Ch. 61
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? An absence seizure A myoclonic seizure A tonic-clonic seizure A partial seizure
An absence seizure Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? Complaints of headache and lack of pupillary response Decerebrate posturing and loss of corneal reflex Mental confusion and pupillary changes Loss of gag reflex and mental confusion
Decerebrate posturing and loss of corneal reflex Explanation: Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood pressure and temperature, widened pulse pressure, Cheyne-Stokes breathing, projectile vomiting, hemiplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? Dyskinesia Pruritus Lactose intolerance Diarrhea
Dyskinesia Explanation: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Elevate the head of the bed. Complete a head-to-toe assessment. Administer Percocet as ordered. Administer morning dose of anticonvulsant.
Elevate the head of the bed. Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? Oliguria and decreased urine osmolality Excessive urine output and serum hypo-osmolarity Excessive urine output and decreased urine osmolality Oliguria and serum hyperosmolarity
Excessive urine output and decreased urine osmolality Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? Offering family support groups Explaining hospice care and services Optimizing nutrition Managing muscle weakness
Explaining hospice care and services Explanation: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? Decorticate Flaccid Rigid Decerebrate
Flaccid Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68). An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate (Fig. 66-1; see also Chapter 65). The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been administered pharmacologic paralyzing agents (i.e., neuromuscular blocking agents).
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? Diplopia Ataxia Gingival hyperplasia Alopecia
Gingival hyperplasia Explanation: Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.
The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following? Pancreatitis Heart failure Diabetes insipidus Kidney failure
Heart failure Explanation: It is possible for the client to have a fluid overload that creates such an increased workload for the heart that it fails.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Cushing response Autoregulation Herniation Monro-Kellie hypothesis
Herniation Explanation: With a herniation, the herniated tissue exerts pressure on the brain area into which it has shifted, which interferes with the blood supply in that area. Cessation of cerebral blood flow results in cerebral ischemia, infarction, and brain death. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that because of limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Increase in cerebral perfusion pressure Exacerbation of uncontrolled hypertension Increased ICP Infection
Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? Risk for injury Risk for infection Fluid volume deficit Ineffective cerebral tissue perfusion
Ineffective cerebral tissue perfusion Explanation: The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The client is at risk for injury, fluid volume deficit due to a possible fluid restriction to maintain normovolemia, and infection due to the placement of the intraventricular catheter, but these are not the priority.
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? One-third normal saline (0.33% NSS) Dextrose 5% in water (D5W) Lactated Ringer's Half-normal saline (0.45% NSS)
Lactated Ringer's Explanation: With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? Blood pressure 100/60 mm Hg Nausea Lethargy Periorbital edema
Lethargy Explanation: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? Lethargy and stupor Bradycardia A bounding pulse Hypertension
Lethargy and stupor Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? Pituitary carcinoma Laryngeal carcinoma Esophageal carcinoma Colorectal carcinoma
Pituitary carcinoma Explanation: Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur. Surgery to treat esophageal carcinoma usually is palliative and involves esophagogastrectomy with jejunostomy. Laryngeal carcinoma may necessitate a laryngectomy. To treat colorectal cancer, the surgeon removes the tumor and any adjacent tissues and lymph nodes that contain cancer cells.
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? Apply oxygen via nasal cannula. Reorient the client while gently holding their arms. Administer lorazepam per orders. Place the client in wrist restraints.
Reorient the client while gently holding their arms. Explanation: Some clients during the postictal phase will become confused and agitated. This reaction is not intentional, and most clients do not later remember becoming agitated. The nurse should attempt to calm and reorient the client, while also gently holding the arms to prevent the client from hitting, thereby preventing the client from doing injury to self or others. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure began at 1300 hours. The client cried out before the seizure began. Seizure was 1 minute in duration including tonic-clonic activity. Sleeping quietly after the seizure
Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Urine output of 100 mL/hr Cool, dry skin Shivering Capillary refill of 2 seconds
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? The patient should attempt to maintain prediagnosis levels of activity and mobility. The patient should perform exercises that are brief but high-intensity. The patient should prioritize energy conservation and remain on bed rest if possible. The patient should perform frequent physical activity but avoid becoming fatigued.
The patient should perform frequent physical activity but avoid becoming fatigued. Explanation: The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.
