Custom HCC 3 Intracranial Regulation SPRING 2022

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who sustained a head injury and is having periods of confusion A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs.

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by an immediate loss of consciousness The nurse should expect the client who has an epidural hematoma to have a lucid period followed by an immediate loss of consciousness, which is caused by arterial bleeding into the space between the dura and skull.

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head. The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/carbidopa Levodopa/carbidopa is the cornerstone of Parkinson's treatment. The nurse should prepare to instruct the client on the use of this medication.

A nurse is assessing a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test corneal reflexes?

Lightly touch the eyes with a wisp of cotton. The nurse should lightly touch a cornea with a wisp of cotton. Absent corneal reflexes, or the loss of the ability to blink, can be caused by a head injury or stroke.

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?

Maintain the client on absolute bed rest. The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for bleeding.

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Mannitol 25% Cushing's Triad is an indication that the client is experiencing increased intracranial pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes diuresis to treat cerebral edema.

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer?

Mannitol 25% The nurse should plan to administer mannitol 25%, an osmotic diuretic that lowers intracranial pressure by promoting diuresis.

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take?

Notify emergency management services. The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering appropriate treatment; therefore, the nurse should call the emergency management services.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access. The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

Oliguria The nurse should expect a client who has developed SIADH following a craniotomy to manifest oliguria. The decrease in urine output can be dramatic with output less than 20 mL/hr.

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform a Romberg's test. The nurse should perform a Romberg's test to check the client's ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the client from falling.

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Slow the rate to 50 mL/hr. The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure.

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

Speak to the client about one idea at a time. The nurse should speak using sentences that contain one clear thought or idea for better communication and understanding.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care. A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Move objects away from the client." The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. Available is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

15mL

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

Apply a protective boot to the right ankle. The nurse should apply padded splints or protective boots to the right ankle to keep the foot at a right angle to the leg to prevent footdrop.

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.) Assess the client's airway patency. Place a tongue depressor in the client's mouth. Remove objects from the client's bed. Place the client in a side-lying position. Restrain the client.

Assess the client's airway patency is correct. The nurse should continually assess the client's airway during a seizure. Remove objects from the client's bed is correct. The nurse should remove objects that can cause injury to the client during a seizure. Place the client in a side-lying position is correct. The client should be positioned side-lying to prevent aspiration of secretions or vomit.

A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?

Bulging fontanel A CNS infection causes increased intracranial pressure. Therefore, a bulging fontanel is a manifestation of a CNS infection.

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Dilated scalp veins Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites. The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache is correct. A client who has increasing ICP might manifest a headache. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Intellectual impairment A client who had a stroke involving the left cerebral hemisphere is likely to have deficits that involve language, mathematical skills, and thinking.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) Loosen restrictive clothing. Insert a bite stick into the client's mouth. Place the client into a supine position. Place a pillow under the client's head. Apply restraints.

Loosen restrictive clothing is correct. Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The client should not be restrained. Place a pillow under the client's head is correct. The nurse should place a pillow or rolled blanket under the client's head to protect the head from injury.

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Minimize environmental stimuli. A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.

A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client?

On the unoperated side The nurse should position the child flat on the unoperated side to prevent a rapid reduction of intracranial fluid and to protect the child for injuring the operative site.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away Pushing away a painful stimulus is an expected response

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Reduce edema of the brain. An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Reduce stimuli. The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

Sensitivity to light The nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise.

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

Shake the container vigorously. A suspension form of medication refers to one in which the particles of medication are mixed with, but not dissolved in, a fluid. It is important for the nurse to shake the container that contains the suspension because the child can be under-medicated if the medication is not evenly distributed.

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor for and report which of the following adverse effects of this medication?

Skin rash Phenytoin is an antiepileptic medication used to treat partial seizures and generalized tonic-clonic seizures. Phenytoin can cause a rash that can progress to Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). If a rash develops, the client should notify the provider immediately and stop the use of phenytoin.

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Supplements via nasogastric tube Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed.

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

"I'll be glad when I can stop taking this medicine." Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant medications commonly require them for lifetime administration, and phenytoin should not be stopped without the advice of the client's provider.

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

"Incorporate nonverbal cues in the conversation." Nonverbal cues enhance the client's ability to comprehend and use language.

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take?

Administer a saline solution after injection. The nurse should flush the injection site with a saline solution after the injection of phenytoin to reduce and prevent venous irritation.

A nurse is preparing to administer phenytoin 50 mg by intermittent IV bolus to a client who has a seizure disorder. Which of the following actions should the nurse take?

Administer the medication over 1 min. The nurse should administer phenytoin slowly, no faster than 50 mg/min.

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

Alcohol increases the chance of phenytoin toxicity. The nurse should include in the home instructions that alcohol alters the blood level of phenytoin.

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

Elevate the head of the bed 20°. The nurse should elevate the head of the bed less than 25° to promote reduction of intracranial pressure.

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?

Allow the drainage to drip onto a sterile gauze pad. The nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data without increasing the risk for further injury.

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness Alternating periods of alertness and unconsciousness is a common manifestation of an epidural hematoma.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia. Nonreactive dilated pupils is correct. Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following nursing interventions should the nurse implement?

Encourage exhaling through mouth during defecation. The nurse should encourage the client to exhale through her mouth when defecating to decrease strain.

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Call emergency services. The client might have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke center.

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Check the oximeter. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to maintain a patent airway. Checking the oximeter is the first indicator of poor oxygen exchange which can cause cerebral edema.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

Cheddar cheese The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?

Decreased tremors Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take?

Elevate the head of the bed to 30°. The client who has surgery to treat a supratentorial brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of the bed to 30° assists in promoting venous and CNS fluid drainage from the head to prevent increased ICP.

A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects?

Difficulty voiding The nurse should instruct the client to report difficulty voiding, which may indicate urinary retention, as an adverse effect of benztropine. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson's disease.

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Dorsiflexion of the great toe Dorsiflexion of the great toe and fanning of the other toes when the plantar reflex is assessed is an indication of a Babinski's sign, an abnormal response that indicates CNS pathology.

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

Increased sleeping Following a head injury, an infant's level of consciousness can deteriorate, show signs of excessive sleeping, and eventually go into a coma.

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

Intracranial pressure (ICP) 18 mm Hg. This client's ICP level is above the expected reference range of 10 to 15 mm Hg. ICP increases with suctioning, coughing, sneezing, straining, and frequent positioning.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Poor impulse control A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Position the child laterally. Positioning the child laterally facilitates airway patency.

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Position the child side-lying. This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

When walking, move your left foot forward first." The client should move her weaker (left) foot with the cane first, then bring her stronger leg forward ahead of the cane and the weaker foot.