MedSurg Chapter 66: Management of Patients With Neurologic Dysfunction
A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?
15 mg
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? A. An absence seizure B. A partial seizure C. A tonic-clonic seizure D. A complex seizure
A
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A. Lethargy and stupor B. Hypertension C. A bounding pulse D. Bradycardia
A
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? A. Recent stress level B. Compliance with the prescribed medication regimen C. Recent weight gain and loss D. The type of anticonvulsant prescribed to manage the epileptic condition
B
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? A. Demonstrates optimal cerebral tissue perfusion B. Attains desired fluid balance C. Maintains a patent airway D. Displays no signs or symptoms of infection
C
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? A. "I will lose strength in my arms." B. "I will have progressive muscle weakness." C. "I need to remain active for as long as possible." D. "My children are at greater risk to develop this disease."
D
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? A. fatal B. excellent C. good D. poor
D
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A. Sleeping quietly after the seizure B. The client cried out before the seizure began. C. Seizure began at 1300 hours. D. Seizure was 1 minute in duration including tonic-clonic activity.
D
Which is the earliest sign of increasing intracranial pressure? A. Vomiting B. Headache C. Change in level of consciousness D. Posturing
C
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? A. 70 mm Hg B. 60 mm Hg C. 80 mm Hg D. 50 mm Hg
A
Which of the following drugs may be used after a seizure to maintain a seizure-free state? A. Valium B. Cerebyx C. Phenobarbital D. Ativan
C
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. A. Opening the patient's jaw and inserting a mouth gag B. Restraining the patient to avoid self injury C. Positioning the patient on his or her side with head flexed forward D. Loosening constrictive clothing E. Providing for privacy
C, D, E
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 in tenths.
97.5 g
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? A. Give the patient some mouthwash to gargle with. B. Notify the physician of a possible cerebrospinal fluid leak. C. Ask the patient to cough to observe the sputum color and consistency. D. Request an antihistamine for the postnasal drip.
B
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? A. Visualization of a hemorrhage B. Aspiration of a brain abscess C. Access for intravenous (IV) fluids D. To assess visual acuity
B
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? A. Lamisil B. Labetalol C. Lamictal D. Lomotil
C
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? A. Tonic clonic B. Decorticate C. Decerebrate D. Flaccidity
C
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? A. Isosorbide B. Urea C. Mannitol D. Glycerin
C
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? A. 150 to 200 mL/h B. 50 to 100 mL/h C. 100 to 150 mL/h D. More than 200 mL/h
D
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. Position the client with the head turned toward the side of the brain tumor. B. Encourage coughing and deep breathing. C. Provide sensory stimulation. D. Administer stool softeners.
D
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? A. Obesity B. Anemia C. Osteoarthritis D. Osteoporosis
D
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: A. pupillary changes. B. decreasing blood pressure. C. diminished responsiveness. D. elevated temperature.
C
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? A. Give acetaminophen per orders. B. Document signs and symptoms of inflammation. C. Assess for weight loss. D. Administer corticosteroids as ordered.
D
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? A. "There is a strong familial tendency." B. "No familial tendency has been demonstrated." C. "Only secondary migraine headaches show a familial tendency." D. "There is a very weak familial tendency." SUBMIT ANSWER
A
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. Low in fat B. At least 50% carbohydrate C. Restricts protein to 10% of daily caloric intake D. High in protein and low in carbohydrate
D
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. dorsal recumbent position. B. supine position with the head slightly elevated. C. Trendelenburg position. D. prone position with the head turned to the unaffected side.
