Neuro-Saunders

The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation should the nurse monitor for, indicating increased intracranial pressure? 1.Altered mental status 2.Decreased urinary output 3.Decreased peripheral sensation 4.Numbness and tingling in the fingers and toes

1.Altered mental status

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1.Blood pressure 2.Motor response 3.Pupillary response 4.Level of consciousness

1.Blood pressure Rationale: Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1.Confusion 2.Bradycardia 3.Sluggish pupils 4.A widened pulse pressure

1.Confusion Rationale: Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1.Eye opening 2.Reflex response 3.Best verbal response 4.Best motor response 5.Pupil size and reaction

1.Eye opening 3.Best verbal response 4.Best motor response Rationale: Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The 3 categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of a total assessment of the neurological status of a client but is not part of this particular scale.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees Rationale: Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1.It is possible the client can hear the family. 2.The family needs immediate crisis intervention. 3.The client might have wanted a visit from the hospital chaplain. 4.The family could benefit from a conference with the primary health care provider.

1.It is possible the client can hear the family. Rationale: Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. In addition, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client. The remaining options are incorrect interpretations.

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 3.Keep the client lying in a supine position. 4.Keep the head and neck in good alignment. 5.Administer prescribed respiratory treatments as needed.

1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 4.Keep the head and neck in good alignment. 5.Administer prescribed respiratory treatments as needed. Rationale: The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 4.Turning and repositioning the client at least every 2 hours Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply 1.Loosening restrictive clothing. 2.Restraining the client's limbs. 3.Removing the pillow and raising padded side rails. 4.Positioning the client to the side, if possible, with the head flexed forward. 5.Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

1.Loosening restrictive clothing. 3.Removing the pillow and raising padded side rails. 4.Positioning the client to the side, if possible, with the head flexed forward. Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1.Mild drowsiness 2.Drooping eyelids 3.Ptosis of the left eyelid 4.Slight slurring of speech 5.Less frequent spontaneous speech

1.Mild drowsiness 4.Slight slurring of speech 5.Less frequent spontaneous speech Rationale: Early changes in LOC relate to orientation, alertness, and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply 1.Padding the side rails of the bed. 2.Placing an airway at the bedside. 3.Placing the bed in the high position. 4.Putting a padded tongue blade at the head of the bed. 5.Placing oxygen and suction equipment at the bedside. 6.Flushing the intravenous catheter to ensure that the site is patent.

1.Padding the side rails of the bed. 2.Placing an airway at the bedside. 5.Placing oxygen and suction equipment at the bedside. 6.Flushing the intravenous catheter to ensure that the site is patent. Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1.Postictal status 2.Duration of the seizure 3.Changes in pupil size or eye deviation 4.Seizure progression and type of movements 5.What the client ate in the 2 hours preceding seizure activity

1.Postictal status 2.Duration of the seizure 3.Changes in pupil size or eye deviation 4.Seizure progression and type of movements Rationale: Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply 1.Provide physical aspects of care. 2.Prevent pushing or straining activities. 3.Limit caffeinated coffee to 1 cup per day. 4.Keeping the lights on in the client's room. 5.Maintain the head of the bed at 15 degrees.

1.Provide physical aspects of care. 2.Prevent pushing or straining activities. 5.Maintain the head of the bed at 15 degrees. Rationale: Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. 1.Providing sensory cues 2.Giving simple, clear directions 3.Providing a stable environment 4.Keeping family pictures at the bedside 5.Encouraging family members to visit at the same time

1.Providing sensory cues 2.Giving simple, clear directions 3.Providing a stable environment 4.Keeping family pictures at the bedside Rationale: Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1.Reduce environmental noise. 2.Allow visitors as desired by the client and family. 3.Awaken the client every 2 to 3 hours to monitor mental status. 4.Cluster nursing activities to reduce the number of interruptions.

1.Reduce environmental noise. Rationale: Nursing interventions to control ICP include maintaining a calm, quiet, and restful environment. Environmental noise should be kept at a minimum. Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP.

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply. 1.Reduced ICP 2.Increased diuresis 3.Increased osmotic pressure of glomerular filtrate 4.Reduced tubular reabsorption of water and solutes 5.Reabsorption of sodium and water in the loop of Henle

1.Reduced ICP 2.Increased diuresis 3.Increased osmotic pressure of glomerular filtrate 4.Reduced tubular reabsorption of water and solutes Rationale: Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma. The incorrect option would cause fluid retention through reabsorption, thereby increasing ICP.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1.Sounds will not be heard clearly unless they are loud. 2.Obtain assistance with ambulation if the client is lightheaded. 3.Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4.Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1.Sounds will not be heard clearly unless they are loud. Rationale: The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? 1.Speech 2.Hearing 3.Balance 4.Level of consciousness

1.Speech Rationale: Broca's area in the brain is responsible for the motor aspects of speech, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia. The items listed in the other options are not the responsibility of Broca's area.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1.The client is aphasic. 2.The client has weakness on the right side of the body. 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

1.The client is aphasic. 2.The client has weakness on the right side of the body. 4.The client has weakness on the right side of the face and tongue. Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1.The intracranial pressure reading is normal. 2.The intracranial pressure reading is elevated. 3.The intracranial pressure reading is borderline. 4.An intracranial pressure reading of 8 mm Hg is low.

