Chapter 16: Disorders of Brain Function
The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced:
generalized seizure. Explanation: When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?
Assess for other signs/symptoms of increased intracranial pressure. Explanation: The tumor may be causing increased intracranial pressure. Vomiting, with or without nausea, is a common symptom of increased intracranial pressure and/or brain stem compression. The nurse's first action is to assess for other signs/symptoms of increased intracranial pressure. Once the assessment is completed, the nurse should contact the physician if indicated by the findings.
The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?
CT scan Explanation: The nurse should anticipate that the client will be ordered a CT scan to rule out hemorrhagic stroke that would preclude the administration of tissue plasminogen activator (tPA).
The nurse is conducting a community education program on concussions. The nurse evaluates that the participants understand the education when they state that which of these offers the brain protection from external forces?
Cerebrospinal fluid Explanation: The brain is protected from external forces by the rigid confines of the skull and the cushioning afforded by the cerebrospinal fluid. The blood-brain barrier assists with metabolic stability in the brain. The reticular formation receives input from sensory pathways and the cerebral cortex is the outermost layer of the cerebrum.
The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be:
Decreased level of oxygen Explanation: Regulation of blood flow to the brain is controlled largely by autoregulatory or local mechanisms that respond to the metabolic needs of the brain. Metabolic factors affecting cerebral blood flow include an increase in carbon dioxide and hydrogen ion concentrations; cerebral blood flow is affected by decreased O2 levels and increased hydrogen ions, carbon dioxide, and PCO2 levels
A family brings a client to the emergency department with increasing lethargy and disorientation. They think the client had a seizure on the drive over to the hospital. The client has been sick with a "cold virus" for the last few days. On admission, the client's temperature is 102°F (38.9°C). Which other clinical manifestations may lead to the diagnosis of encephalitis?
Impaired neck flexion resulting from muscle spasm Explanation: Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity (impaired neck flexion resulting from muscle spasm), but more often clients also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma. Meningococcal meningitis is characterized by a petechial (petite hemorrhagic spots) rash with palpable purpura (red-purple discolorations on the skin that do not blanch on applying pressure) in most people. This BP is within normal range.
Following a head injury, a client is diagnosed with intracranial epidural hematoma. During the initial assessment, the client suddenly becomes unconscious. What additional clinical manifestations correlate with this diagnosis?
Ipsilateral pupil dilation Explanation: With rapidly developing unconsciousness, there are focal symptoms related to the area of the brain involved. These symptoms can include ipsilateral (same side) pupil dilation and contralateral (opposite side) hemiparesis. Because bleeding is arterial in origin, rapid compression of the brain occurs from the expanding hematoma. Communicating hydrocephalus occurs as the result of impaired reabsorption of cerebrospinal fluid (CSF) from the arachnoid villi into the venous system. This is unrelated to this situation.
The most common cause of an ischemic stroke is which of the following?
Thrombosis Explanation: Thrombi are the most common cause of ischemic strokes, usually occurring in atherosclerotic blood vessels.
A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is:
characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing. Explanation: Expressive or nonfluent aphasia is characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing. Conduction aphasia manifest as impaired repetition and speech riddled with letter substitutions, despite good comprehension and fluency. Anomic aphasia is speech that is nearly normal except for difficulty with finding singular words. Wernicke aphasia is characterized by an inability to comprehend the speech of others or to comprehend written material.
A client has developed global ischemia of the brain. The nurse determines this is:
inadequate to meet the metabolic needs of the entire brain. Explanation: Global ischemia occurs when blood flow is inadequate to meet the metabolic needs of the entire brain. The result is a spectrum of neurologic disorders reflecting diffuse brain dysfunction.
The most common cause of ischemic stroke is:
thrombosis. Explanation: Ischemic stroke includes those caused by large artery thrombosis (20%), small artery thrombosis (25%), cardiogenic embolism (20%) and cryptogenic (undetermined cause)(30%), making thrombosis the most common cause (45%).
A nurse is teaching a client newly diagnosed with a seizure disorder. Which statement is most important for the nurse to provide regarding antiepileptic medications?
Antiepileptic medications should never be discontinued abruptly. Explanation: Consistency in taking seizure medications is essential to obtaining and maintaining therapeutic blood levels of the medication. Abrupt withdrawal can cause seizure recurrence. Monitoring and assessment of drug levels are important. Each prescribed drug will provide information regarding administration to provide client safety. For women with epilepsy who become pregnant, antiseizure drugs increase the risk for congenital abnormalities. However, these medications need to be continued throughout the pregnancy.
