c) Clients generally do not adhere to the drug regimen. d) Drugs administered may cause a wide variety of adverse effects.

Drugs administered may cause a wide variety of adverse effects. Correct Explanation: Drugs administered for Parkinsonism may cause a wide variety of adverse effects, which requires careful observation of the client. Over time, clients may respond less and less to their standard drug therapy and have more frequent "off episodes" of hypomobility. As a result, the nurse should administer the drugs closely to the schedule. Generally, a single drug called levodopa is administered to clients with Parkinson's disease. It is also not true that drugs may not cause the requisite therapeutic effect or such clients do not adhere to the drug regimen.

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

"You must avoid coughing, sneezing, and blowing your nose." Explanation: 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

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? a) Continue the assessment because no actions are indicated at this time. b) Check the equipment. c) Document the reading because it reflects that the treatment has been effective. d) Contact the physician to review the care plan.

Check the equipment. Explanation: 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 patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a) Administering prescribed antipyretics b) Restricting fluid intake and hydration c) Maintaining adequate hydration d) Hyperoxygenation before and after tracheal suctioning

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

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

Administer corticosteroids as ordered. Correct Explanation: Cranial arteritis is caused by inflammation. The inflammation 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 patient 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. Documentation of signs and symptoms of inflammation should be done by the nurse after measures have been taken to decrease complications.

The nurse is taking care of a patient with a history of headaches. The nurse takes measures to reduce headaches in the patient in addition to administering medications. Which of the following appropriate nursing interventions may be provided by the nurse to such a patient? a) Maintain hydration by drinking eight glasses of fluid a day b) Perform the Heimlich maneuver c) Use pressure-relieving pads or a similar type of mattress d) Apply warm or cool cloths to the forehead or back of the neck

Apply warm or cool cloths to the forehead or back of the neck Explanation: 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. These measures are aimed at reducing the occurrence of headaches in the patient. A patient with transient ischemic attacks is advised to maintain the hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the patient cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the patient's body.

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? a) Record the type of seizure and the time that it occurred. b) Initiate the code team response. c) Put a padded tongue blade into the client's mouth and restrain his extremities. d) 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. Correct Explanation: The nurse should protect the client from injury by assisting him to the floor, in a side-lying position, and protect him from harm by padding the floor with bed linens. Initiating a response from the code team isn't necessary because seizures are self-limiting. As long as the client's airway is protected, his cardiopulmonary status isn't affected. The nurse shouldn't force anything into the client's mouth during a seizure; doing so may cause injury. Documenting seizure activity is important, but it doesn't take priority over client safety.

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.) a) Loosening constrictive clothing b) Restraining the patient to avoid self injury c) Opening the patient's jaw and inserting a mouth gag d) Providing for privacy e) Positioning the patient on his or her side with head flexed forward

• Loosening constrictive clothing • Providing for privacy • Positioning the patient on his or her side with head flexed forward Correct Explanation: During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

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.) a) Positioning the patient on his or her side with head flexed forward b) Providing for privacy c) Restraining the patient to avoid self injury d) Loosening constrictive clothing e) 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 • Loosening constrictive clothing Correct Explanation: During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.