Exam 5
What are some considerations for a patient post op brain surgery?
-Space out interventions to allow pt to recover -Maintain calm atmosphere and prevent emotional stress -Decrease environmental, need quiet environment with minimal stimulation -Keep head in a neutral position (midline) -Avoid rotation & flexion of the neck
What is the treatment of a thrombotic stroke?
2 PIV's, any invasive procedures, THEN fibrinolytic therapy, TPA clot buster (no anticoags until 24hr after TPA)
What is a normal adult ICP?
5-15mmHg
What is a normal cerebral perfusion pressure?
70-80 mm Hg
What are considerations for patients that have suffered a spinal cord injury?
Back board, head & neck in neutral position to prevent incomplete injury from becoming complete. Never move pt until head is stable. No part of the body should be twisted or turned. Do not allow the patient to sit up.
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded.
D. the patients urinary catheter became occluded
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
Decerebrate
When should you call OPO?
GCS less than 5, severe CVA, anoxia, brain trauma with decreased neuro exam function
The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately?
IV diazepam (lorazepam)
The diagnosis of multiple sclerosis is based on which test?
MRI
What is the primary neuroimaging diagnostic tool used to evaluate brain structure?
MRI and CT
Which disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells?
Parkinsons
What criteria is needed to diagnose diabetes insipidus?
UO greater than 200ml x2 consecutive hours
Which patient should the nurse notify the organ procurement organization (OPO) to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic male with a history of unstable angina status post resuscitation
a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg
a. A patient with a complete spinal injury at the C5 dermatome level - A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise
The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient's mouth and insert a padded tongue blade. d. Restrain the patient's extremities until the seizure subsides.
a. Assist the patient to the floor and provide soft head support.
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous
a. Mannitol 1 g intravenous
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?
absolute bed rest in a quite, non stimulating environment
The nurse is caring for a patient with permanent neurological impairments resulting from a traumatic head injury. When working with this patient and their family, what mutual goal should be prioritized?
achieve as high level of function as possible
What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?
alteration in LOC
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?
an area of bruising over the mastoid
The nurse is caring for a patient whose recent health history includes altered LOC. What should be the nurses first action when assessing this patient?
assessing the patient's verbal responses
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
avoid hot baths and showers
What is the treatment for a basilar skull fracture?
bed rest, OG tube if needed for gastric decompression, C collar until spine is deemed ok
What medication is given during the emergent stages of a seizure because they are quick onset strong anticonvulsants (given IV)?
benzodiazepines (lorazepam)
Which signs are manifestations of the Cushing triad? Select all that apply.
bradypnea, bradycardia, hypertension
What are common symptoms of a basilar skull fracture?
bruising behind the ears (battle sign), around the eyes (raccoon eyes), and blood behind ear drums
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
bruising over the mastoid
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5 F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bed rest at all times.
c. Implement seizure precautions.
A patient with a C5 spinal injury is a tetraplegic. After being moved out of the ICU, the patient complains of a severe headache. What would the nurse do first?
check the patients indwelling catheter for kinks to ensure patency
After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.
d. Apply a small nasal drip pad.
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action to assure effective care? a. Assess for the presence of a headache. b. Assess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.
d. Determine the time of symptom onset.
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient's head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.
d. Provide rest periods between nursing interventions.
What is one of the earliest signs of increased ICP?
decreased LOC
What complication is common with a basilar fracture?
delayed symptoms of meningitis caused by dural tears
A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:
diplopia
Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?
dopamine
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
What is decerbrate posturing?
extension of upper extremities, pronated - most conerning positioning
What is decorticate posturing?
flexion of upper extremities to the core (drawing to core)
What nursing interventions would the nurse most likely initiate if a patient develops SIADH?
fluid restriction
How is diabetes insipidus treated?
fluids, electrolytes, and desmopressin
What are common S/S of increased ICP?
headache, blurred vision, confusion, hypertension, shallow breathing, behavioral changes
What medication is used to treat edema?
high dose methylprednisolone
What might cause an increased cerebrospinal fluid?
high sodium and low potassium
What is the cushings triad?
increased BP (big difference between sys and dia), decreased pulse, and decreased and irregular respirations
What is the treatment for increased ICP?
insert an ICP monitor, elevate HOB atleast 15*, intubate to hyperventilate, IV mannitol to reverse brian swelling, 3% saline
What must you know before beginning TPA therapy?
last known well time
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.
loosen restrictive clothing, provide privacy, positioning the patient on his or her side with head flexed forward
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
loosen the patients restrictive clothing
What signs should a nurse assess for that indicate approaching death?
loss of brain stem reflexes
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment?
lumbar puncture
The nurse is providing care for a patient who is unconscious. What nursing intervention takes the highest priority?
maintaining an airway
What drug is used to decreased brain swelling?
mannitol
A patient is being admitted to the neurological ICU following an acute head injury that resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication?
mannitol (osmitrol)
A patient with an increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
meningitis
What requirements are needed to deem brain death?
must state etiology of irreversible coma, absence of motor response to pain, absence of brainstem reflexes during 2 different exams at least 6 hours apart. Absence of RR w pCO2 > 60
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is priority for the nurse?
notify physician immediately
What are clinical manifestations of meningitis?
nuchal rigidity and photophobia
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
phenytoin
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
place the patient in a side-lying position
What is included in pt care after a seizure?
position rt side lying suctioning may be done. Bed in low position, padded side rails, remove restrictive clothing/jewelry
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conductive to communication?
provide a board of commonly used needs and phrases
What are contraindications for thrombolytic therapy?
recent intracranial pathology, current anticoagulation therapy, symptom onset greater than 3 hours prior to admission
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurological assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?
report this to the physician as a possible sign of deterioration
What should the nurse include in discharge education for a patient that was hospitalized for an ischemic stroke?
take antihypertensive medication as ordered
What should the nurse be sure to document for a patient that experiences a seizure?
the patients activities immediately prior to the seizure
What is the best rationale for the following physician orders; elevate the HOB, keep the head in neutral alignment with no neck flexion or head rotation, and avoid sharp hip flexion
to avoid impeding venous flow
What is the treatment for SIADH?
treat with fluid restriction and 3% saline
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?
washing face
What are late signs of increased ICP?
widening pulse pressures, bradycardia, and abnormal respirations