An older adult is brought to the emergency department after experiencing some confusion, slurred speech, and a weak arm. Now the client is back to acting normally. Suspecting a transient ischemic attack (TIA), the health care provider prescribes diagnostic testing looking for which cause of this episode?
Atherosclerotic lesions in cerebral vessels Explanation: The traditional definition of TIA as a neurologic deficit resolving within 24 hours was developed before the mechanisms of ischemic cell damage and the penumbra were known and before the newer, more advanced methods of neuroimaging became available. A more accurate definition now is a transient deficit without time limits, best described as a zone of penumbra without central infarction. TIAs are important because they may provide warning of impending stroke. The causes of TIAs are the same as those of ischemic stroke, and include atherosclerotic disease of cerebral vessels and emboli. The most common predisposing factors for cerebral hemorrhage are advancing age and hypertension; other causes include aneurysm rupture. Cerebral electrical malfunctions usually occur with seizure activity.
A nurse is preparing for a course in cardiopulmonary resuscitation (CPR) and realizes that ventricular fibrillation quickly disrupts blood flow to the brain that causes which result in a matter of seconds?
Global ischemia Explanation: Ischemia includes an interruption in blood flow; hypoxia is a decrease in oxygen without interruption in blood flow. With ventricular fibrillation, there is no effective contraction of the ventricles and therefore no cardiac output that would cause global ischemia of the brain due to the lack of perfusion.
Which pathophysiologic process occurs in cases of bacterial meningitis?
Inflammation allows pathogens to cross into the cerebrospinal fluid. Explanation: In the pathophysiologic process of bacterial meningitis, the bacterial organisms replicate and undergo lysis in the CSF, releasing endotoxins or cell wall fragments. These substances initiate the release of inflammatory mediators, which set off a complex sequence of events permitting pathogens, neutrophils, and albumin to move across the capillary wall into the CSF. Cerebral hypoxia does not result directly from meningitis, and the causative pathogens are not introduced from the skin nor is trauma an initiating event. Spinal cord compression is not an expected consequence of meningitis.
A nurse at a long-term care facility provides care for a client who has had recent transient ischemic attacks (TIAs). What significance should the nurse attach to the client's TIAs?
TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke. Explanation: TIAs can be considered a warning sign for future strokes. They are not hemorrhagic in nature and their effects are not normally cumulative. They may require treatment medically or surgically.
A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose?
Thrombolysis Explanation: Synthetic tissue plasminogen activators work with the body's natural tissue plasminogen activators to convert plasminogen to plasmin, which breaks down clots to allow for the reestablishment of blood flow. There are two causes of strokes: hemorrhagic and thrombotic, with thrombotic strokes occurring much more frequently. Thrombolytics play a large role in increased outcomes seen with thrombotic strokes.
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be:
"Because the skull sutures are not fused there may be no brain damage." Explanation: When hydrocephalus develops in utero, before the cranial sutures have fused, the head can swell and decrease intracranial pressure, thereby decreasing the amount of brain tissue that is compressed.
Which intracranial pressure (ICP) would the nurse consider a normal reading?
0 to 15 mm Hg Explanation: The cranial cavity contains blood, cebrospinal fluid, and brain tissue. Each of these three volumes contributes to ICP, which is normally maintained within a range of 0 to 15 mm Hg when measured in the lateral ventricles.
According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score?
2 Explanation: Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
The regulation of cerebral blood flow is accomplished through both autoregulation and local regulation. This allows for the brain to meet its metabolic needs. What is the low parameter for arterial blood pressure before cerebral blood flow becomes severely compromised?
60 mm Hg Explanation: If blood pressure falls below 60 mm Hg, cerebral blood flow becomes severely compromised, and if it rises above the upper limit of autoregulation, blood flow increases rapidly and overstretches the cerebral vessels.
The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed?
Administration of antibiotics Explanation: The nurse should prepare to administer antibiotics as ordered by the physician while the diagnostic tests are being completed. Delay in initiation of antimicrobial therapy, most frequently due to medical imaging prior to lumbar puncture or transfer to another medical facility, can result in poor client outcomes.
A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for:
Brain death Explanation: Severe brain injury that results in seriously compromised brain function can result in brain death.
Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors?
Brain edema and disturbances in blood flow Explanation: Intracranial tumors give rise to focal disturbances in brain function and increased ICP. Focal disturbances occur because of brain compression, tumor infiltration, disturbances in blood flow, and brain edema. Blood pressure, either increased or decreased, is not a manifestation of a brain tumor.
Which intracranial volume is most capable of compensating for increasing intracranial pressure?
