Chapter 66
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?
Compliance with the prescribed medication regimen Explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.
Bradycardia Bradypnea Hypertension Explanation: At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?
Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
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 Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?
Semisolid food with thick liquids Explanation: A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Side-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.
A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?
Turn the client to the side Explanation: When a client is seizing, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway should not be inserted while the client is actively seizing. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the client is actively seizing could cause harm to the client and is not indicated for seizure activity.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?
Vasopressin Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.
A nurse is caring for client with late-stage Parkinson's disease. The client's plan of care includes a nursing diagnosis of "Potential for Injury." Which would not be included as a cause for this diagnosis?
choreiform movements Explanation: Choreiform, described as uncontrollable writhing and twisting of the body, is a typical sign associated with Huntington's disease. The other signs are commonly seen in clients with Parkinson's disease.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered
low. Explanation: Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?
Maintains a patent airway Explanation: Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to
dehydrate the brain and reduce cerebral edema. Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?
"There is a strong familial tendency." Explanation: Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"You must avoid coughing, sneezing, and blowing your nose." Explanation: After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.
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 Explanation: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).
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?
Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.
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?
Aspiration of a brain abscess Explanation: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.
Which phase of a migraine headache usually lasts less than an hour?
Aura Explanation: The aura phase occurs in about 20% of clients who have migraines and may be characterized by focal neurological symptoms. The premonitory phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the postdrome phase, clients may sleep for extended periods.
Which is the earliest sign of increasing intracranial pressure?
Change in level of consciousness Explanation: The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.
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 Explanation: As increased ICP progresses, the consequences include impaired cellular activity, temporary or permanent neurologic dysfunction, or death.
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?
Decorticate Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?
Dyskinesia Explanation: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed. Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings?
Excessive urine output and decreased urine osmolality Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolatity, and serum hyperosmolarity.
The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?
Explaining hospice care and services Explanation: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
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 nursing diagnoses would be the first priority for the plan of care?
Ineffective airway clearance related to altered LOC Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?
More than 200 mL/h Explanation: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Pituitary carcinoma Explanation: Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur. Surgery to treat esophageal carcinoma usually is palliative and involves esophagogastrectomy with jejunostomy. Laryngeal carcinoma may necessitate a laryngectomy. To treat colorectal cancer, the surgeon removes the tumor and any adjacent tissues and lymph nodes that contain cancer cells.
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?
Respiratory function Explanation: Respiratory function is profoundly affected by ALS and would be prioritized over integumentary assessment. Cardiac function and cognition are not normally affected by the disease.
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
Which method is used to help reduce intracranial pressure?
Using a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing Explanation: Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.
The initial sign of increasing intracranial pressure (ICP) includes
decreased level of consciousness. Explanation: The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may be herniated through the tentorium, causing pressure on the brain stem. Vomiting and headache are not initial signs of increasing ICP.
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise. Explanation: Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
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 secondary headache is associated with an organic cause, such as a brain tumor." Explanation: A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.
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?
Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Explanation: Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or illness.
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?
Decerebrate Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
Lamictal Explanation: Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).
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?
poor Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.
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?
Apply warm or cool cloths to the forehead or back of the neck Explanation: Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction?
B Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing (B) indicates deeper and more severe dysfunction than does decorticate posturing (A). Decerebrate implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of the forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
Brain tumor Explanation: The incidence of brain tumor decreases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids Explanation: Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.
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?
Elevated 30 degrees Explanation: After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
increase the frequency of the catheterizations. Explanation: As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.
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 secondary headache is associated with an organic cause, such as a brain tumor." Explanation: A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy Explanation: During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3 Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
Administer corticosteroids as ordered. Explanation: Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?
Decreased muscle spasms in the lower extremities Explanation: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. It is not used to promote continence or to increase strength. Avonex and Betaseron reduce the appearance of new lesions on the MRI.
The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge?
The patient should perform frequent physical activity but avoid becoming fatigued. Explanation: The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:
Parkinson's disease. Explanation: Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are most commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated. Explanation: After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
An absence seizure Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?
Monro-Kellie Explanation: The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hasimoto's disease is related to the thyroid gland.
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
unequal response Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.
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 level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.
Which is a late sign of increased intracranial pressure (ICP)?
Altered respiratory patterns Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.