1.The intracranial pressure reading is normal. Rationale: The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response

1.The left side of the body Rationale: Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? 1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX)

1.Vagus (CN X) Rationale: The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1."Alcohol is not contraindicated while taking this medication." 2."Good oral hygiene is needed, including brushing and flossing." 3."The medication dose may be self-adjusted, depending on side effects." 4."The morning dose of the medication should be taken before a serum medication level is drawn."

2."Good oral hygiene is needed, including brushing and flossing." Rationale: Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a primary health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a MedicAlert bracelet.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1."When did the injury occur?" 2."Was the client awake and talking right after the injury?" 3."What medications has the client received since the fall?" 4."What was the client's level of consciousness before the injury?"

2."Was the client awake and talking right after the injury?" Rationale: Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1.Intracranial pressure changes 2.A long-term sequela of the injury 3.A worsening of the original injury 4.A short-term problem that will resolve in about 1 month

2.A long-term sequela of the injury Rationale: Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1.Normal 2.Abnormal 3.Insignificant 4.Inconclusive

2.Abnormal Rationale: In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 1.Turn the flashlight on directly in front of the eye and watch for a response. 2.Ask the client to follow the flashlight through the 6 cardinal positions of gaze. 3.Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 4.Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

2.Ask the client to follow the flashlight through the 6 cardinal positions of gaze. Rationale: The nurse asks the client to follow the flashlight through the 6 cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? 1.Spastic 2.Ataxic 3.Festinating 4.Dystrophic or broad-based

2.Ataxic Rationale: An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? 1.Occipital lobe impairment 2.Damage to the auditory association areas 3.Frontal lobe and optic nerve tracts damage 4.Difficulty with concept formation and abstraction areas

2.Damage to the auditory association areas Rationale: Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure. 1.Opisthotonos 2.Decorticate rigidity 3.Decerebrate rigidity 4.Flaccid quadriplegia

2.Decorticate rigidity Rationale: In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. Opisthotonos is prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem.

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be mostconcerned about? 1.Glaucoma 2.Emphysema 3.Hypertension 4.Diabetes mellitus

2.Emphysema Rationale: The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a stroke. The client with a stroke is vulnerable to respiratory complications such as atelectasis and pneumonia. Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant. Although the other conditions of glaucoma, hypertension, and diabetes mellitus are important, they are not as significant as emphysema.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 1.Discouraging the family from touching the client 2.Explaining equipment and procedures on an ongoing basis 3.Ensuring adherence to visiting hours to ensure the client's rest 4.Encouraging the family not to "give in" to their feelings of grief

2.Explaining equipment and procedures on an ongoing basis Rationale: Families often need assistance to cope with the illness of a loved one. The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the primary health care provider. Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1.Clustering nursing activities 2.Hyperoxygenating before suctioning 3.Maintaining 20 degree flexion of the knees 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

2.Hyperoxygenating before suctioning 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation Rationale: Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intra-abdominal pressure and consequently ICP.

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1.Thalamus 2.Hypothalamus 3.Limbic system 4.Reticular activating system

2.Hypothalamus Rationale: The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1.Electrolyte panel 2.Liver function studies 3.Renal function studies 4.Blood glucose level determination

2.Liver function studies Rationale: Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. The studies in the remaining options are not required with the use of this medication.

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom? 1.Vomiting 2.Minor headache 3.Difficulty speaking 4.Difficulty awakening

2.Minor headache Rationale: A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the PHCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? 1.Sternal rub 2.Nailbed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2.Nailbed pressure

The nurse is caring for a client receiving mannitol via intravenous (IV) infusion. A vial is sent from the pharmacy, and in preparing the medication the nurse notes that the vial contains crystals. What is the most appropriate nursing action? 1.Discard the vial. 2.Place the vial in warm water. 3.Send the vial back to the pharmacy. 4.Shake the vial to dissolve the crystals.

2.Place the vial in warm water. Rationale: Crystals form in a mannitol solution if the solution is cooled, but they will quickly dissolve if the container is placed in warm water and then cooled to body temperature before administration. However, if crystals remain after the warming procedure, the medication should not be used and should be returned to the pharmacy. The nurse would not discard the medication. The medication is not initially returned to the pharmacy because it is not defective. Shaking the vial should not be done and will not dissolve the crystals.