Cerebrospinal fluid Explanation: Initial increases in intracranial pressure (ICP) are largely buffered by a translocation of cerebrospinal fluid (CSF) to the spinal subarachnoid space and increased reabsorption of CSF. Of the intracranial volumes, the tissue volume is least capable of undergoing change. Surface sulcus fluid is negligible and not a factor in increased ICP. The compensatory ability of the intravascular blood compartment is also limited by the small amount of blood that is in the cerebral circulation. As the volume-buffering capacity of this compartment becomes exhausted, venous pressure increases and cerebral blood volume and ICP rise.
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.
Cognition Level of consciousness Motor function Sensory function Explanation: Brain injuries can cause changes in level of consciousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a client with a traumatic brain injury should assess for changes in these areas.
A nurse on a neurology unit is assessing a client with a brain injury. The client is unresponsive to speech, with dilated pupils that do not react to light. The client is breathing regularly with a respiratory rate is 45 breaths per minute. In response to a noxious stimulus, the client's arms and legs extend rigidly. What is the client's level of impairment?
Coma Explanation: The continuum of loss of consciousness is marked by the degree of client responsiveness to stimuli, in addition to the preservation of brain stem reflexes. Since this client still exhibits a pain response (the extended arms and legs indicate decerebrate posturing), even though her pupils are not responsive to light, she has sustained sufficient brain function that she fails to qualify as brain-dead or in a vegetative state.
A client who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the client has been smacking his lips prior to having a seizure. Which type of seizure disorder presents with these symptoms?
Complex partial or focal seizure with impairment of consciousness Explanation: Complex partial seizures, or focal seizures with impairment of consciousness, are often accompanied by automatisms, which are repetitive, nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. They are sometime called psychomotor seizures. Simple partial seizures, or prodromes, would not have a loss of consciousness. Atonic seizures, a category of generalized seizures, indicate involvement of both brain hemispheres at the onset.
An adult client is admitted to the emergency department reporting a headache, stiff neck and lethargy. Based on the intake interview, the nurse suspects that the client had a seizure the day before. The client's vital signs are within reference range with the exception of a heart rate of 102 bpm and oral temperature of 38.6°C (101.5°F). Which diagnosis is most likely?
Encephalitis Explanation: Encephalitis is characterized by fever, headache, and nuchal rigidity, but more often clients also experience neurologic disturbances such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma. Epilepsy is confined to recurrent seizures. An ischemic stroke would present with more focal symptoms and no fever, as would a hemorrhage.
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following?
Encephalitis Explanation: Less frequent causes of encephalitis include ingesting toxic substances such as lead. People experience neurologic disturbances such as lethergy, disorientation, seizures, focal paralysis, delirium and coma. Bacterial and viral meningitis are caused by bacterial and viral infections. Meningiomas are a type of brain tumor that are seen in the middle or later years of life.
An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following?
Flaccid motor response Explanation: A score of 3 on the Glasgow Coma Scale indicates the lowest possible score in each of the three scoring categories (eye opening, motor response, and verbal response) and includes flaccid or no motor response, no verbal response and the inability to open the eyes.
The nurse caring for a client with an epidural hematoma recognizes the bleeding is associated with which physiological finding?
Arterial tear Explanation: The bleeding associated with an epidural hematoma is associated with a tear in the artery, most often in the middle meningeal and in association with a skull fracture.
The nurse is working in the emergency room. One client's presenting symptoms include the worst headache ever, nuchal rigidity, and nausea. Another client's presenting symptoms include fever, stiff back, and positive Kernig sign. Which client should the nurse assess first?
Client with the worst headache, nuchal rigidity, and nausea Explanation: The nurse should assess the client with presenting symptoms of worst headache ever, nuichal rigidity, and nausea because these are presenting signs of aneurysmal subarachnoid hemorrhage from a ruptured cerebral aneurysm. The client with the presenting symptoms of fever, stiff back, and positive Kernig sign is experiencing symptoms of meningitis. Ruptured cerebral aneurysm is a medical emergency with a higher priority than meningitis.
A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which pathophysiologic condition has contributed to this client's diagnosis?
Weakness in the muscular wall of an artery Explanation: Aneurysms are direct manifestations of a weakness that exists in the muscular wall of an arterial vessel. Hypertension is a significant risk factor, but autonomic contributions are not common. Levels of cerebrospinal fluid (CSF) and hypo- or hypercoagulability are not implicated in the pathogenesis of aneurysms.
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted?