The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? The patient should perform frequent physical activity but avoid becoming fatigued. The patient should attempt to maintain prediagnosis levels of activity and mobility. The patient should prioritize energy conservation and remain on bed rest if possible. The patient should perform exercises that are brief but high-intensity.
The patient should perform frequent physical activity but avoid becoming fatigued. Explanation: The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements? "A migraine headache is an example of a secondary headache." "A secondary headache is associated with an organic cause, such as a brain tumor." "A secondary headache is one for which no organic cause can be identified." "A secondary headache is located in the frontal area."
"A secondary headache is associated with an organic cause, such as a brain tumor." Explanation: A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? "Clients and families are the focus of hospice care." "Hospice care uses a team approach and provides complete care." "The physician coordinates all the care delivered." "All hospice clients die at home."
"Clients and families are the focus of hospice care." Explanation: The most important component of hospice care is the focus that is placed on the care of the client as well as the family. Hospice does take a team approach and coordinates care through the hospice physician, but these are not the focus. Not all hospice clients wish to die at home.
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? "For many people with epilepsy, the disorder is synonymous with mental illness." "Cases of epilepsy are often associated with intellectual level." "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." "In most people, epilepsy is usually synonymous with intellectual disability."
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Explanation: Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or mental illness.
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "I will have progressive muscle weakness." "I will lose strength in my arms." "My children are at greater risk to develop this disease." "I need to remain active for as long as possible."
"My children are at greater risk to develop this disease." Explanation: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
Cerebral edema peaks at which time point after intracranial surgery? 12 hours 24 hours 48 hours 72 hours
24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? Assess for weight loss. Document signs and symptoms of inflammation. Administer corticosteroids as ordered. Give acetaminophen per orders.
Administer corticosteroids as ordered. Explanation: Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.
The nurse is caring for a client hospitalized with a severe exacerbation of Myasthenia Gravis. When administering medications to this client what is a priority nursing action? Administer medications at exact intervals ordered. Give client plenty of fluids with medications. Document medication given and dose. Assess client's reaction to new medication schedule.
Administer medications at exact intervals ordered. Explanation: He or she must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? Access for intravenous (IV) fluids Aspiration of a brain abscess Visualization of a hemorrhage To assess visual acuity
Aspiration of a brain abscess Explanation: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.
Which phase of a migraine headache usually lasts less than an hour? Aura Postdrome Premonitory Headache
Aura Explanation: The aura phase occurs in about 20% of clients who have migraines and may be characterized by focal neurological symptoms. The premonitory phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the postdrome phase, clients may sleep for extended periods.
Which is the earliest sign of increasing intracranial pressure? Change in level of consciousness Vomiting Headache Posturing
Change in level of consciousness Explanation: The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Continue the assessment because no actions are indicated at this time. Check the equipment. Contact the physician to review the care plan. Document the reading because it reflects that the treatment has been effective.
Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Displays no signs or symptoms of infection Attains desired fluid balance Maintains a patent airway Demonstrates optimal cerebral tissue perfusion
Maintains a patent airway Explanation: Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? Midbrain Diencephalon Medulla Cortex
Midbrain Explanation: Damage to the midbrain causes decerebrate posturing that's characterized by abnormal extension in response to painful stimuli. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Hashimoto's disease Cushing's Dawn phenomenon Monro-Kellie
Monro-Kellie Explanation: The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.
A client is having a tonic-clonic seizure. What should the nurse do first? Take measures to prevent injury. Elevate the head of the bed. Restrain the client's arms and legs. Place a tongue blade in the client's mouth.
Take measures to prevent injury. Explanation: Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is high. The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate.
The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.
Which method is used to help reduce intracranial pressure? Rotating the neck to the far right with neck support Using a cervical collar Extreme hip flexion, with the hip supported by pillows Keeping the head of bed flat
Using a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? Diet containing extra sodium Vasopressin therapy Fluid restriction Hypertonic saline solution
Vasopressin therapy Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity. Treatment consists of administration of fluids, electrolyte replacement, and vasopressin therapy. SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment consists of fluid restriction (less than 800 mL/day with no free water). In severe cases, careful administration of a 3% hypertonic saline solution may be therapeutic.
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: increase the frequency of the catheterizations. use a condom catheter instead of an invasive one. place the client on fluid restrictions. insert an indwelling urinary catheter.
increase the frequency of the catheterizations. Explanation: As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered high. within normal limits. inaccurate. low.
low. Explanation: Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? "There is a very weak familial tendency." "There is a strong familial tendency." "Only secondary migraine headaches show a familial tendency." "No familial tendency has been demonstrated."