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? 1.Difficulty speaking 2.Problem with understanding language 3.Difficulty controlling voluntary motor activity 4.Problem with articulating events from the remote past

2.Problem with understanding language Rationale: Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1.Body stiffening 2.Spasms of the entire body 3.Sudden loss of consciousness 4.Brief flexion of the extremities

2.Spasms of the entire body Rationale: The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? 1.The client will be unable to recall past events. 2.The client will have difficulty understanding language. 3.The client will have difficulty moving 1 side of the body. 4.The client will demonstrate difficulty articulating words.

2.The client will have difficulty understanding language. Rationale: Wernicke's area consists of a small group of cells in the temporal lobe, the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex? 1.Cough reflex 2.Withdrawal reflex 3.Munro-Kellie reflex 4.Accommodation reflex

2.Withdrawal reflex Rationale: The withdrawal reflex is one of the spinal reflexes. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli. The cough reflex is a brainstem-associated reflex. Accommodation reflex is associated with cranial nerve III and is part of the ocular motor system. Munro-Kellie is not a reflex; it is a doctrine or a hypothesis addressing the cerebral volume relationships among the brain, the cerebrospinal fluid, and intracranial blood and their cumulative impact on intracranial pressure.

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the mostreassurance to the client about the procedure? 1."The MRI machine is a long, narrow, hollow tube and may make you feel somewhat claustrophobic." 2."You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 3."Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." 4."It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."

3."Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure."

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1.Dilated pupils 2.Lumbar trauma 3.A cervical cord injury 4.Altered level of consciousness

3.A cervical cord injury Rationale: In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign 4.A Glasgow Coma Scale score of 15

3.A positive Brudzinski's sign Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1.An involuntary rhythmic, rapid, twitching of the eyeballs 2.A dorsiflexion of the great toe with fanning of the other toes 3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4.A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. 1.Basilar artery 2.Vertebral artery 3.Anterior cerebral artery 4.Internal carotid arteries 5.Posterior cerebral artery

3.Anterior cerebral artery 4.Internal carotid arteries 5.Posterior cerebral artery Rationale: The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries.

At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98º F (37.2º C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99º F (36.7º C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1.Reorient the client. 2.Retake the vital signs. 3.Call the primary health care provider (PHCP). 4.Administer an antihypertensive PRN (as needed)

3.Call the primary health care provider (PHCP). Rationale: The important nursing action is to call the PHCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.

The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? 1.Disoriented to client, place, and time 2.Affect flat, with periods of emotional lability 3.Cannot recall what was eaten for breakfast today 4.Unable to add and subtract; does not know who is president

3.Cannot recall what was eaten for breakfast today Rationale: Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate 1.Insert nasal packing. 2.Document the findings. 3.Contact the primary health care provider (PHCP). 4.Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3.Contact the primary health care provider (PHCP). Rationale: Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the PHCP because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation.

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1.Check cranial nerve functioning. 2.Determine the cause of the accident. 3.Draw blood for arterial blood gas analysis. 4.Perform a pulmonary wedge pressure measurement.

3.Draw blood for arterial blood gas analysis. Rationale: Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. The actions in the remaining options are not priorities, although they may be a component in the assessment process, depending on the injury and client condition.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3.Flaccid paralysis Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1.GCS = 3 2.GCS = 6 3.GCS = 9 4.GCS = 11

3.GCS = 9 Rationale: The GCS is a method for assessing neurological status. The highest possible GCS score is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response, the score is 1. The total score is then equal to 9.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1.Head of bed flat, head and neck midline 2.Head of bed flat, head turned to the nonoperative side 3.Head of bed elevated 30 to 45 degrees, head and neck midline 4.Head of bed elevated 30 to 45 degrees, head turned to the operative side

3.Head of bed elevated 30 to 45 degrees, head and neck midline Rationale: After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? 1.Loss of consciousness 2.Presence of diaphoresis 3.History of prior trauma 4.Rotating eye movements

3.History of prior trauma Rationale: Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or medication consumption. The remaining options address signs, rather than an origin of the seizure.

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1.Fever 2.Seizures 3.Hypoxia 4.Ischemia 5.Hypotension 6.Increased intracranial pressure (ICP)

3.Hypoxia 4.Ischemia 5.Hypotension 6.Increased intracranial pressure (ICP) Rationale: Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. Manifestations of secondary injury include hypoxia, ischemia, hypotension, and increased ICP that follows primary injury. It does not include fever or seizures.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the primary health care provider (PHCP). 4.Mark the area of drainage with a pen and monitor for further drainage.

