NUR 1700 Q5 Randoms

A nurse in a critical care unit is completing an admission assessment on a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? Select all that apply. A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. Headache B. Dilated Pupils D. Decorticate posturing

A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits? A. Pushes the painful stimulus away. B. Extends the body part toward the stimuli. C. Shows no reaction to the painful stimuli. D. Flexes the upper and extends the lower extremities.

A. Pushes the painful stimulus away.

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicates the nurse understands the rationale for using this solution? A. Reduce edema of the brain. B. Provide fluid hydration. C. Increase cell size in the brain. D. Expand extracellular fluid volume.

A. Reduce edema of the brain.

A nurse is performing mental status exam(MSE). The nurse includes which of the following?

-the ability to perform calculation -level of LOC -depressing suicidal thoughts -the level of orientation

The nurse in the neurological unit is monitoring a client 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 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. Options 2, 3, and 4 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 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; pupillary sluggishness and dilatation appear in the late stages

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the best information about these cranial nerves? 1. Eye movements 2. Response to verbal stimuli 3. Affect, feelings, or emotions 4. Insight, judgment, and planning

1. Eye movements Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

A student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. The student understands that which categories of client functioning are included in this assessment? 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 Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three 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 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 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 the head 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 neck or turning the head from side to side.

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. 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 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.

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? 1. Normal condition 2. Increased pressure 3. Borderline situation 4. Compensating condition

1. Normal condition The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

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. Cluster nursing activities to reduce the number of interruptions. 4. Awaken the client every 2 to 3 hours to monitor mental status.

1. Reduce environmental noise. Nursing interventions to control the 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.

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. The nurse understands that these symptoms are caused by stimulation of which cranial nerve (CN)? 1. Vagus (CN X) 2. Hypoglossal (CN XII) 3. Spinal accessory (CN XI) 4. Glossopharyngeal (CN IX)

1. Vagus (CN X) 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.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? 1) Observing for facial asymmetry 2) Checking pupillary responses to light 3) Eliciting the gag reflex 4) Testing visual acuity

2) Checking pupillary responses to light

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea

2) Hypertension

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

2. Abnormal 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 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.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1. Extend the arms. 2. Extend the tongue. 3. Turn the head toward the nurse's arm. 4. Focus the eyes on the object held by the nurse.

2. Extend the tongue. Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. Options 1, 3, and 4 do not test the function of cranial nerve XII.

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

2. Head turned to the side The head of a client with increased intracranial pressure should be kept in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

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 Measures aimed at preventing increased ICP in the post-stroke 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 is caring for the client with increased intracranial pressure. 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 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 is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2. Nail bed pressure Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? 1) Serum sodium 145 mEq/L 2) Urine specific gravity 1.028 3) Urine output 650 mL/hr 4) Blood glucose 198 mg/dL

3) Urine output 650 mL/hr

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 1. A walker 2. Eyeglasses 3. A hearing aid 4. A bath thermometer

3. A hearing aid The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.

A nurse is caring for a client who was recently admitted to the ED following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement

A. Keep neck stabilized.

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 health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3. Contact the health care provider (HCP). 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 HCP, because this finding requires immediate intervention. Options 1, 2, and 4 are inappropriate nursing actions in this situation.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should avoid placing the client in which positions? 1. Head midline 2. Neck in neutral position 3. Flat, with head turned to the side 4. Head of bed elevated 30 to 45 degrees

3. Flat, with head turned to the side The client who is at risk for or with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The post-head injury client 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 The GCS is a method is assessing neurological status. The highest possible score in the GCS 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 a 1. The total score is then equal to 9.

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 health care provider (HCP). 4. Mark the area of drainage with a pen and monitor for further drainage.

3. Notify the health care provider (HCP). 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 HCP needs to be notified. Options 1, 2, and 4 are inappropriate nursing actions.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position immediately after the procedure? 1. Prone in semi-Fowler's position 2. Supine in semi-Fowler's position 3. Prone with a small pillow under the abdomen 4. Lateral with the head slightly lower than the rest of the body

3. Prone with a small pillow under the abdomen After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. Options 1, 2, and 4 are incorrect.

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the clients right nostril. Which of the following actions should the nurse take first? 1) Take the clients temperature. 2) Place a dressing under the clients nose. 3) Notify the charge nurse. 4) Test the drainage for glucose.

4) Test the drainage for glucose.

A 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 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 planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? 1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Encouraging multiple visitors at one time

4. Encouraging multiple visitors at one time 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.

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 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 nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? A. Provide oral fluids B. Monitor for nausea C. Maintain fetal position D. Check level of consciousness E. Check sensation in the toes

A. Provide oral fluids B. Monitor for nausea D. Check level of consciousness E. Check sensation in the toes

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. 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.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What important nursing intervention is necessary for this client? 1. Take and record vital signs every 4 to 8 hours. 2. Prophylactically hyperventilate during the first 20 hours. 3. Treat a central fever with the administration of antipyretic medications such as acetaminophen (Tylenol). 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 Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 20 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse should plan to do to ensure client safety? 1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. 4. Provide a clear path for ambulation without obstacles.