"There is a strong familial tendency." Explanation: Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.
Which value indicates a normal intracranial pressure (ICP)? 5 mm Hg 17 mm Hg 20 mm Hg 27 mm Hg
5 mm Hg Explanation: ICP is usually measured in the lateral ventricles. Pressure measuring 0 to 10 mm Hg is considered normal. The other values are incorrect.
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? Deficient fluid volume Risk for impaired skin integrity Airway clearance Risk of injury
Airway clearance Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? Perform the Heimlich maneuver Maintain hydration by drinking eight glasses of fluid a day Use pressure-relieving pads or a similar type of mattress Apply warm or cool cloths to the forehead or back of the neck
Apply warm or cool cloths to the forehead or back of the neck Explanation: Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. Bradycardia Hypertension Bradypnea Tachycardia Pupillary constriction
Bradycardia Bradypnea Hypertension Explanation: At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? Hypostatic pneumonia Trigeminal neuralgia Brain tumor Epilepsy
Brain tumor Explanation: The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? Damage to the vagal nerve Damage to the optic nerve Damage to the olfactory nerve Damage to the facial nerve
Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.
A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." What information will the nurse give the husband during discharge teaching? Signs and symptoms of chronic back pain that should be reported to the health care provider Ergonomic principles and body mechanics Nutritional changes for the client with paraplegia The importance of monitoring urinary elimination
Ergonomic principles and body mechanics Explanation: The husband's statement indicates a need for teaching in regard to client mobility and transfer techniques. Although urinary elimination, nutrition, and pain are components of care for clients with paraplegia, education about ergonomic principles and body mechanics is most appropriate at this time based on the husband's statement.
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? The pupils are dilated and fixed. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). Increased ICP is 12 mm Hg. Cerebral perfusion pressure (CPP) is 21 mm Hg.
Increased ICP is 12 mm Hg. Explanation: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? Give the patient some mouthwash to gargle with. Request an antihistamine for the postnasal drip. Ask the patient to cough to observe the sputum color and consistency. Notify the physician of a possible cerebrospinal fluid leak.
Notify the physician of a possible cerebrospinal fluid leak. Explanation: Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? Excessive urine output and decreased urine osmolality Oliguria and serum hyponatremia Oliguria and serum hyperosmolarity Excessive urine output and serum hyponatremia
Oliguria and serum hyponatremia Explanation: SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.
Which is a late sign of increased intracranial pressure (ICP)? Altered respiratory patterns Irritability Slow speech Headache
Altered respiratory patterns Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.
Which signs are manifestations of the Cushing triad? Select all that apply. Bradycardia Hypertension Bradypnea Tachycardia
Bradycardia Hypertension Bradypnea Explanation: Cushing triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Providing for privacy Positioning the patient on his or her side with head flexed forward Loosening constrictive clothing Restraining the patient to avoid self injury Opening the patient's jaw and inserting a mouth gag
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy Explanation: During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? 150 to 200 mL/h More than 200 mL/h 100 to 150 mL/h 50 to 100 mL/h
More than 200 mL/h Explanation: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus.
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Administering prescribed antipyretics Hyperoxygenation before and after tracheal suctioning Maintaining adequate hydration Restricting fluid intake and hydration
Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? Turn the client to the side during a seizure and do not restrain movements Provide oxygen or anticonvulsants, whichever is available Suction the client's mouth and pharynx Place a cooling blanket beneath the client
Turn the client to the side during a seizure and do not restrain movements Explanation: When a client is in a seizure, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. The nurse should suction the mouth and pharynx after a seizure has occurred, not during the seizure. Anticonvulsants may be administered to reduce the chances of seizure. Oxygen should not be given to clients with seizures. Clients with respiratory distress are given oxygen. Finally, a cooling blanket is placed beneath the client when hyperthermia occurs, not a seizure.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? Phenobarbital Mannitol Vasopressin Furosemide (Lasix)
Vasopressin Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration. It is treated with vasopressin but occasionally persists.
