Intracranial Regulation
Which clinical manifestation is associated with hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias
2 Seizures Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.
Which type of surgery involves opening the skull with a drill? 1 Burr hole 2 Craniotomy 3 Craniectomy 4 Cranioplasty
1 Burr hole A burr hole involves opening the cranium using a drill. A craniotomy is a cranial surgery that involves opening the cranium with the removal of the bone flap and opening the dura to remove the lesion. A craniectomy is an excision into the cranium to cut away a bone flap. A cranioplasty is the repair of a cranial defect caused by trauma.
Which part of the brain primarily regulates muscle functioning and coordinates movement? 1 Cerebrum 2 Cerebellum 3 Epithalamus 4 Hypothalamus
2 Cerebellum The cerebellum regulates motor movements resulting in smooth and balanced muscular activity. The cerebrum is associated with higher brain functions, such as thought and action. The epithalamus acts as a connection between the motor pathways and regulates emotions. The hypothalamus regulates body temperature and secretions of the endocrine gland.
An unconscious child is admitted to the pediatric intensive care unit with a closed head injury. What is the nurse's primary goal for this child? 1 Prevention of unnecessary trauma to the vital organs 2 Limitation of stimuli that increase intracranial pressure 3 Establishment of access routes for infusion of medications 4 Enhancement of the health team's management of the illness
2 Limitation of stimuli that increase intracranial pressure Increased intracranial pressure is associated with a high risk for mortality; stimuli must be minimized. Although prevention of trauma to the vital organs, establishment of routes for the delivery of medications, and fulfilling the health team's needs are all important, none is the priority.
Which assessment would the nurse use to assess the client's trigeminal nerve function? 1 Corneal sensation 2 Facial expressions 3 Ocular muscle movement 4 Shrugging of the shoulders
1 Corneal sensation The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea. Facial expressions (e.g., smiling, frowning) reflect the functioning of cranial nerve VII. The ocular muscle movement tests the function of cranial nerves III, IV, and VI. Shrugging of the shoulders tests the function of cranial nerve XI.
A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. Which explanation would the nurse give the client as the reason she is receiving this medication? 1 "It acts as a diuretic." 2 "It has a sedative effect." 3 "It acts as an anticonvulsant." 4 "It has an antihypertensive effect."
3 "It acts as an anticonvulsant." The target tissue of magnesium sulfate is the myoneural junction; it decreases secretion of acetylcholine, thereby depressing neuromuscular transmission, which acts as an anticonvulsant and prevents seizures. Although diuresis occurs, this is not the purpose of giving magnesium sulfate. Magnesium sulfate does not have a sedative effect. It has a minimum hypotensive effect.
A client who sustained a head injury reports to the nurse that food always tastes unappealingly bland even though the food is has been prepared to be flavorful. Which area of the brain would the nurse suspect to be affected in the client? 1 Frontal lobe 2 Parietal lobe 3 Occipital lobe 4 Temporal lobe
Functions of the parietal lobe of brain include interpretation of taste impulses and spatial perception and understanding of sensory inputs. Any injury to the parietal lobe causes absence of taste perception. Functions of the frontal lobe are voluntary eye movement, access to current sensory data, affective response to a situation, ability to develop long-term goals, and ability to reason and concentrate. Any injury to the frontal lobe may cause an inability to perform these tasks. Injury to the occipital lobe may be associated with compromised vision. Injury to the temporal lobe may be associated with hearing impairments.
A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. Which would be the client's total score?.
13 The Glasgow Coma Scale (GCS) is used to measure the level of a client's consciousness and assigns a numerical score for each area of neurological status. The score for opening eyes on sound or speech is a 3. The score assigned for confused verbal responses is a 4. A score of 6 is assigned to the motor response of obeying commands. The total score of the client is 13.
Which action will the nurse ask the client to perform when assessing for damage to the glossopharyngeal and vagus nerves? 1 Smile 2 Shrug 3 Smell 4 Swallow
4 Swallow Having the client swallow or checking the gag reflex is a test of cranial nerves IX and X. Shrugging tests the accessory nerve (cranial nerve XI). The sense of smell tests the olfactory nerve (cranial nerve I). Smiling tests the facial nerve (cranial nerve VII).
