Neuro Prep U

A client is diagnosed with a traumatic brain injury. Which action will the nurse take to reduce this client's risk of increasing intracranial pressure (ICP)? Select all that apply.

Keep head midline. Avoid rotation of the neck. Elevate the head 30 to 45 degrees. Prevent compression of jugular veins

A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure?

Pituitary gland

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Record intake and output

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neuro deficit

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

Subdural

A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply.

The procedure generally takes 45 to 60 minutes. This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo. Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

Vasodilation

The cerebral circulation receives approximately what percentage of the cardiac output?

15%

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

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?

70 mm Hg

TBI signs and symptoms

Altered LOC nausea and vomiting seizures increased ICP

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar

Which of the following types of skull fractures may be evident by Battle's sign?

Basilar

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.

Cerebral edema Ischemia Infection Seizures Hyperthermia

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?

Contusion

Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function?

Decreased or absent deep tendon reflexes.

Diabetes Insipidus signs and symptoms

Diuresis Increased serum sodium Polyuria Polydipsia

Which activity should be avoided in clients with increased intracranial pressure (ICP)?

Enemas

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

Epidural

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

Flaccid

Which of the following is an early sign of increasing intracranial pressure (ICP)?

Headache

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?

Immediate craniotomy

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?

Performing a lumbar puncture

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result?

Positive Romberg test, indicating a problem with equilibrium

The nurse in the intensive care unit (ICU) is using the neurological assessment flow chart to evaluate a calm client with traumatic brain injury (TBI) that has several medications infusing. Which medication would best allow an accurate assessment of the client's neurological status?

Propofol

A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients?

Provide brief instructions, 1 step at a time.

The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client?

Transcranial doppler

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because

shivering in hypothermia can increase ICP.

Which Glasgow Coma Scale score is indicative of a severe head injury?

8 or less

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants

Concussion signs and symptoms

altered LOC nausea and vomiting

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?

Administer acetaminophen per orders

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

Anticonvulsant medications on day two of injury

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is

Change in LOC

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test?

Coffee

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 Seizures

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor?

Dexamethasone

The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply.

Displacing or shifting cerebral spinal fluid (CSF) Increasing the absorption of CSF Decreasing cerebral blood volume

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining a patent airway

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?

Mannitol

Nursing interventions for mannitol administration

Monitor serum electrolytes every 8 hours. Check the mannitol infusion for crystals. Use an in-line filter to administer mannitol. Infuse mannitol over 30 to 60 minutes.

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?

Safety

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply.

Transcranial Doppler flow study Cerebral angiography MRI

Thyroid Storm signs and symptoms

blood pressure 145/95 mm Hg altered mental status oxygen saturation 89% sinus tachycardia temperature 102.7°F (38.7°C) thyroid stimulating hormone 0.1 white blood cell count 10.0 × 103 cells/mm3 (10.0 × 109/l)

Sepsis signs and symptoms

blood pressure 145/95 mm Hg altered mental status oxygen saturation 89% sinus tachycardia temperature 102.7°F (38.7°C)

Cerebrovascular accident signs and symptoms

blood pressure 145/95 mm Hg altered mental status oxygen saturation 89% sinus tachycardia temperature 102.7°F (38.7°C) white blood cell count 10.0 × 103 cells/mm3 (10.0 × 109/l)

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply.

Apnea Coma Absence of brain stem reflexes

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?

Are you allergic to seafood or iodine?

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?

Assess for patent airway

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining LOC

Because the increased intracranial pressure may not be reduce with the treatments of choice, the nurse will monitor for possible complications including

brain herniation diabetes insipidus SIADH

The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client?

Apply an external urinary sheath catheter