Chapter 61: Management of Patients with Neurologic Dysfunction

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.

A client is returning to the medical unit after surgery and has a history of migraines. Which intervention would the nurse prioritize for the overall treatment of this client?

Administer hydromorphone and/or sumatriptan medications for relief.

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

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:

Diplopia.

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

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?

Glasgow Coma Scale

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

Headache

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

Heart failure

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 the jugular veins.

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 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 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?

Damage to the optic nerve