MedSurg2 Exam 2 Part 4

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

Lethargy and stupor

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?

Respiratory function

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a. pupillary changes. b. diminished responsiveness. c. decreasing blood pressure. d. elevated temperature.

b Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

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

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?

Fluid restriction

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

Generalized seizure

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?

Osteoporosis

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a. Rising blood pressure and bradycardia b. Hypotension and bradycardia c. Hypotension and tachycardia d. Hypertension and narrowing pulse pressure

a Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? a. Baclofen b. Riluzole c. Dantrolene sodium d. Diazepam

b Riluzole, a glutamate antagonist, has been shown to prolong survival for persons with ALS for 3 to 6 months.

Which is a late sign of increased intracranial pressure (ICP)? a. Irritability b. Slow speech c. Altered respiratory patterns d. Headache

c Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

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)?

Administering a stool softener as ordered

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? a. It suggests onset of metabolic problems. b. It indicates paralysis on the right side of the body. c. It indicates paralysis of cranial nerve X (CN X). d. It indicates an injury at the midbrain level.

D Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?

Decerebrate posturing and loss of corneal reflex

A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case? a. Narcotic analgesics increase CSF pressure. b. Narcotic analgesics are ineffective against pain in head trauma. c. Narcotic analgesics decrease CSF pressure. d. Avoidance is inappropriate because narcotic analgesics are the drug of choice in treating pain associated with head trauma.

a Narcotic analgesics depress the respiratory center and raise CSF pressure. Their use is contraindicated in clients with head trauma or increased ICP, unless administration is an absolute necessity.

A client fell at home and sustained a head injury. The client exhibits signs and symptoms of head trauma with indications of increased ICP. What is the normal ventricular ICP? a. 5 to 15 mm Hg b. 16 to 20 mm Hg c. 21 to 30 mm Hg d. 31 to 40 mm Hg

a Normal ICP is 5 to 15 mm Hg.

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a. chewing b. swallowing c. smelling d. tasting

a Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.

Which activity should be avoided in clients with increased intracranial pressure (ICP)? a. Suctioning b. Enemas c. Position changes d. Minimal environmental stimuli

b Enemas should be avoided in clients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the client increases the ICP, rotating beds, turning sheets, and holding the client's head during turning may minimize the stimuli that cause increased ICP.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately? a. Intravenous phenobarbital b. Intravenous diazepam c. Oral lorazepam d. Oral phenytoin

b Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? a. Generalized seizure b. Absence seizure c. Focal seizure d. Unclassified seizure

b Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

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

3

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? a. Chronic confusion b. Impaired urinary elimination c. Impaired verbal communication d. Bowel incontinence

C cImpaired communication is an appropriate nursing diagnosis; the voice in clients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in clients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

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. The type of anticonvulsant prescribed to manage the epileptic condition b. Recent stress level c. Recent weight gain and loss d. Compliance with the prescribed medication regimen

D The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?

Phenytoin

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? a. The CPP is high. b. The CPP is low. c. The CPP is within normal limits. d. The CPP reading is inaccurate.

b The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? a. Encephalitis b. CSF leak c. Meningitis d. Catheter occlusion

c Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter.

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.

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses? a. Prepare an advance directive. b. Designate a most responsible health care provider (MRP) early in the course of the disease. c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. d. Ensure that witnesses are present when he provides instruction.

A Clients with ALS are encouraged to complete an advance directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?a. Hemiplegia b. Dry mucous membranes c. Signs of internal bleeding d. Loss of brain stem reflexes

d Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? a. Monitoring of pulse oximetry b. Administration of a low-protein diet c. Administration of thorough oral hygiene d. Fluid restriction as prescribed

c Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

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. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure

A Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

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. Loosening constrictive clothing b. Opening the patient's jaw and inserting a mouth gag c. Positioning the patient on his or her side with head flexed forward d. Providing for privacy e. Restraining the patient to avoid self injury

a, c, d During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? a. Solumedrol b. Dextromethorphan c. Dexamethasone d. Furosemide

c If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

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. Attains desired fluid balance b. Displays no signs or symptoms of infection c. Maintains a patent airway d. Demonstrates optimal cerebral tissue perfusion

c Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.

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. Restricts protein to 10% of daily caloric intake c. High in protein and low in carbohydrate d. At least 50% carbohydrate

c A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).

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:

Parkinson's disease.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? a. The ability of the client to follow instructions during the seizure. b. The success or failure of the care team to physically restrain the client. c. The client's ability to explain his seizure during the postictal period. d. The client's activities immediately prior to the seizure.

d Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure is not clinically relevant.

Which is the earliest sign of increasing intracranial pressure? a. Vomiting b. Change in level of consciousness c. Headache d. Posturing

B The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? a. Sensory symptoms b. Motor symptoms c. Impaired consciousness d. Compound forms

C A complex partial seizure is characterized by complex symptoms with the impairment of consciousness. A simple partial seizure generally occurs without impairment of consciousness.

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. Administering prescribed antipyretics c. Restricting fluid intake and hydration d. Hyperoxygenation before and after tracheal suctioning

C Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

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. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction

a, b, c At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? a. Alopecia b. Gingival hyperplasia c. Diplopia d. Ataxia

b Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? a. IV phenobarbital b. IV diazepam c. IV lidocaine d. Oral phenytoin

b Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way? a. Ascending paralysis b. Numbness and tingling in the lower extremities c. Weakness starting in the muscles supplied by the cranial nerves d. Jerky, uncontrolled movements in the extremities

c The chief symptoms are fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and incoordination. In about 25% of patients, weakness starts in the muscles supplied by the cranial nerves, and difficulty in talking, swallowing, and ultimately breathing occurs.