Which information would the nurse expect the client who has multiple sclerosis with hand tremors to report? 1 The tremors increase when I fall asleep. 2 The tremors increase when I feel fatigued. 3 The tremors increase when I become nervous. 4 The tremors increase when I perform an activity.
4 The tremors increase when I perform an activity. Multiple foci of demyelination cause interruption or distortion of the impulse, resulting in intention tremors (tremor when performing an activity). There are no tremors when the client is asleep. Fatigue will exacerbate the signs and symptoms of multiple sclerosis, but it will not precipitate intention tremors. Intention tremors are associated with muscle contraction, not feelings; however, stress can exacerbate the signs and symptoms of multiple sclerosis.
Which assessment finding alerts the nurse to increasing intracranial pressure? 1 Hypervigilance 2 Constricted pupils 3 Increased heart rate 4 Widening pulse pressure
4 Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.
Which cranial nerve emerges from the client's medulla? 1 Trochlear 2 Trigeminal 3 Hypoglossal 4 Oculomotor
3 Hypoglossal The medulla is a part of the brainstem. The hypoglossal nerve (cranial nerve XII) emerges from the medulla. The trochlear nerve and oculomotor nerve (cranial nerves IV and III) emerge from the midbrain. The trigeminal nerve (cranial nerve V) emerges from the pons.
Which intervention would the nurse include in the plan of care for a client with moderate Alzheimer disease? 1 Discuss recent current events. 2 Teach the client new social skills. 3 Maintain a daily routine of living. 4 Encourage new activities daily.
3 Maintain a daily routine of living. The nurse would include the intervention to maintain a daily routine of living. The client with this disorder will be most comfortable with a familiar and repetitive daily routine because it will produce less anxiety. Cognitive changes probably make a discussion of current events unrealistic. It probably is beyond the client's capability to develop new social skills. Encouraging new activities daily can increase anxiety and agitation in clients who have moderate Alzheimer disease.
How would the nurse describe the clonic phase of a tonic-clonic seizure? 1 Generalized rigidity 2 Loss of consciousness 3 Rhythmic body jerking 4 Tremors of upper extremities
3 Rhythmic body jerking The clonic phase of a tonic-clonic seizure is associated with the rapid rhythmic extension and relaxation of muscle groups throughout the body. Rigidity occurs during the tonic phase of a seizure. Loss of consciousness is not specific to the clonic phase; it occurs at the beginning of the tonic phase and continues into the clonic phase. The movements during the clonic episode are more marked than the movements of a tremor and occur throughout the body, not just in the extremities.
A client with an abdominal aortic aneurysm is suddenly pale and reports feeling light-headed and having abdominal pain. Which action would the nurse take first? 1 Assess the respiratory rate for hyperventilation. 2 Check the blood pressure for hypotension. 3 Administer the prescribed morphine for pain. 4 Inspect the abdomen for distension and firmness.on.
2 Check the blood pressure for hypotension. The history of abdominal aortic aneurysm, with new symptoms of pallor, lightheadedness, and abdominal pain, suggests bleeding or dissection of the aneurysm. The nurse would first check blood pressure and report hypotension immediately to the health care provider, anticipating the need to give intravenous fluids and prepare the client for emergency surgery. The other actions are also appropriate after the nurse has obtained the blood pressure. Hyperventilation may cause lightheadedness. Treatment of pain is appropriate if the blood pressure is stable, but morphine would further lower blood pressure if the client is hypotensive. Inspection of the abdomen would help confirm a diagnosis of bleeding or dissection but would not be first action.
Which clinical manifestations are found in the client diagnosed with stage 3 of Parkinson disease? Select all that apply. One, some, or all responses may be correct. 1 Akinesia 2 Masklike face 3 Postural instability 4 Unilateral limb involvement 5 Increased gait disturbances
2 Masklike face 3 Postural instability 5 Increased gait disturbances Parkinson disease is a progressive neurodegenerative disease that is one of the most common neurological disorders of older adults. Stage 3 of Parkinson disease is characterized by postural instability and increased gait disturbances. The "masklike" face begins in stage 2 and continues in stage 3. Akinesia is manifested in stage 4 of the disease. In stage 1 of Parkinson disease, only unilateral limb involvement is seen, but it progresses to bilateral in later stages.
