3rd test

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?

A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this clientfirst. Client with a Glasgow Coma Scale score that was 10 and is now is 8

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?

A fever is a poor prognostic indicator in clients with brain injuries.

The nurse is caring for a patient with increased intracranial pressure (ICP). Which action would be considered as a collaborative intervention?

Administering an osmotic diuretic

A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?

Airway patency and breathing are the most vital functions and should be assessed first.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?a. Administer ceftizoxime (Cefizox) 1 g IV. Give acetaminophen (Tylenol) 650 mg PO. Use a cooling blanket to lower temperature. Swab the nasopharyngeal mucosa for cultures.

Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

Decreased short-term memory is one indication of postconcussion syndrome.

A nurse assesses a client who has encephalitis. Which manifestationsshould the nurse recognize assigns of increased intracranial pressure (ICP), a complication of encephalitis?

Dilated pupils Widened pulse pressure Bradycardia Increased ICP is a complication of encephalitis.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?

Even when my seizuresstop, I will continue to take this drug. Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? Document intracranial pressure every hour. Turn and reposition the patient every 2 hours. Check capillary blood glucose level every 6 hours. Monitor cerebrospinal fluid color and volume hourly.

Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill.

After shunt procedure, the nurse would monitor the patient's neurologic status by using which test?

GCS

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (

Glasgow Coma Scale score of 8 . Decerebrate posturing Diminished cognition

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care?

Have suction equipment at the bedside Keep bed rails up at alltimes. Ensure that the client has IV access.

late signs of increased intracranial pressure and indications of impending herniation (Cushing triad).

Hypertension with widening pulse pressure, bradycardia, and respiratory changes

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage?

Hyperthermia increases the metabolic demands of the brain and may indicate brainstem damage.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indGicRatAesDtEhSe nMeOedREfo.r CanOtiMbiotics or removal of the monitor.

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

Intracranial pressure

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestationsshould the nurse assess?

Lip smacking Picking at clothing Patting of the hand on the leg

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider.

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

ROM exercises will help prevent the complications of immobility.

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

Risk for injury related to neurologic deficit

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?

Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption.

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

Take daily weights.

24. After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? A 20-yr-old patient whose cranial x-ray shows a linear skull fracture A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 A 30-yr-old patient who lost consciousness for a few seconds after a fall A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure.

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? Pale yellow urine output of 1200 mL over the past 2 hours. Ventriculostomy drained 40 mL of fluid in the past 2 hours. Intracranial pressure spikes to 16 mm Hg when patient is turned. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?

The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous.

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?

The nurse should turn the clients head to the side to prevent aspiration and allow drainage of secretions

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?

The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection.

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?

This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level.

The nurse assesses a clients Glasgow Coma Scale (GCS)score and determinesit to be 12 (a 4 in each category). What care should the nurse anticipate for this client?

This client will most likely be confused and need frequent re-orientation.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures?

a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury. Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever

the nurse observes a patient ambulating in the hosptial hall when they suddenly jerk and patient falls to the floor. the nurse will first a. assess the patient for possible injury b. give the scheduled divalproex c. document the timing and description of the seizure d. notify the patients health care provider about seizure

a. assess the patient for injury

the patient reports feeling numbness and tingling in right arm. before having the seizure. The nurse determines that this history is consistent with what type of seziure? a. focal b. atonic c. absence d. myclonic

a. focal

a hospital patient has experienced a seizure. in the immediate recover period what action best protects the patient's safety? a. place the patient in side lying b. pad the patients bed rails c. administer antianxiety meds d. reassure the patient and family

a. place the patient in side lying

the nurse caring for a patient who is rapidly progressing toward brain death. the nurse should be aware of what cardinal signs of brain death?

apnea, coma, absence of brain stem reflexes

the nurse has implemented interventions aimed facilitating family coping in the care of a patient with tramatic brain injury. How can the nurse best facilittate the family coping?

assist the family in setting appropriate short term goals.

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have expressive aphasia. c. right-sided weakness. impaired judgment. d. difficulty swallowing.

b The frontal lobe controls intellectual activities such as judgment.

the nurse is caring for a patient with status epilepticus what medication does the nurse know may be given to halt the seizure immediately. a. intravenous phenobarbital b. intravenous diazepam c. oral lorazepam d oral phenytoin

b intravenous diazepam

The ed nurse is caring for a patient who has been brought in by ambulance. What physical assessment is suggestive of a basilar skull fracture?

brusing over the mastoid

what persciribed interventions will the nurse implement first for a patient in the emergency room who is experiencing continous tonic clonic seizures. a. phenytoin b. monitor loc c. administer lorazepam d. obtain a CT

c. lorazepam.

the nurse is providing care to a patient with high alcohol use. the nurse and other members of the are present by the bedside when the patient has a seizure. in prep to document the event the nusrse should note which of the following? a. the ability for the patient to follow the instructions b. the success or failure of the team to restrain the patient c. the pateints ability to explain his seizures during the postictial phase d. the patients activities immediately prior to the seizures

d the patients activities prior to seizure

by administering an osmotic diuretic it would

decreasing edema which in turn would lead to decreased ICP and improved oxygenation

a patient is brought to the ed by her family after falling off the roof. the patient was "knocked out" but then came to and "seemed ok". Now she is companing about a severe headache and not feeling well. the care team suspects an epidural hematoma, prompting the nurse to prepare for a priority intervention?

emergency crainiotomy

. A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?

intravenous lorazepam is administered to stop motor movements

a nurse is reviewing the trend of a patients scores on the GCS. This allows the nurse to gauge what aspect of the patients status?

level of consciousness

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?

manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team.

A client has an intraventricular catheter. What action by the nurse takes priority?

performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

a patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?

watchful waiting and close monitoring