Large number of polymorphonulcear neutrophils Explanation: Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The CSF typically contains large numbers of polymorphonuclear neutrophils (up to 90,000/mm3), increased protein content, and reduced sugar content.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:
Lumbar puncture Explanation: The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition?
Muscle atrophy Explanation: Muscle atrophy can occur with prolonged immobilization following a chronic illness. The client suffering from hemiplegia will have paralysis and immobility. Muscular dystrophy is a genetic disorder characterized by muscle necrosis and increased muscle size. Pseudohypertrophy is associated with muscular dystrophy. Involuntary movements are associated with extrapyramidal tract disorders. Stroke is a pyramidal tract disorder with extrapyramidal tract disorder.
The nurse is preparing a client for oculovestibular reflex assessment (cold caloric test). The nurse explains that the test is used to elicit which of the following?
Nystagmus Explanation: The oculovestibular reflex test (cold caloric test) consists of instilling cold water into the ear canal to elicit nystagmus.
A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem?
Placement of a shunt Explanation: Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in cerebrospinal fluid (CSF) volume. This increase in CSF volume can be resolved by the placement of a shunt to drain the offending fluid volume. Diuresis, hypertonic solution administration, and lumbar puncture are not usual treatment modalities.
As a client explains to the nurse what occurred prior to the onset of seizure activity, the client describes perceiving a feeling or warning that the seizure would occur. The nurse documents the perceived warning as which of the following?
Prodrome Explanation: The nurse should document the perception of a warning of impending seizure activity as a prodrome; it is also referred to as an aura.
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client's care? Assessment of:
Respiratory status and oxygen saturation Explanation: Tonic-clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
The emergency department nurse is caring for a client who fell and has a head injury. Which assessment would be noted during the early stage of increased intracranial pressure?
Stable vital signs Explanation: The vital signs remain unchanged in the early stage of increased intracranial pressure. The remaining options are characteristic of late signs.
What term is used to describe a level of consciousness during which a client responds only to vigorous and repeated stimuli and has minimal or no spontaneous movement?
Stupor Explanation: Stupor is unresponsiveness except to vigorous and repeated stimuli; responds appropriately to painful stimuli; lies quietly with minimal spontaneous movement; may have incomprehensible sounds and/or eye opening. Stupor is the only option that accurately includes the description presented by the question.
The nurse is explaining to a client's family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be:
The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid. Explanation: Vasogenic brain edema occurs with conditions that impair the function of the blood-brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes.
An adult client has been admitted to a rehabilitation center after hospital treatment for an ischemic stroke. Which aspect of the client's history would be considered to have contributed to his stroke?
The client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg. Explanation: Black ethnicity, male gender, hypertension, and diabetes are all well-documented risk factors for stroke. Anemia, autoimmune disorders like rheumatoid arthritis, and the use of corticosteroids are not noted to predispose to stroke.
A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:
Transient ischemic attack (TIA) Explanation: Transient ischemic attacks are brief episodes of neurologic function resulting in focal cerebral ischemia not associated with infarction that usually resolve in 24 hours. The causes of transient ischemic attack are the same as they are for stroke. Embolic stroke usually has a sudden onset with immediate maximum deficit. Lacunar infarcts produce classic recognizable "lacunar syndromes" such as pure motor hemiplegia, pure sensory hemiplegia, and dysarthria with clumsy hand syndrome.
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should:
assess the client for additional signs/symptoms of increased intracranial pressure. Explanation: Since decreased alertness and/or drowsiness can be an early sign of increased intracranial pressure, the nurse should assess for additional signs/symptoms of increased intracranial pressure. Then, once the assessment is complete, the nurse should contact the physician as needed. There is no indication that the client will undergo EEG testing at this time and the spouse should not be instructed to keep the client awake.
The nurse is caring for a client experiencing a seizure. During the seizure the nurse notes that the client repetitively rubs his/her clothing. When contacting the client's physician, the nurse notes that the client exhibited:
automatisms. Explanation: The nurse reports that the client exhibited automatisms, defined as repetitive nonpurposeful activities such as lip smacking, grimacing, patting and/or rubbing clothing.
The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will:
decrease the likelihood of further neurological deficits. Explanation: The placement of a shunt to drain excess cerebrospinal fluid decreases intracranial pressure and thereby decreases the likelihood of further neurologic deficits. The placement of a shunt may or may not affect the size of the infant's head or reverse neurologic deficits that may have already occurred.
The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as:
rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet. Explanation: Decerebrate (extensor) posturing results from increased muscle excitability. It is characterized by rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet. Flexion of the arms, wrists, and fingers, with abduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities, would be a response of decorticate posturing. The other options are not specific to a diagnosis.