Which action would the nurse implement to assist a client's development of independence, after experiencing a cerebrovascular accident (CVA) 2 weeks ago? 1 Establish long-range goals for the client. 2 Reinforce success in tasks accomplished. 3 Point out errors in performance on which to focus. 4 Explain ways the client can regain independence in activities.
2 Reinforce success in tasks accomplished. To aid in motivation, the nurse should focus on positive aspects of the client's progress. Short-term, not long-term, attainable goals provide positive reinforcement; the nurse should assist the client to set goals. Negative reinforcement may result in discouragement. Return demonstration by the client is more effective than telling or showing what to do.
The emergency department received a client who was a passenger in an automobile collision, with rhinorrhea and bleeding from their ear. Having sustained a basilar head injury, which interventions would the nurse anticipate as the initial focus of this client's care? 1 Physical therapy 2 Psychosocial support 3 Nutritional management 4 Antimicrobial administration
4 Antimicrobial administration Preventing infection is the initial priority and accomplished with the use of prophylactic antibiotics because tearing of the meninges may have introduced infectious organisms. Physical therapy is premature; physical therapy begun too early can increase intracranial pressure. Although psychosocial support is important, it is not the priority. Nutrition is not the priority at this time.
Which assessment would the nurse perform to monitor for a major complication in an infant after surgery to correct a myelomeningocele? 1 Daily weights 2 Fluid output every 8 hours 3 Blood pressure every 12 hours 4 Daily head circumference measurements
4 Daily head circumference measurements Hydrocephalus, which may occur after surgical correction, is a major complication of myelomeningocele. Measuring the daily head circumference provides an accurate basis for day-to-day comparisons. Although important, daily weights are not specific to monitoring for a developing hydrocephalus. An infant's output is unrelated to hydrocephalus. Vital signs should be taken every 2 to 4 hours after surgery.
A client is prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication is primarily given for which purpose? 1 Lower blood pressure 2 Prevent hypoglycemia 3 Increase cardiac output 4 Decrease fluid in the brain
4 Decrease fluid in the brain Osmotic diuretics remove excessive cerebrospinal fluid (CSF), reducing intracranial pressure. Osmotic diuretics increase, not decrease, the blood pressure by increasing the fluid in the intravascular compartment. Osmotic diuretics do not directly influence blood glucose levels. Although there is an increase in cardiac output when the vascular bed expands as CSF is removed, it is not the primary purpose of administering the medication.
After a head injury, a client reports hearing ringing noises. Which area would the nurse assess further? 1 Frontal lobe 2 Occipital lobe 3 Sixth cranial nerve (abducens) 4 Eighth cranial nerve (vestibulocochlear)
4 Eighth cranial nerve (vestibulocochlear) The eighth cranial nerve has two parts: the vestibular nerve and the cochlear nerve. Sensations of hearing are conducted by the cochlear nerve. The frontal lobe is concerned with thinking and emotions. The occipital lobe is concerned with sight, particularly shape and color. Cranial nerve VI (abducens) is concerned with abduction of the eye.
After interacting with a client, the nurse thinks the client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? Select all that apply. One, some, or all responses may be correct. 1 "I feel drowsy all the time." 2 "I feel severe pain over my ear." 3 "I feel a throbbing pain in my head." 4 "I feel confused at this point in time." 5 "I feel weakness in the left side of my body."
1 "I feel drowsy all the time." 4 "I feel confused at this point in time." 5 "I feel weakness in the left side of my body." A migraine is a clinical syndrome characterized by recurrent episodic attacks of head pain. The first phase of a migraine headache is called the prodromal phase. In the prodromal phase, a variety of neurological changes are seen. These include drowsiness, acute confusion, vertigo, numbness and tingling of lips or tongue, aphasia, and unilateral weakness. Severe pain over the ear is pain in the templar region and is the second phase of a migraine headache. Throbbing pain in the head occurs in the third phase of a migraine.
