Lesson 1 - Intracranial Regulation

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA) with residual hemiparesis and hemianopsia? A. Necessity for bed rest at home B. Use of o2 therapy at home C. Significance of a safe environment D. Need for decreased protein in the diet

C. Significance of a safe environment

The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow up? A. Periorbital ecchymosis B. Retroarticular or mastoid ecchymosis C. Temperature 100.9 F D. Headache

C. Temperature 100.9 F

Which clinical finding in a child with a diagnosis of meningitis indicates an increase in intracranial pressure? Select all that apply. A. Irritability B. Bradycardia C. Hyper alertness D. Decrease pulse pressure E. Decreased systolic blood pressure

A. Irritability B. Bradycardia

Which statement by the client would be consistent with a history of injury to the frontal lobe? Select all that apply. A. "I am unable to remember past events." B. "I am unable to hear properly." C. "I am unable to move my eyes." D. "I am unable to concentrate on anything." E. "I am unable to taste any flavors in the foods I eat."

A. "I am unable to remember past events." C. "I am unable to move my eyes." D. "I am unable to concentrate on anything."

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following? A. Atonic seizure B. Tonic-clonic seizure C. Absence seizure D. Complex partial seizure

A. Atonic seizure

Which explanation would the nurse provide about the client's behavior when family members of a client who has a cerebrovascular accident(CVA) ask why the client cries easily and without provocation? A. Has little control over this behavior B. Is making an attempt to get attention C. Feel guilty about the demands being made on the family D. Has selective memory from the past, especially the sad events

A. Has little control over this behavior

Which exercises would the nurse incorporate into the plan of care while the client is on bed rest after a cerebrovascular accident resulted in right hemiplegia? A. Passive range of motion exercises B. Active exercises of the extremities C. Light weight lifting exercises of the right side D. Isotonic exercises that will capitalize on returning muscle function

A. Passive range of motion exercises

Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure? A. Place the head and neck in in neutral alignment B. Obtain a prescription for 100 mg of IV phenobarbital C. Administer 1 g IV mannitol as prescribed D. Increase the ventilators respiratory rate to 20 breaths/min

A. Place the head and neck in in neutral alignment

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure? Select all that apply. A. Vomiting B. Irritability C. Hypotension D. Increased respirations E. Increased level of consciousness

A. Vomiting B. Irritability

The nurse is caring for a client who sustained an ischemic cerebrovascular accident(CVA) three hours ago. The client's most recent blood pressure is 168/101. The nurse should take which action? A. Place the client supine B. Continue to monitor C. Obtain orthostatic blood pressure D. Request a prescription for an antihypertensive

B. Continue to monitor

The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad? A. Hypotension, JVD, and muffled heart sounds B. Irregular respirations, bradycardia, and widening pulse pressure C. Fixed pupils, hypotension, and bradycardia D. Bradycardia, hypotension, and bradypnea

B. Irregular respirations, bradycardia, and widening pulse pressure

Which action would the nurse take while a client is seizing on the hallway floor? A. Hold the client's extremities firmly B. Protect the client's head from injury C. Insert an airway between the client's teeth D. Have staff members move the client to a soft surface

B. Protect the client's head from injury

Which assessment finding reflects increased intracranial pressure? A. Tachycardia B. Unequal pupil size C. Decreasing body temperature D. Decreasing systolic blood pressure

B. Unequal pupil size

A nurse is caring for a client with a history of seizures who is at risk for injury. Which intervention is the highest priority to reduce the client's risk of injury? A. Keeping the client's room dimly lit to minimize visual stimulation B. Administer antiepileptic medications as prescribed C. Implement seizure precautions, including padded side rails up and the bed in the lowest position D. Provide education to the client and family about seizure triggers and safety measures.

C. Implement seizure precautions, including padded side rails up and the bed in the lowest position

Which finding for a client with a head injury indicates increasing intracranial pressure? A. Polyuria B. Tachypnea C. Increased restlessness D. Intermittent tachycardia

C. Increased restlessness

How would the nurse describe the clonic phase of a tonic-clonic seizure? A. Generalized rigidity B. Loss of consciousness C. Rhythmic body jerking D. Tremors of upper extremities

C. Rhythmic body jerking

Which assessment finding alerts the nurse to increasing intracranial pressure? A. Hypervigilance B. Constricted pupils C. Increased heart rate D. Widening pulse pressure

D. Widening pulse pressure

You are working the ER when a patient with a suspected stroke arrives. All of the tasks below should be done for this patient. What is the correct sequence for these tasks? A. Neurologic assessment by stroke team B. Obtain non-contrast CT scan C. Administer rtPA D. General assessment and stabilization

D. General assessment and stabilization A. Neurologic assessment by stroke team B. Obtain non-contrast CT scan C. Administer rtPA

Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is rising. For which condition would the nurse prepare to intervene? A. Spinal shock B. Brain herniation C. Hypovolemic shock D. Increase intracranial pressure

D. Increase intracranial pressure

Which clinical finding is consistent with an increase in intracranial pressure? A. Thready, weak pulse B. Narrowing pulse pressure C. Regular, shallow breathing D. Lowered level of consciousness

D. Lowered level of consciousness

Which action would the nurse take when a client complains of a headache and drowsiness after an automobile accident while being oriented to person and place but confused to time with pupils equal and reactive? A. Keep the client in the supine position B. Prepare the client for Mannitol administration C. Stimulate the client to maintain responsiveness D. Monitor the client for increasing intracranial pressure

D. Monitor the client for increasing intracranial pressure