Ch 66 Neuro questions
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? "You must report ringing in your ears immediately." "You must restrict your fluid intake." "You must lie flat for 24 hours after surgery." "You must avoid coughing, sneezing, and blowing your nose."
"You must avoid coughing, sneezing, and blowing your nose." *to avoid disturbing the surgical graft used to close the wound.
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.
Administer stool softeners. *Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return
Which is a late sign of increased intracranial pressure (ICP)? Slow speech Headache Irritability Altered respiratory patterns
Altered respiratory patterns *late signs of increased ICP and may indicate pressure or damage to the brainstem
Which positions is used to help reduce intracranial pressure (ICP)? Keeping the head flat, avoiding the use of a pillow Rotating the neck to the far right with neck support Avoiding flexion of the neck with use of a cervical collar Extreme hip flexion, with the hip supported by pillows
Avoiding flexion of the neck with use of a cervical collar *Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP.
Which is the earliest sign of increasing intracranial pressure? Posturing Headache Vomiting Change in level of consciousness
Change in level of consciousness
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? Contact the physician to review the care plan. Check the equipment. 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. *A reading of 0 mm Hg indicates equipment malfunction
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 facial nerve Damage to the vagal nerve Damage to the olfactory nerve Damage to the optic nerve
Damage to the optic nerve
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? Cranial nerve function Glasgow Coma Scale Cerebellar function Mental status evaluation
Glasgow Coma Scale
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?
Increased ICP *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 infection Risk for injury Ineffective cerebral tissue perfusion Fluid volume deficit
Ineffective cerebral tissue perfusion *The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? Lethargy and stupor A bounding pulse Bradycardia Hypertension
Lethargy and stupor *As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli.
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? Demonstrates optimal cerebral tissue perfusion Attains desired fluid balance Maintains a patent airway Displays no signs or symptoms of infection
Maintains a patent airway *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 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? Cushing's Monroe-Kellie Dawn phenomenon Hashimoto's disease
Monroe-Kellie
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? equal response unequal response constricted response rapid response
Unequal response *In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to reduce cellular metabolic demand. control shivering. control fever. dehydrate the brain and reduce cerebral edema.
dehydrate the brain and reduce cerebral edema. *Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness
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: *insert an indwelling urinary catheter. *use a condom catheter instead of an invasive one. *increase the frequency of the catheterizations. *place the client on fluid restrictions.
increase the frequency of the catheterizations. *if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 12 5 7 3
3 *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 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? Loss of gag reflex and mental confusion Mental confusion and pupillary changes Decerebrate posturing and loss of corneal reflex Complaints of headache and lack of pupillary response
Decerebrate posturing and loss of corneal reflex *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).
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate
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?
Heart failure *It is possible for the client to have a fluid overload that creates such an increased workload for the heart that it fails.
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)? Encouraging oral fluid intake Suctioning the client once each shift Administering a stool softener as ordered Elevating the head of the bed 90 degrees
Administering a stool softener as ordered
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