Management of Patients with Neurologic Dysfunction

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? A. Assessment of pupillary light reflexes B. Maintenance of a patent airway C. Determination of the cause D. Positioning to prevent complications

B. Maintenance of a patent airway

A client with newly diagnosed seizures asks about stigma related to epilepsy. The nurse will respond with which of the following statements? A. "Many people with developmental disabilities resulting from neurological damage also have epilepsy." B. "Cases of epilepsy are often associated with intellectual level." C. "In most people, epilepsy is usually synonymous with intellectual disability." D. "For many people with epilepsy, the disorder is synonymous with mental illness."

A. "Many people with developmental disabilities resulting from neurological damage also have epilepsy."

"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? A. "You must avoid coughing, sneezing, or blowing your nose." B. "You must report tingling in your ears immediately." C. "You must restrict your fluid intake." D. "You must lie flat for 24 hours after surgery."

A. "You must avoid coughing, sneezing, or blowing your nose."

A patient is admitted to the hospital with an ICP reading of 20 mmHg and a mean arterial pressure of 90 mmHg. What would the nurse calculate the CPP to be? A. 70 mmHg B. 50 mmHg C. 80 mmHg D. 60 mmHg

A. 70 mmHg

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? A. Administer stool softeners B. Position the client with the head turned toward the side of the brain tumor C. Provide sensory stimulation D. Encourage coughing and deep breathing

A. Administer stool softeners

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: A. Carefully move the client to a flat surface and turn him to his side B. Place an oral airway in the client's mouth to maintain an open airway C. Allow the client to remain in the chair but move all objects out of his way D. Hold the client's arm still to keep him from hitting anything

A. Carefully mov the client to a flat surface and turn him to his side

Which is the earliest sign of increasing intracranial pressure? A. Change in level of consciousness B. Vomiting C. Posturing D. Headache

A. Change in level of consciousness

An osmotic diuretic such a mannitol is given to a client with increased intracranial pressure (ICP) to: A. Dehydrate the brain and reduce cerebral edema B. Control fever C. Control shivering D. Reduce cellular metabolic demand

A. Dehydrate the brain and reduce cerebral edema

A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? A. Keep the client on one side B. Place a cooling blanket beneath the client C. Pry the client's mouth open to allow a patent airway D. Help the client sit up

A. Keep the client on one side

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 15 B. 3 C. 6 D. 9

B. 3

A client with a traumatic brain injury has developed increased intracranial pressure result in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? A. Oliguria and decreased urine osmolality B. Excessive urine output with deceased urine osmolality C. Excessive urine output with serum hypo-osmolality D. Oliguria and serum hyperosmolality

B. Excessive urine output with decreased urine osmolality

The nurse is caring for the patient with an altered level of consciousness (LOC). What is the priority of treatment of or this patient? A. Determination of the cause B. Maintenance of a patent airway C. Assessment of pupillary light reflexes D. Positioning to prevent complications

B. Maintenance of a patent airway

Which positions is used to help reduce intracranial pressure (ICP)? A. Rotating the neck to the far right with neck support B. Keeping the head flat, avoiding the use of a pillow C. Avoiding flexion of the neck with use of a cervical collar D. Extreme hip flexion, with the hip supported by pillows

C. Avoiding flexion of the neck with use of a cervical collar

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. Restrict protein to 10% of daily caloric intake B. At least 50% carbohydrate C. High in protein and low in carbohydrate D. Low in fat

C. High in protein and low in carbohydrate

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? A. Risk for impaired skin integrity r/t prolonged immobility B. Risk for injury r/t decreased LOC C. Ineffective airway clearance r/t altered LOC D. Deficient fluid volume r/t inability to take fluids by mouth

C. Ineffective airway clearance r/t altered LOC

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Half-normal saline (0.45% NS) B. Dextrose 5% in water (D5W) C. Mannitol D. One-third normal saline (0.33% NS)

C. Mannitol

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the: A. Prone position with the head turned to the unaffected side B. Trandelenburg position C. Supine position with the head slightly elevated D. Dorsal recumbent position

C. Supine positoin with the head slightly elevated

A nurse is working on a neurological unit with a nursing student who asks the different between primary and secondary headaches. The nurse's correct response will include which of the following statements? A. "A migraine headache is an example a secondary headache." B. "A secondary headache is one for which no organism cause can be identified." C. "A secondary headache is located in the frontal area." D. "A secondary headache is associated with an organic cause, such as a brain tumor."

D. "A secondary headache is associated with an organic cause, such as a brain tumor."

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: A. Multiple sclerosis B. Seizure disorder C. Huntington's disease D. Parkinson's disease

D. Parkinson's disease