Ch. 66: Mgmt of Pts w/ Neurologic Dysfunction
A nurse is caring for client with late-stage Parkinson's disease. The client's plan of care includes a nursing diagnosis of "Potential for Injury." Which would not be included as a cause for this diagnosis? uncontrolled movements choreiform movements shuffling gait rigidity
Correct response: choreiform movements Explanation: Choreiform, described as uncontrollable writhing and twisting of the body, is a typical sign associated with Huntington's disease. The other signs are commonly seen in clients with Parkinson's disease.
What is one of the earliest signs of increased ICP? headache decreased level of consciousness (LOC) Cushing's triad coma
Correct response: 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's triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.
Which is the earliest sign of increasing intracranial pressure? Change in level of consciousness Vomiting Headache Posturing
Correct response: 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.
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: hypothermia is indicative of severe meningitis. hypothermia is indicative of malaria. hypothermia can cause death to the client. shivering in hypothermia can increase ICP.
Correct response: shivering in hypothermia can increase ICP. Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 6 9 12 3
Correct response: 3 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).
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? Aspiration of a brain abscess Visualization of a hemorrhage To assess visual acuity Access for intravenous (IV) fluids
Correct response: 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.
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? Lomotil Lamictal Lamisil Labetalol
Correct response: Lamictal Explanation: Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Restricting fluid intake and hydration Administering prescribed antipyretics Hyperoxygenation before and after tracheal suctioning Maintaining adequate hydration
Correct response: 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 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 illnes." "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." "Cases of epilepsy are often associated intellectual level." "In most people, epilepsy is usually synonymous with intellectual disability."
Correct response: "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 illness.
Which signs are manifestations of the Cushing triad? Select all that apply. Hypertension Bradypnea Tachycardia Bradycardia
Correct response: Bradycardia Hypertension Bradypnea Explanation: Cushing triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
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? "Only secondary migraine headaches show a familial tendency." "No familial tendency has been demonstrated." "There is a very weak familial tendency." "There is a strong familial tendency."
Correct response: "There is a strong familial tendency." Explanation: Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 70 mm Hg 50 mm Hg 80 mm Hg 60 mm Hg
Correct response: 70 mm Hg Explanation: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? Bradycardia A bounding pulse Hypertension Lethargy and stupor
Correct response: 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.
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? Epilepsy Trigeminal neuralgia Hypostatic pneumonia Brain tumor
Correct response: Brain tumor Explanation: The incidence of brain tumor decreases 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.
After a seizure, the nurse should place the patient in which of the following positions to prevent complications? Side-lying, to facilitate drainage of oral secretions Semi-Fowler's, to promote breathing High Fowler's, to prevent aspiration Supine, to rest the muscles of the extremities
Correct response: Side-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.
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 secondary headache is one for which no organic cause can be identified." "A secondary headache is located in the frontal area." "A migraine headache is an example of a secondary headache." "A secondary headache is associated with an organic cause, such as a brain tumor."
Correct response: "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 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? Muscle spasms Sensitivity to bright light Drooping eyelids Shortness of breath
Correct response: 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 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. Administer Percocet as ordered. Administer morning dose of anticonvulsant. Complete a head-to-toe assessment.
Correct response: 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.
Which of the following drugs may be used after a seizure to maintain a seizure-free state? Phenobarbital Cerebyx Ativan Valium
Correct response: 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.
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 within normal limits. The CPP is high. The CPP reading is inaccurate. The CPP is low.
Correct response: The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? Complete the course of antibiotics as prescribed. Use ophthalmic lubricant and protect the eye. Encourage semiannual dental exams. Avoid stimuli that trigger pain.
Correct response: Use ophthalmic lubricant and protect the eye. Explanation: The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux(cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsybecause it is thought to be caused by a virus.
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? smelling swallowing chewing tasting
Correct response: chewing Explanation: Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? Urea Glycerin Mannitol Isosorbide
Correct response: Mannitol Explanation: If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: hold the client's arm still to keep him from hitting anything. place an oral airway in the client's mouth to maintain an open airway. carefully move the client to a flat surface and turn him on his side. allow the client to remain in the chair but move all objects out of his way.
Correct response: carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as decorticate. normal. flaccid. decerebrate.
Correct response: decerebrate. Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The client has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
The initial sign of increasing intracranial pressure (ICP) includes headache. vomiting. herniation. decreased level of consciousness.
Correct response: decreased level of consciousness. Explanation: The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may be herniated through the tentorium, causing pressure on the brain stem. Vomiting and headache are not initial signs of increasing ICP.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the prioritynursing intervention? Administer corticosteroids as ordered. Assess for weight loss. Give acetaminophen per orders. Document signs and symptoms of inflammation.
Correct response: 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.
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Position the client with the head turned toward the side of the brain tumor. Provide sensory stimulation. Administer stool softeners. Encourage coughing and deep breathing.
Correct response: Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? Elevating the head of the bed 90 degrees Suctioning the client once each shift Encouraging oral fluid intake Administering a stool softener as ordered
Correct response: 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.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A partial seizure An absence seizure A complex seizure A tonic-clonic seizure
Correct response: 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. A generalized seizure involves the whole brain.