4. Provide a clear path for ambulation without obstacles. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg's position 4. Side-lying with the legs pulled up and the head bent down onto the chest

4. Side-lying with the legs pulled up and the head bent down onto the chest A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

The nurse is planning care for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1. Place the client in Sims 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. Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims is side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30% 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.

A nurse is caring for a client after a craniotomy for pituitary tumor who has developed diabetes insipidus. The client is receiving vasopressin(Pitressin). The desired response to the medication is evident when the nurse observes which of the following findings? A. A decrease in blood sugar. B. A decrease in blood pressure. C. A decrease in urine output. D. A decrease in specific gravity.

A decrease in urine output.

A nurse is caring for a client who is 6 days postoperative following a craniotomy for removal of an intracerebral aneurysm. The client has been transferred from the ICU to the PACU. The nurse should assess the client for early signs of increased intracranial pressure (ICP) when the client states: A. "Could you get me a bowl? I feel nauseated." B. "I'm so bored in here. I want to go home." C. "Can you assist me to the bathroom? I need to urinate." D. "I think I'm constipated. I haven't had a stool since before surgery."

A. "Could you get me a bowl? I feel nauseated."

A client has increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client? A. Cough and deep breathe. B. Elevate the head of the bed. C. Avoid neck and hip flexion D. Log roll when repositioning.

A. Cough and deep breathe.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension

A. Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of following actions should the nurse take? A. Encourage fluid intake B. Monitor the puncture site for hematoma C. Insert a urinary catheter D. Elevate the client's head of bed E. Apply a cervical collar to the client

A. Encourage fluid intake B. Monitor the puncture site for a hematoma

A nurse is assessing a client who has a score of six on the Glasgow coma scale. The nurse should expect which of the following outcomes based on the score? A. The client needs total nursing care B. The client is alert & oriented C. The client is in a deep coma D. Indicates stable neurologic status

A. The client needs total nursing care A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect? A. The client requires total nursing care B. The client is alert and orientated C. The client is in a deep coma D. The client has a stable neurological status

A. The client requires total nursing care

A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. Ifthe client manifests increased intracranial pressure, which of the following findings should the nurse expect?(Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness

A. Violent headache C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness

A nurse perfoms a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? A: Dysphagia B: Positive Babinski sign C: Decreased deep tendon reflexes D: Ataxia

A: Dysphagia (difficulty swallowing may occur as a result of the cranial nerves IX -glossopharyngeal & V -vagus nerve.)

A nurse is caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, The nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? A. Observing for facial asymmetry B. Checking pupillary responses to light C. Eliciting the gag reflex D. Testing visual acuity

B. Checking pupillary responses to light

A nurse is contributing to the plan of care for a client who has increased intracranial pressure following a closed-head injury. Which of the following interventions should the nurse recommend? A. Have the client perform huff coughing hourly B. Elevate the head of the bed C. Place pillows under the client's knees D. Encourage liberal fluid intake

B. Elevate the head of the bed

A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure? A. Brisk pupillary reaction to light B. Irritability C. Tachycardia D. Increased sensory response to painful stimuli

B. Irritability

A nurse is caring for a client who has an intracranial pressure ICP reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? Select all that apply. Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred Speech

Bradycardia Nonreactive dilated pupils

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm/Hg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.) A. Tachypnea B. Hyperthermia C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure

C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure

A nurse is caring for a client who has increased intracranial pressure. Which of the following nursing interventions should the nurse take? A. Instruct the client to perform controlled coughing and deep breathing B. Provide a brightly lit environment C. Elevate the head of the bed 30 degrees D. Encourage a minimum intake of 2,000 mL/day of clear fluids

C. Elevate the head of the bed 30 degrees The nurse should elevate the head of the bed 15 degrees to 30 degrees to reduce intracranial pressure

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrated decorticate posturing. Which of the following findings should the nurse expect to observe? A. Extension of the extremities B. Pronation of the hands C. Plantar flexion of the legs D. External rotation of the lower extremities

C. Plantar flexion of the legs

A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hour. Which of the following is an appropriate action by the nurse? A. Slow the rate to 20 mL/hr. B. Continue the rate at 125 mL/hr. C. Slow the rate to 50 mL/hr. D. Increase the rate to 250 mL/hr.

C. Slow the rate to 50 mL/hr.

A nurse is assessing a client who was just admitted to the hospital for observation following a closed-head injury. Which of the following is the most essential nursing assessment to detect early signs of a worsening condition? A: Vital signs B: Body posture C: LOC D: Focal neurological exam

C: LOC

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion? A. Cyanotic fingertips B. Nuchal rigidity. C. Fever. D. Diplopia.

