Management of Patients with Neurologic Dysfunction (Chapter 66)

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

Which is a late sign of increased intracranial pressure (ICP)?

altered respiratory patterns

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise

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

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness

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

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

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

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

notify the physician of a possible cerebrospinal fluid leak

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

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

anticonvulsants

Which signs are manifestations of the Cushing triad? Select all that apply.

bradycardia

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

When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as

decerbrate

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness

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."

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

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

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

administer corticosteroids as ordered

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 output and decreased urine osmolality

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

generalized

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?

turn client to side-lying position

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

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."

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

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

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

increased intracranial pressure (ICP)

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number ONLY.

97.5

Which phase of a migraine headache usually lasts less than an hour?

aura

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

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

maintenance of a patent airway

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

mannitol

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."

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

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 r/t altered LOC

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

lethargy and stupor

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