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction? A - decorticate B - decerebrate both demonstrate severe dysfunction neither is considered severe
Correct response: B Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing (B) indicates deeper and more severe dysfunction than does decorticate posturing (A). Decerebrate implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of the forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.
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? Document the reading because it reflects that the treatment has been effective. Continue the assessment because no actions are indicated at this time. Check the equipment. Contact the physician to review the care plan.
Correct response: 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 is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? Recent stress level The type of anticonvulsant prescribed to manage the epileptic condition Recent weight gain and loss Compliance with the prescribed medication regimen
Correct response: Compliance with the prescribed medication regimen Explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.
The 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 facial nerve Damage to the olfactory nerve Damage to the optic nerve
Correct response: 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 client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? Decerebrate posturing and loss of corneal reflex Mental confusion and pupillary changes Loss of gag reflex and mental confusion Complaints of headache and lack of pupillary response
Correct response: 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 presure and temperature, widened pulse pressure, Chenyne-Stokes breathing, projectile vomiting, heimplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Flaccid Decerebrate Decorticate Normal
Correct response: 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 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? Elevated no more than 10 degrees Elevated 30 degrees Turned onto the operative side Flat
Correct response: 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.
Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. Ensure access to a language board when communicating with the client. Establish a voiding time schedule. Obtain daily weights to monitor weight gain. Encourage the client to walk with feet wide apart.
Correct response: Ensure access to a language board when communicating with the client. Establish a voiding time schedule. Encourage the client to walk with feet wide apart. Explanation: Language assistive devices may be needed if communication is severely affected. Occasional bladder incontinence may lead to total incontinence. A voiding time schedule will allow the client greater independence. If motor dysfunction causes problems of incoordination and clumsiness, the patient is at risk for falling. As the disease progresses, nutritional deficiencies may develop. Weight should be assessed to ensure that there is no significant weight loss.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? Excessive urine output and decreased urine osmolality Oliguria and decreased urine osmolality Excessive urine output and serum hypo-osmolarity Oliguria and serum hyperosmolarity
Correct response: 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 osmolatity, and serum hyperosmolarity.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? Low in fat High in protein and low in carbohydrate Restricts protein to 10% of daily caloric intake At least 50% carbohydrate
Correct response: High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
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 Infection Exacerbation of uncontrolled hypertension Increased ICP
Correct response: 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.
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care? Risk for impaired skin integrity related to prolonged immobility Ineffective airway clearance related to altered LOC Deficient fluid volume related to inability to take fluids by mouth Risk of injury related to decreased LOC
Correct response: Ineffective airway clearance related to altered LOC Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Blood pressure apparatus Nebulizer and thermometer Incentive spirometer Intubation tray and suction apparatus
Correct response: Intubation tray and suction apparatus Explanation: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.
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. Use St. John's Wort. Maintain a headache diary. Sleep no more than 5 hours at a time. Keep a food diary. Exercise in a dark room.
Correct response: 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.
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? Attains desired fluid balance Demonstrates optimal cerebral tissue perfusion Maintains a patent airway Displays no signs or symptoms of infection
Correct response: 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 is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Mannitol Half-normal saline (0.45% NSS) One-third normal saline (0.33% NSS) Dextrose 5% in water (D5W)
Correct response: Mannitol Explanation: With increasing ICP, hypertonic solutions, like mannitol, 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 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? Monro-Kellie Cushing's Dawn phenomenon Hashimoto's disease
Correct response: 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 cerbral 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. Hasimoto's disease is related to the thyroid gland.
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? 100 to 150 mL/h 150 to 200 mL/h More than 200 mL/h 50 to 100 mL/h
Correct response: 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 (Hickey, 2009).
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? Request an antihistamine for the postnasal drip. Give the patient some mouthwash to gargle with. Ask the patient to cough to observe the sputum color and consistency. Notify the physician of a possible cerebrospinal fluid leak.
Correct response: 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.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Obesity Osteoarthritis Anemia Osteoporosis
Correct response: Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: seizure disorder. multiple sclerosis. Huntington's disease. Parkinson's disease.
Correct response: Parkinson's disease. Explanation: Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are most commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.
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? Place the client in wrist restraints. Apply oxygen via nasal cannula. Administer lorazepam per orders. Reorient the client while gently holding their arms.
Correct response: 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 remember becoming agitated. The nurse should attempt to calm and reorient the client, but also should gently hold the arms to prevent the client from hitting. 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.
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Administering prescribed antipyretics Maintaining adequate hydration Restricting fluid intake and hydration Hyperoxygenation before and after tracheal suctioning
Correct response: 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 neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.
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? Hypotension and bradycardia Rising blood pressure and bradycardia Hypertension and narrowing pulse pressure Hypotension and tachycardia
Correct response: 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 client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Shivering Urine output of 100 mL/hr Cool, dry skin
Correct response: 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.
To meet the sensory needs of a client with viral meningitis, the nurse should: increase environmental stimuli. minimize exposure to bright lights and noise. promote an active range of motion. avoid physical contact between the client and family members.
Correct response: minimize exposure to bright lights and noise. Explanation: Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
