Chapter 66: Management of Patients With Neurologic Dysfunction

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

Answer; C.) Restricting fluid intake and hydration

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

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

Answer: A.) choreiform movements Rationale: Choreiform, described as uncontrollable writhing and twisting of the body, is a typical sign associated with Huntington disease and would be a risk for injury. The other signs are commonly seen in clients with Parkinson's disease.

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.) "A secondary headache is one for which no organic cause can be identified." B.) "A secondary headache is located in the frontal area." C.) "A secondary headache is associated with an organic cause, such as a brain tumor." D.) "A migraine headache is an example of a secondary headache."

Answer; C.) "A secondary headache is associated with an organic cause, such as a brain tumor." Rationale: A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.

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

Answer: A.) Lamictal

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

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

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

Answer: B.) diminished responsiveness.

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.) Decorticate C.) Flaccidity D.) Tonic clonic

Answer: A.) Decerebrate Rationale: 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.

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

Answer: D.) Mannitol

Cerebral edema peaks at which time point after intracranial surgery? A.) 12 hours B.) 24 hours C.) 48 hours D.) 72 hours

Answer: B.) 24 hours

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.) Visualization of a hemorrhage B.) Aspiration of a brain abscess C.) Access for intravenous (IV) fluids D.) To assess visual acuity

Answer: B.) Aspiration of a brain abscess Rationale: 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.

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? A.) Alopecia B.) Gingival hyperplasia C.) Diplopia D.) Ataxia

Answer: B.) Gingival hyperplasia

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

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

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

Answer: - Bradycardia - Bradypnea - Hypertension Rationale: 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 nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A.) 3 B.) 6 C.) 9 D.) 12

Answer: A.) 3 Rationale: 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).

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

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

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

Answer: A.) Apply warm or cool cloths to the forehead or back of the neck

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

Answer: A.) Avoiding flexion of the neck with use of a cervical collar Rationale: 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 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.) Monro-Kellie B.) Cushing's C.) Dawn phenomenon D.) Hashimoto's disease

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

The initial sign of increasing intracranial pressure (ICP) includes A.) decreased level of consciousness. B.) herniation. C.) vomiting. D.) sore throat.

Answer: A.) decreased level of consciousness.

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

Answer: A.) minimize exposure to bright lights and noise.

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

Answer: A.) unequal response

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.) Pituitary carcinoma C.) Laryngeal carcinoma D.) Colorectal carcinoma

Answer: B.) 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? A.) Place the client in wrist restraints. B.) Reorient the client while gently holding their arms. C.) Administer lorazepam per orders. D.) Apply oxygen via nasal cannula.

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

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

Answer: C.) Administer stool softeners.

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? A.) Airway clearance B.) Risk of injury C.) Deficient fluid volume D.) Risk for impaired skin integrity

Answer: A.) Airway clearance Rationale: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

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

Answer: B.) supine position with the head slightly elevated.

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.) Restricts protein to 10% of daily caloric intake C.) High in protein and low in carbohydrate D.) At least 50% carbohydrate

Answer: C.) High in protein and low in carbohydrate Rationale: 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).

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A.) The type of anticonvulsant prescribed to manage the epileptic condition B.) Recent stress level C.) Recent weight gain and loss D.) Compliance with the prescribed medication regimen

Answer: D.) Compliance with the prescribed medication regimen Rationale: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

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

Answer: C.) Maintains a patent airway Rationale: 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.

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

Answer: C.) Seizure was 1 minute in duration including tonic-clonic activity.

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

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

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

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

A 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.) Request an antihistamine for the postnasal drip. C.) Ask the patient to cough to observe the sputum color and consistency. D.) Notify the physician of a possible cerebrospinal fluid leak.

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

Answer: C.) "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Rationale: 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 intellectual disability or mental illness.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: A.) place the client on his back, remove dangerous objects, and insert a bite block. B.) place the client on his side, remove dangerous objects, and insert a bite block. C.) place the client on his back, remove dangerous objects, and hold down his arms. D.) place the client on his side, remove dangerous objects, and protect his head.

Answer: D.) place the client on his side, remove dangerous objects, and protect his head. Rationale: During the active seizure phase, the nurse should initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Placing the client on his back and holding down the arms could cause injury to the client and the nurse.