D. Diplopia.

A nurse is contributing to the plan of care for a client following a lumbar puncture. Which of the following interventions should the nurse include? A. Provide the client a low-sodium diet B. Change the client's dressing every 12 hours C. Place the client in high-Fowler's position D. Encourage oral fluids

D. Encourage oral fluids

A nurse is assisting with caring for a client who has a new concussion following a motor vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Polyuria B. Battle's sign C. Nuchal rigidity D. Lethargy

D. Lethargy

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of the following findings is the earliest indicator of the client's cerebral status? A. Pupil response B. Deep tendon reflexes C. Muscle strength D. Level of consciousness

D. Level of consciousness

The 24-year-old client diagnosed with a TBI is being transferred to a rehabilitation unit. Which healthcare provider order should the nurse question? A. Physical therapy to work on lower extremity strength daily. B. Occupational therapy to work on cognitive functioning bid. C. A soft diet with mechanical ground meats and thickening of agent in fluids. D. Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.

D. Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action? A. Apply restraints B. Administer opioids C. Blacken the room D. Reduce stimuli

D. Reduce stimuli

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure ICP? A. Tachycardia B. Hypotension C. Amnesia D. Restlessness

D. Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands B. The client is unable to make vocal sound C. The client is unconscious D. The client opens his eyes when spoken to

D. The client opens his eyes when spoken to A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is orientated, and is able to localize pain

A nurse is monitoring a client who is at risk for increased intracranial pressure. While assessing the client'scranial nerves, the nurse should check the function of cranial nerve III by: A. testing visual acuity. B. observing for facial asymmetry C. eliciting the gag reflex. D. checking pupillary response to light.

D. checking pupillary response to light.

A client injured in an automobile accident is being evaluated in the ER for possible head injury. What test should not be done if there is an indication of increased intracranial pressure? Lumbar puncture MRI CT scan Electroencephalogram

Do not perform a lumbar puncture (may lead to brain herniation)

A client is recovering from head injury. A nurse determines that the client understands measure to prevent elevation of intracranial pressure if the nurse observes the client doing the following activities?

Eating high fibers than using enemas and laxatives

A nurse is contributing to the plan of care for a client who has increased ICP following a closed-head injury. Which of the following interventions should the nurse recommend? 1. have the client perform huff coughing hourly 2. elevate the head of the bed 3. place pillows under the client's knees 4. encourage liberal fluid intake

Elevate the head of the bed neutral position with elevated HOB promotes venous drainage from the brain. Fluid intake should be limited to reduce cerebral edema.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

Headache Disorientation Pupillary changes Slurred speech

A nurse is performing a neurological assessment fora client who is receiving treatment for head trauma.Which of the following will give the nurse information about the function of the third cranial nerve? 1. Instruct client to look up and down without moving his head 2. observe client's ability to smile and frown 3. evaluate client's pupillary reaction to light 4. ask client to shrug his shoulders against passive resistance

Instruct client to look up and down without moving his head observes extraocular eye movements as part of evaluation of oculomotor nerve.

A nurse is caring for 4 clients in a neurologic ICU. After receiving the handoff report, which of the clients should the nurse see first?

Patient with Glasgow coma scale score declining

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately? 1. sudden sleepiness 2. diplopia 3. headache 4. slight ataxia

Sudden sleepiness this client is unstable due to increased ICP. Diplopia can indicate injury to the optic tract, but it is not a priority finding.

The critical care nurse is caring for a client with ahead injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? A. The client has purposeful movement when the nurse rubs the sternum. B. The client extends the upper and lower extremities in response to painful stimuli. C. The client is aimlessly thrashing in the bed when a noxious stimulus is applied. D. The client is able to squeeze the nurse's hand on a verbal request.

The client extends the upper and lower extremities in response to painful stimuli.

A nurse is assessing a client with a neurological condition who is reporting difficulty chewing. The nurse suspects that which cranial nerve is affected? a. Trigeminal (CN V) b. Facial (CN VII) c. Abducens (CN VI) d. Trochlear (CN IV)

a. Trigeminal (CN V)

A client with a head injury is being monitored for increased intracranial pressure (ICP). His mean arterial pressure (MAP) is 70 and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: a.) 52 mm Hg b.) 88 mm Hg c.) 48 mm Hg d.) 68 mm Hg

a.) 52 mm Hg Rationale:CCP=MAP-ICP70-18=52CCP=52 CCP is maintained above 60 mm Hg

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a.) Evaluate urine specific gravity b.) Anticipate treatment for renal failure c.) Provide emollients to the skin to prevent breakdown d.) Slow down the IV fluids and notify the physician

a.) Evaluate urine specific gravity Rationale:Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a.) Normal saline. b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS

a.) Normal saline. Rationale:A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water.#2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema.#3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal

a.) Urine output increases Rationale:Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracranial hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent

a.) hypoventilation Rationale:Hypoventilation leads to vasodilation and increased intracranial pressure.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a.) Prevent respiratory alkalosis. b.) Lower arterial pH. c.) Promote carbon dioxide elimination. d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

c.) Promote carbon dioxide elimination. Rationale:The goal in treatment is to prevent acidemia by eliminating carbon dioxide.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale:The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

A Nurse is collecting data from a client who had a recent closed head injury. The nurse should recognize which of the following findings is a priority to report?

difficulty speaking

The nurse is assisting in care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

encourage fluid intake monitor puncture site

A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day, which of the following instructions should the nurse include?

the nurse should include repeatedly ask client questions to check for orientation