Which amount of time is the maximum amount the nurse would permit an older adult with a cerebrovascular accident (CVA, also known as "brain attack") to remain in one position? 1 1 to 2 hours 2 3 to 4 hours 3 15 to 20 minutes 4 30 to 40 minutes
1 1 to 2 hours Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility. Too protracted a period in one position, such as every 3 to 4 hours, increases the potential for respiratory, urinary, and neuromuscular impairment; prolonged physical pressure increases the possibility of skin breakdown. Fifteen to 20 minutes and 30 to 40 minutes are unnecessarily short time intervals; too frequent repositioning may interfere with the client's rest.
Three days after admission to the hospital for a brain attack (cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action would the nurse take to evaluate whether the feeding is being absorbed? 1 Aspirate for a residual volume. 2 Evaluate the intake in relation to the output. 3 Instill air into the client's stomach while auscultating. 4 Compare the client's body weight with the baseline data.
1 Aspirate for a residual volume. A gastric residual of more than 200 mL or as specified by the primary health care provider or facility will alert the nurse that the feeding is not being absorbed; conversely, a residual of less than 200 mL indicates the feeding is being absorbed. Evaluation of intake to output gauges fluid balance, not whether feeding is absorbed. Instilling air into the client's stomach is not advocated and does not determine if the feeding is absorbed. Comparing the body weight with the baseline is a fluid issue and is performed on a daily basis, or it is a weight gain/loss issue. Because weight can fluctuate based on fluid, the aspirate is the better choice for absorption.
A male client with a brain attack (cerebrovascular accident) is incontinent of urine. Which action would the nurse encourage to help the client reestablish bladder control? 1 Assume a standing position for voiding. 2 Void every 4 hours at set times. 3 Void more frequently in the afternoon. 4 Drink a minimum of 4 L of fluid daily.
1 Assume a standing position for voiding. Assuming a standing position for voiding reduces tension (physical and psychological), facilitates the movement of urine into the lower portion of the bladder, and relaxes the external sphincter (increasing pressure and initiating the micturition reflex). Bladder training should be instituted by encouraging voiding every 1 to 2 hours and progressively increasing the time between attempts. Voiding should be encouraged at regular and frequent intervals during waking hours, not just in the afternoon. Four liters is a large fluid intake and is unnecessary; it will result in a large volume of urine, probably increasing the frequency of incontinence.
Which action would the nurse take for a daughter who states that she gives sleeping pills to her live-in mother who has dementia to stop wandering at night? 1 Explore hiring a home health aide to stay with the client at night. 2 Discuss the possibility of having the client placed in a nursing home. 3 Suggest moving the client among family members on a monthly basis. 4 Empathize with the daughter but suggest that wrist restraints would be preferable.
1 Explore hiring a home health aide to stay with the client at night. Exploring hiring a home health aide to stay with the client at night will reduce the need for sleeping pills, which may exacerbate the older client's confusion and wandering. The daughter is not asking that the client be moved from the home; the nurse's focus would be helping reduce the confusion the client experiences at night, keeping the client safe, and easing the burden on the daughter. Continually changing a cognitively impaired client's environment and routine will increase confusion and anxiety. This client needs a consistent environment with a set daily routine of activities, which provides structure and comfort. Restraints add to the client's confusion and tend to worsen inappropriate behavior.
The nurse is caring for a client who underwent a transsphenoidal hypophysectomy and notices clear nasal drainage. Which intervention would the nurse perform first to prevent complications? 1 Test fluid for glucose. 2 Place client on bed rest. 3 Document the findings. 4 Administer glucocorticoids.
1 Test fluid for glucose. To determine the source of the fluid draining from the nose, the nurse would first test the fluid for glucose. Other interventions are based on knowing the source of the fluid. If the fluid is cerebrospinal fluid, the client would be placed on bed rest. After all interventions are performed, the nurse would document the findings. Glucocorticoids are given to treat a client who underwent pituitary gland removal.
A young adult is unconscious after an accident. As part of the assessment, the nurse applies a painful stimulus to the client's left lower leg. Which response is expected in a healthy adult? 1 Withdrawing the leg 2 Making no movement 3 Plantar-flexing the left foot 4 Flexing the upper extremities
1 Withdrawing the leg Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.
A client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record? 1. 8 2. 9 3. 12 4. 15
1. 8 The score is 8. The Glasgow Coma Scale is a three-part neurological assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma. Nine and 12 are too high a rating for the behaviors exhibited by the client. A rating of 15 indicates that the client is opening the eyes spontaneously, obeying commands, and fully oriented.
Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue? 1 Facial 2 Trigeminal 3 Hypoglossal 4 Glossopharyngeal
3 Hypoglossal Damage to the nerve that supplies the skeletal muscles of the tongue may lead to the loss of its ability to move. These muscles are supplied by the hypoglossal nerve ( cranial nerve XII), which assists with motor functions of the tongue such as talking. The facial nerve (cranial nerve VII) assists with sensory functions such as taste perception of the anterior two-thirds of the tongue. The trigeminal nerve (cranial nerve V) assists in the sensory perception from the skin of the face and scalp and the mucous membranes of the mouth and nose. It also assists with the motor functions of the mouth such as mastication (chewing). The glossopharyngeal nerve (cranial nerve IX) assists with sensory perception such as taste at the posterior one-third of the tongue.
An alert and oriented client who hit his or her head while playing basketball arrived at the emergency department (ED). Which intervention would the nurse implement immediately? 1 Assess full range of motion (ROM) to determine extent of injuries. 2 Call for immediate head computed tomography (CT). 3 Immobilize the client's head and neck. 4 Open the airway with the head-tilt chin-lift maneuver.
3 Immobilize the client's head and neck. Nursing staff would treat all clients with a head injury as if a cervical spine injury is present until x-rays confirm the absence. The nurse would not perform ROM assessments at this time. After immobilizing the client's head and neck, the completion of a prescribed head CT occurs. The airway does not need opening because the client appears alert and not in respiratory distress. Additionally, the nurse would not use the head-tilt chin-lift maneuver until ruling out the potential cervical spine injury.
Which priority parameter would the nurse assess when caring for an older adult client with a neurocognitive disorder who demonstrates disorientation and numerous unmanageable behaviors? 1 Orientation to time, place, and person 2 Ability to perform daily activities without assistance from others 3 Stressors that appear to precipitate the client's disruptive behavior 4 Cognitive impairments until complete adjustments are accomplished
3 Stressors that appear to precipitate the client's disruptive behavior The nurse's priority assessment would be to assess for stressors that appear to precipitate the client's disruptive behavior. Additional information must be collected to determine what may be precipitating the disruptive behavior. Clients with cognitive impairment may have difficulty controlling behaviors and may need the environment to provide the structure needed to act appropriately. The client's disorientation is documented, so orientation to time, place, and person is not the priority. The client's ability to perform daily activities is important, but it is not the priority. Although cognitive impairments are important, the phrase "until complete adjustments are accomplished" makes this a low priority. The client may never achieve complete adjustment to the facility.
In which order would the nurse perform assessments to determine the client's neurological status? 1. Speak in loud voice 2. Apply painful stimuli 3. Speak in normal voice 4. Shake the client gently
3. Speak in normal voice 1. Speak in loud voice 4. Shake the client gently 2. Apply painful stimuli The assessment of neurological status should start with speaking to the client in a normal voice. If the client does not respond, the nurse would speak loudly. If the client does not respond to this, the nurse would gently shake the client. The degree of shaking should be similar to that used in waking a child. If the client does not respond to this, painful stimuli can be applied.
Which nursing intervention would the nurse implement for a forgetful, disoriented client who has Alzheimer disease? 1 Restricting gross motor activity 2 Preventing further deterioration 3 Keeping the client oriented to time 4 Managing the client's unsafe behaviors
4 Managing the client's unsafe behaviors The nurse would manage the client's unsafe behaviors. Clients with Alzheimer disease require external controls to minimize the danger of injury caused by lack of judgment. The staff would not prevent gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration cannot be prevented in this disorder. It is not recommended to continually orient a client with Alzheimer disease; this can increase agitation.
Which type of nerve helps the client's pupil constrict? 1 Motor 2 Sensory 3 Sympathetic 4 Parasympathetic-motor
4 Parasympathetic-motor The parasympathetic-motor nerves located in the midbrain help in pupil constriction. The motor nerves help in eye movement. The sensory nerves help in sensory perception. The sympathetic nerves help in involuntary functions of the body.