Chapter 66 PrepU
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A Elevate the head of the bed. B Complete a head-to-toe assessment. C Administer morning dose of anticonvulsant. D Administer Percocet as ordered.
A
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
A 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 nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. A Keep a food diary. B Maintain a headache diary. C Sleep no more than 5 hours at a time. D Exercise in a dark room. E Use St. John's Wort.
A,B
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 Bradypnea C Hypertension D Tachycardia E Pupillary constriction
ABC
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? A Excessive urine output and decreased urine osmolality B Oliguria and serum hyponatremia C Oliguria and serum hyperosmolarity D Excessive urine output and serum hyponatremia
B SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? A The CPP is high. B The CPP is low. C The CPP is within normal limits. D The CPP reading is inaccurate.
B The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.
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
C
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.
C
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 50 mm Hg B 60 mm Hg C 70 mm Hg D 80 mm Hg
C
While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? A Migraine B Tension C Cluster D Sinus
C A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; rather he or she paces or thrashes about.
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 Initiate the code team response. B Put a padded tongue blade into the client's mouth and restrain his extremities. C Record the type of seizure and the ti me that it occurred. D Assist the client to the floor, in a side-lying position, and protect him with linens.
D
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? AVEpilepsy B Trigeminal neuralgia C Hypostatic pneumonia D Brain tumor
D
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A A bounding pulse B Bradycardia C Hypertension D Lethargy and stupor
D
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
D After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins.
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."
c 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 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? A Decerebrate posturing and loss of corneal reflex B Loss of gag reflex and mental confusion C Complaints of headache and lack of pupillary response D Mental confusion and pupillary changes
A
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? A Excessive urine output and decreased urine osmolality B Oliguria and decreased urine osmolality C Oliguria and serum hyperosmolarity D Excessive urine output and serum hypo-osmolarity
A
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
A
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? A Verapamil (Calan) B Metoprolol (Lopressor) C Amiodarone (Cordarone) D Carvedilol (Coreg)
A
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: A Parkinson's disease. B Huntington's disease. C seizure disorder. D multiple sclerosis.
A
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
A
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? A Increased ICP B Exacerbation of uncontrolled hypertension C Infection D Increase in cerebral perfusion pressure
A
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 Check the equipment. B Contact the physician to review the care plan. C Continue the assessment because no actions are indicated at this time. D Document the reading because it reflects that the treatment has been effective.
A
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
A
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 his progress across the playground. The school nurse suspects what in this child? A An absence seizure B A complex seizure C A partial seizure D A tonic-clonic seizure
A 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 Decorticate C Flaccidity D Tonic clonic
A 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.
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
A 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 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
A 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).
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.
A 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. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? A chewing B swallowing C smelling D tasting
A Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.
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
A 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
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.
B
A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because A hypothermia can cause death. B shivering in hypothermia can increase ICP. C hypothermia is indicative of severe meningitis. D hypothermia is indicative of malaria.
B
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? A Fluid restriction B Vasopressin therapy C Hypertonic saline solution D Diet containing extra sodium
B
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.
B
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? A Decerebrate B Decorticate C Flaccidity D Tonic clonic
B
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
B
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
B
Cerebral edema peaks at which time point after intracranial surgery? A 12 hours B 24 hours C 48 hours D 72 hours
B
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
B
Which is the earliest sign of increasing intracranial pressure? A Vomiting B Change in level of consciousness C Headache D Posturing
B
Which of the following drugs may be used after a seizure to maintain a seizure-free state? A Valium B Phenobarbital C Ativan D Cerebyx
B
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 lie flat for 24 hours after surgery." B "You must avoid coughing, sneezing, and blowing your nose." C "You must restrict your fluid intake." D "You must report ringing in your ears immediately."
B 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.
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.
B 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.
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
B 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 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 "No familial tendency has been demonstrated." C "There is a strong familial tendency." D "Only secondary migraine headaches show a familial tendency."
C
The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? A Optimizing nutrition B Managing muscle weakness C Explaining hospice care and services D Offering family support groups
C
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
C
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 Anemia B Osteoarthritis C Osteoporosis D Obesity
C
Which is a late sign of increased intracranial pressure (ICP)? A Irritability B Slow speech C Altered respiratory patterns D Headache
C
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? A Fluid volume deficit B Risk for infection C Ineffective cerebral tissue perfusion D Risk for injury
C
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? A Jacksonian B Absence C Generalized D Sensory
C A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.
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."
C 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 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
C Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.
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 have progressive muscle weakness." B "I will lose strength in my arms." C "My children are at greater risk to develop this disease." D "I need to remain active for as long as possible."
C 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
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: A prevent respiratory alkalosis. B lower arterial pH. C promote carbon dioxide elimination. D maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.
C 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.
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 A normal. B flaccid. C decorticate. D decerebrate.
D 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.
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
D 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.