What is one of the earliest signs of increased ICP? Cushing triad coma decreased level of consciousness (LOC) headache
decreased level of consciousness (LOC) Explanation: Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to control shivering. reduce cellular metabolic demand. control fever. dehydrate the brain and reduce cerebral edema.
dehydrate the brain and reduce cerebral edema. Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: pupillary changes. elevated temperature. diminished responsiveness. decreasing blood pressure.
diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson disease and Huntington disease is the development of what symptom in clients with advanced Huntington disease? hallucinations and delusions depression bradykinesia muscle fasciculations
hallucinations and delusions Explanation: As Huntington disease progresses, hallucinations, delusions, and impaired judgment develop due to degeneration of the cerebral cortex. Depression is a likely symptom for clients with both Parkinson disease and Huntington disease. Bradykinesia, slowness in performing spontaneous movement, is commonly associated with Parkinson disease. Muscle fasciculations, or twitching, are commonly associated with ALS.
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: place the client on his side, remove dangerous objects, and insert a bite block. place the client on his side, remove dangerous objects, and protect his head. place the client on his back, remove dangerous objects, and hold down his arms. place the client on his back, remove dangerous objects, and insert a bite block.
place the client on his side, remove dangerous objects, and protect his head. Explanation: During the active seizure phase, the nurse should initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Placing the client on his back and holding down the arms could cause injury to the client and the nurse.
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? good poor fatal excellent
poor Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.
A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because hypothermia can cause death. hypothermia is indicative of severe meningitis. hypothermia is indicative of malaria. shivering in hypothermia can increase ICP.
shivering in hypothermia can increase ICP. Explanation: The nurse should avoid hypothermia in a client with increased ICP because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia in a client with ICP does not indicate malaria or meningitis and is not likely to cause death.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the prone position with the head turned to the unaffected side. dorsal recumbent position. supine position with the head slightly elevated. Trendelenburg position.
supine position with the head slightly elevated. Explanation: After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? vasoconstriction hypertension increased PaO vasodilation
vasodilation Explanation: Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? Pureed food with water Solid food with thin liquids Thin liquids only Semisolid food with thick liquids
Semisolid food with thick liquids Explanation: A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? smelling chewing swallowing tasting
chewing Explanation: Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 15 3 9 6
3 Explanation: Each criterion in the Glasgow Coma Scale (eye opening, verbal response, and motor response) is rated on a scale from 3 to 15. A total score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive.
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: 68 mm Hg. 88 mm Hg. 52 mm Hg. 48 mm Hg.
52 mm Hg. Explanation: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP) In this case MAP = 60 mm Hg + 1/3(90 mm Hg - 60 mm Hg) = 70 mm Hg CPP = MAP - ICP CPP = 70 mm Hg - 18 mm Hg = 52 mm Hg
A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number in tenths. ______________________
97.5 Explanation: 143 lbs/2.2 = 65 kg. 65 kg x 1.5 = 97.5 grams.
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Decerebrate Flaccid Normal Decorticate
Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? Promotion of urinary continence Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) Decreased muscle spasms in the lower extremities Increased muscle strength in the upper extremities
Decreased muscle spasms in the lower extremities Explanation: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. It is not used to promote continence or to increase strength. Avonex and Betaseron reduce the appearance of new lesions on the MRI.
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? Sensitivity to bright light Muscle spasms Drooping eyelids Shortness of breath
Drooping eyelids Explanation: Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? Turned onto the operative side Elevated no more than 10 degrees Flat Elevated 30 degrees
Elevated 30 degrees Explanation: After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? Apnea Infection High blood pressure Coma
Infection Explanation: The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.
The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. Exercise in a dark room. Sleep no more than 5 hours at a time. Use St. John's Wort. Maintain a headache diary. Keep a food diary.
Keep a food diary. Maintain a headache diary. Explanation: The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? Rising blood pressure and bradycardia Hypotension and tachycardia Hypertension and narrowing pulse pressure Hypotension and bradycardia
Rising blood pressure and bradycardia Explanation: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.
A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? Activity Self-care Safety Skin care
Safety Explanation: Clients who have seizures are carefully monitored and protected from injury. Therefore, safety is the priority.
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? Suctioning the client once each shift Administering a stool softener as ordered Encouraging oral fluid intake Elevating the head of the bed 90 degrees
Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.
While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? Cluster Migraine Tension Sinus
Cluster Explanation: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed.
Which of the following drugs may be used after a seizure to maintain a seizure-free state? Ativan Cerebyx Phenobarbital Valium
Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.