B
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? A. Elevated 30 degrees B. Flat C. Elevated no more than 10 degrees D. Turned onto the operative side
A
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? A. Pituitary carcinoma B. Laryngeal carcinoma C. Esophageal carcinoma D. Colorectal carcinoma
A
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? A. Apply warm or cool cloths to the forehead or back of the neck B. Maintain hydration by drinking eight glasses of fluid a day C. Perform the Heimlich maneuver D. Use pressure-relieving pads or a similar type of mattress
A
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. A. Hypertension B. Tachycardia C. Bradycardia D. Bradypnea E. Pupillary constriction
A, C, D
Which is a late sign of increased intracranial pressure (ICP)? A. Irritability B. Altered respiratory patterns C. Slow speech D. Headache
B
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to A. control fever. B. control shivering. C. dehydrate the brain and reduce cerebral edema. D. reduce cellular metabolic demand.
C
When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as A. decorticate. B. normal. C. decerebrate. D. flaccid.
C
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? A. Continue the assessment because no actions are indicated at this time. B. Document the reading because it reflects that the treatment has been effective. C. Contact the physician to review the care plan. D. Check the equipment.
D
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? A. Exacerbation of uncontrolled hypertension B. Increased ICP C. Infection D. Increase in cerebral perfusion pressure
B
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. "A migraine headache is an example of a secondary headache." B. "A secondary headache is one for which no organic 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
The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? A. Offering family support groups B. Optimizing nutrition C. Managing muscle weakness D. Explaining hospice care and services
D
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 on his side. B. hold the client's arm still to keep him from hitting anything. C. place an oral airway in the client's mouth to maintain an open airway. D. allow the client to remain in the chair but move all objects out of his way.
A
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? A. Normal B. Decorticate C. Flaccid D. Decerebrate
B
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? A. Apply oxygen via nasal cannula. B. Place the client in wrist restraints. C. Reorient the client while gently holding their arms. D. Administer lorazepam per orders.
C
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% NSS) B. One-third normal saline (0.33% NSS) C. Mannitol D. Dextrose 5% in water (D5W)
C
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Administer morning dose of anticonvulsant. B. Complete a head-to-toe assessment. C. Administer Percocet as ordered. D. Elevate the head of the bed.
D
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. 9 C. 6 D. 3
D
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? A. Maintaining adequate hydration B. Hyperoxygenation before and after tracheal suctioning C. Administering prescribed antipyretics D. Restricting fluid intake and hydration
D
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? A. Decerebrate B. Tonic clonic C. Flaccidity D. Decorticate
D
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? A. Suctioning the client once each shift B. Encouraging oral fluid intake C. Administering a stool softener as ordered D. Elevating the head of the bed 90 degrees
C
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? A. "Cases of epilepsy are often associated with intellectual level." B. "For many people with epilepsy, the disorder is synonymous with mental illness." C. "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." D. "In most people, epilepsy is usually synonymous with intellectual disability."
C
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? A. Hypostatic pneumonia B. Trigeminal neuralgia C. Brain tumor D. Epilepsy
C
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? A. Deficient fluid volume B. Risk of injury C. Risk for impaired skin integrity D. Airway clearance
D
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? A. constricted response B. rapid response C. unequal response D. equal response
C
A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client? A. Assess neurological findings. B. Assessing skull dressing for excess drainage C. Maintain airway via artificial ventilation. D. Time, distance, and shielding against radiation
A
To meet the sensory needs of a client with viral meningitis, the nurse should: A. promote an active range of motion. B. increase environmental stimuli. C. minimize exposure to bright lights and noise. D. avoid physical contact between the client and family members.
C
Which positions is used to help reduce intracranial pressure (ICP)? A. Avoiding flexion of the neck with use of a cervical collar B. Keeping the head flat, avoiding the use of a pillow C. Rotating the neck to the far right with neck support D. Extreme hip flexion, with the hip supported by pillows
A
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? A. Urine output of 100 mL/hr B. Cool, dry skin C. Capillary refill of 2 seconds D. Shivering
D
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: A. hypothermia can cause death to the client. B. shivering in hypothermia can increase ICP. C. hypothermia is indicative of malaria. D. hypothermia is indicative of severe meningitis.
B
