PUCH61 NEUROLOGIC DYSFUNCTION PART 1

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: A. shivering in hypothermia can increase ICP. B. hypothermia is indicative of severe meningitis. C. hypothermia is indicative of malaria. D. hypothermia can cause death to the client.

A

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

Which is the earliest sign of increasing intracranial pressure? A. Vomiting B. Change in level of consciousness C. Headache D. Posturing

B

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

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 3 B. 6 C. 9 D. 15

A

A nurse is caring for client diagnosed with Huntington disease. The client's plan of care includes interventions to address the client's potential for injury. Which would be included as a cause for this risk? A. choreiform movements B. shuffling gait C. uncontrolled movements D. rigidity

A

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

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? A. Apply warm or cool cloths to the forehead or back of the neck. B. Encouraging the client to drink eight glasses of fluid a day. C. Perform the Heimlich maneuver. D. Use pressure-relieving pads or a similar type of mattress.

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

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 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

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

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? A. Decerebrate B. Decorticate C. Flaccid D. Normal

B

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? A. Severe depression B. Choreiform movements C. Urinary tract infection D. Emotional apathy

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 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

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

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

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, 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 myoclonic seizure C. A partial seizure D. A tonic-clonic seizure

A

Which signs are manifestations of the Cushing triad? Select all that apply. A. Bradycardia B. Hypertension C. Bradypnea D. Tachycardia

A B C

A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. A. Medication regimen B. Appointments for chemotherapy or radiotherapy C. Adverse effects of chemotherapy or radiation and techniques for managing them D. Nutritional support E. Electromyography

A B C D

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A. Insert an airway or bite block. B. Manually restrain the extremities. C. Turn client to side-lying position. D. Monitor vital signs.

C

A client with neurological 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

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

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

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

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

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

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

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

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A. Damage to the optic nerve B. Damage to the vagal nerve C. Damage to the olfactory nerve D. Damage to the facial nerve

A

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? A. Capillary refill of 2 seconds B. Shivering C. Cool, dry skin D. Urine output of 100 mL/hr

B

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: A. hold the client's arm still to keep him from hitting anything. B. carefully move the client to a flat surface and turn him on his side. C. allow the client to remain in the chair but move all objects out of his way. D. place an oral airway in the client's mouth to maintain an open airway.

B

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? A. Positioning to prevent complications B. Maintenance of a patent airway C. Assessment of pupillary light reflexes D. Determination of the cause

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

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? A. Alopecia B. Gingival hyperplasia C. Diplopia D. Ataxia

B

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Dextrose 5% in water (D5W) B. Half-normal saline (0.45% NSS) C. One-third normal saline (0.33% NSS) D. Lactated Ringer's

D

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? A. Give the patient some mouthwash to gargle with. B. Request an antihistamine for the postnasal drip. C. Ask the patient to cough to observe the sputum color and consistency. D. Notify the physician of a possible cerebrospinal fluid leak.

D