Chapter 66: Management of Patients With Neurologic Dysfunction

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

Herniation

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

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

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

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

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

A 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 at which time point after intracranial surgery?

24 hours

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

Brain tumor

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

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?

Drooping eyelids

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate

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?

Increased intracranial pressure (ICP)

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

Lethargy and stupor

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Parkinson's disease.

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

Which method is used to help reduce intracranial pressure?

Using a cervical collar

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

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

chewing

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

diminished responsiveness.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis?

poor

The Monro-Kellie hypothesis explains

the dynamic equilibrium of cranial contents.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

unequal response

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?

An absence seizure

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

Which signs are manifestations of the Cushing triad? Select all that apply.

Bradycardia Hypertension Bradypnea

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate

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

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

Phenobarbital

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

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

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency."

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

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

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mmHg

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 ONLY.

97.5 g

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

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.

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

Explaining hospice care and services

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?

Gingival hyperplasia

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 mL/h

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as ordered

The nurse 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?

Apply warm or cool cloths to the forehead or back of the neck

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?

Aspiration of a brain abscess

Which phase of a migraine headache usually lasts less than an hour?

Aura

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

Avoiding flexion of the neck with use of a cervical collar

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction?

B

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

Decorticate

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

Decorticate

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings?

Excessive urine output and decreased urine osmolality

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized

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 nursing diagnoses would be the first priority for the plan of care?

Ineffective airway clearance related to altered LOC

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

A nurse 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?

Maintenance of a patent airway

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Notify the physician of a possible cerebrospinal fluid leak.

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?

Pituitary carcinoma

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?

Reorient the client while gently holding their arms.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity.

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

Shivering

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

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

Turn the client to the side

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following?

Vasopressin therapy

When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as

decerebrate

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness.

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.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

promote carbon dioxide elimination.

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.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

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

3

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Osteoporosis