3.Notify the primary health care provider (PHCP). Rationale: Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the PHCP needs to be notified. The remaining options are inappropriate nursing actions.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? 1.Hypotension 2.Tachycardia 3.Slurred speech 4.No abnormal finding

3.Slurred speech Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur.

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? 1.Vagal 2.Peripheral nervous system 3.Sympathetic nervous system 4.Parasympathetic nervous system

3.Sympathetic nervous system Rationale: The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1.Sudden loss of consciousness occurred. 2.Signs and symptoms occurred suddenly. 3.The client experienced paresthesias a few days before admission to the hospital. 4.The client complained of a severe headache, which was followed by sudden onset of paralysis.

3.The client experienced paresthesias a few days before admission to the hospital. Rationale: Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

After review of the client's laboratory values, the nurse notes that a phenytoin level for a client receiving phenytoin is 7 mcg/mL (27.78 mmol/L). The nurse makes which interpretation regarding this laboratory result? 1. The level is within the expected therapeutic range. 2.The level indicates the medication should be stopped. 3.The level is lower than the expected therapeutic range. 4.The level is higher than the expected therapeutic range.

3.The level is lower than the expected therapeutic range. Rationale: The target range for a therapeutic serum level of phenytoin is between 10 and 20 mcg/mL (40 to 79 mmol/L). Levels below 10 mcg/mL are too low to control seizures. At levels above 20 mcg/mL (79 mmol/L), signs of toxicity begin to appear. This client has a low serum level, and the dosage is likely to be increased.

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1.Taste 2.Smell 3.Vision 4.Hearing

3.Vision Rationale: The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa in which position? 1.15 degrees of Trendelenburg's 2.Side-lying with the head of the bed flat 3.With the head of the bed elevated at least 30 degrees 4.With the head of the bed elevated no more than 10 degrees

3.With the head of the bed elevated at least 30 degrees Rationale: Correct positioning of the client following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always followed. The client with an incision in the anterior or middle fossa should be positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client should not be positioned to the operative side. Trendelenburg's position is contraindicated in the postoperative phase following cranial surgery.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."

4."We need to remind him to turn his head to scan the lost visual field." Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1.5 mm Hg 2.8 mm Hg 3.14 mm Hg 4.22 mm Hg

4.22 mm Hg Rationale: Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1.Brain death 2.A cerebral lesion 3.A temporal lesion 4.An intact brainstem

4.An intact brainstem Rationale: Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1.Gets angry with family if they interrupt a task 2.Experiences bouts of depression and irritability 3.Has difficulty with using modified feeding utensils 4.Consistently uses adaptive equipment in dressing self

4.Consistently uses adaptive equipment in dressing self

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4.Exhaling during repositioning Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4.Fluid separates into concentric rings and tests positive for glucose. Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids, because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1.Prone 2.Supine 3.Semi-Fowler's with the hip and the neck flexed 4.Head of the bed elevated 30 degrees with the head in midline position

4.Head of the bed elevated 30 degrees with the head in midline position

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1.Take and record vital signs every 4 to 8 hours. 2.Prophylactically hyperventilate during the first 24 hours. 3.Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

The nurse is caring for a client with bacterial meningitis. The nurse should anticipate that an antibiotic with which characteristics will be prescribed for the client? 1.One that has a long half-life 2.One that acts within minutes to hours 3.One that can be easily excreted in the urine 4.One that is able to cross the blood-brain barrier

4.One that is able to cross the blood-brain barrier Rationale: A primary consideration regarding medications to treat bacterial meningitis is the ability of the medication to cross the blood-brain barrier. If the medication cannot cross, it will not be effective. The duration, onset, and excretion of the medication are also of general concern but apply to all medications and not specifically to those that are used to treat meningitis.

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

4.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg) Rationale: The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1.Keep the window blinds open. 2.Turn on a small spotlight above the client's head. 3.Make sure the door to the room is open at all times. 4.Prohibit or limit the use of a radio or television and reading.

4.Prohibit or limit the use of a radio or television and reading. Rationale: Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the primary health care provider.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1.Serosanguineous only 2.Bloody with very small clots 3.Sanguineous only with no clot formation 4.Serosanguineous, surrounded by clear to straw-colored fluid

4.Serosanguineous, surrounded by clear to straw-colored fluid

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1.Unchanged weight 2.Shift intake 950 mL, output 900 mL 3.Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg) Rationale: After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O (285 to 295 mmol/kg). A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate overhydration or underhydration.

The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1.Place the client in the modified left lateral recumbent position. 2.Change the drainage tubing every 48 hours. 3.Level the transducer at the lowest point of the ear. 4.Use strict aseptic technique when touching the monitoring system.

4.Use strict aseptic technique when touching the monitoring system. Rationale: Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. The modified left lateral recumbent position is a side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.