Chapter 66: Management of Patients With Neurologic Dysfunction

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options. Death Permanent neurologic dysfunction Impaired cellular activity Insomnia Seizures

Death Permanent neurologic dysfunction Impaired cellular activity Seizures Rationale: As increased ICP progresses, the consequences include impaired cellular activity, seizures, temporary or permanent neurologic dysfunction, or death.

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

High in protein and low in carbohydrate 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).

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

Phenobarbital Rationale: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as normal. flaccid. decorticate. decerebrate.

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

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

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

A nurse is 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 B of the accompanying image. Which posturing is the patient exhibiting? Decerebrate Decorticate Flaccidity Tonic clonic

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 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? Decerebrate Decorticate Flaccidity Tonic clonic

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

Bradycardia Bradypnea Hypertension 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.

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action? Inspect the ICP monitor to ensure it is working properly. Administer acetaminophen per orders. Provide ventriculostomy care. Assess for signs and symptoms of infection.

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

The nurse is 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 Maintain hydration by drinking eight glasses of fluid a day Perform the Heimlich maneuver Use pressure-relieving pads or a similar type of mattress

Apply warm or cool cloths to the forehead or back of the neck Rationale: 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 client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client 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 client's body.

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

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

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

Cloudy cerebral spinal fluid Purpura of hands and feet Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.

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

Pituitary carcinoma Rationale: 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.

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? Mannitol Furosemide (Lasix) Vasopressin Phenobarbital

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