Chapter 37
A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? Cyclobenzaprine Ampicillin Acyclovir Cyclosporine
Acyclovir
The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change? Monitor vital sign fluctuation. Monitor for elevation of glucose levels. Observe for jaundice. Assess for euphoria.
Monitor vital sign fluctuation.
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? Confusion Body rigidity Urinary incontinence Epileptic cry
Confusion
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? Epileptic cry Body rigidity Confusion Urinary incontinence
Confusion
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A bounding pulse Hypertension Bradycardia Lethargy and stupor
Lethargy and stupor
The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change? Monitor for elevation of glucose levels. Observe for jaundice. Assess for euphoria. Monitor vital sign fluctuation.
Monitor vital sign fluctuation.
The nurse is assessing a client with sudden bilateral lower extremity weakness and dyskinesia. The client reports accompanying numbness and tingling episodes. Which question will the nurse ask the client to help determine the reason for the client's symptoms? "How much alcohol do you ingest each day?" "What medication do you routinely take?" "What other illnesses are you being treated for?" "Have you had a recent illness?"
"Have you had a recent illness?"
A client asks the nurse to explain the development of Parkinson disease (PD). Which response will the nurse provide the client? "It has been linked by untreated or poorly managed bacterial or viral infections in early adolescence." "It is caused by low levels of dopamine that are not available to counteract the effects of acetylcholine." "While there is no average age of onset, studies suggest neurologic aging deficits put clients at risk after age 70." "It is a genetic disorder that has a strong corralation to women who began menopause earlier than age 45."
"It is caused by low levels of dopamine that are not available to counteract the effects of acetylcholine."
An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease? "He's forgotten the names of some people that we've known for years." "He often complains that his joints are terribly stiff when he wakes up in the morning." "Lately he seems to move far more slowly than he ever has in the past." "He's losing weight even though he has a ravenous appetite."
"Lately he seems to move far more slowly than he ever has in the past."
An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease? "He's losing weight even though he has a ravenous appetite." "He's forgotten the names of some people that we've known for years." "He often complains that his joints are terribly stiff when he wakes up in the morning." "Lately he seems to move far more slowly than he ever has in the past."
"Lately he seems to move far more slowly than he ever has in the past."
A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports that he has been achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? "It's important to drink plenty of fluids while you're taking laxatives." "Make sure that you supplement your laxatives with a nutritious diet." "You should ideally be using herbal remedies rather than medications to promote bowel function." "Let's explore other options, because laxatives can have side effects and create dependency."
"Let's explore other options, because laxatives can have side effects and create dependency."
A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports that he has been achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? "You should ideally be using herbal remedies rather than medications to promote bowel function." "Let's explore other options, because laxatives can have side effects and create dependency." "Make sure that you supplement your laxatives with a nutritious diet." "It's important to drink plenty of fluids while you're taking laxatives."
"Let's explore other options, because laxatives can have side effects and create dependency."
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? Focal seizure Absence seizure Generalized seizure Unclassified seizure
Absence seizure
A client with head trauma is taken to surgery to insert an ICP monitor as signs and symptoms indicating increased ICP have continued to worsen. What increase in ICP (from a previous measurement) is cause for concern? 1.0 mm Hg 2 mm Hg 1.5 mm Hg 0.5 mm Hg
2 mm Hg
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? Administer stool softeners. Position the client with the head turned toward the side of the brain tumor. Encourage coughing and deep breathing. Provide sensory stimulation.
Administer stool softeners.
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 Encouraging oral fluid intake Suctioning the client once each shift Administering a stool softener as ordered
Administering a stool softener as ordered
Which is a late sign of increased intracranial pressure (ICP)? Headache Altered respiratory patterns Slow speech Irritability
Altered respiratory patterns
Which is a late sign of increased intracranial pressure (ICP)? Slow speech Altered respiratory patterns Headache Irritability
Altered respiratory patterns
A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? Chewing on the affected side to prevent unilateral neglect Avoiding brushing the teeth Applying a protective eye shield at night Avoiding the use of analgesics whenever possible
Applying a protective eye shield at night
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? Assess pupils. Assess Glasgow Coma Scale. Assess vital signs. Assess for a patent airway.
Assess for a patent airway.
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 Pupillary constriction Tachycardia Bradypnea
Bradycardia Bradypnea Hypertension
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. Document the reading because it reflects that the treatment has been effective. Check the equipment. Contact the physician to review the care plan.
Check the equipment.
A client being treated for a brain tumor is exhibiting signs and symptoms of cerebral edema. The nurse anticipates that the practitioner will most likely prescribe which agent? Diuretic Immunotherapy agent Anticonvulsant agent Corticosteroid
Corticosteroid
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 Complaints of headache and lack of pupillary response Loss of gag reflex and mental confusion Mental confusion and pupillary changes
Decerebrate posturing and loss of corneal reflex
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? Pupillary asymmetry Declining level of consciousness (LOC) Irregular breathing pattern Involuntary posturing
Declining level of consciousness (LOC)
A client is preparing to undergo diagnostic testing for suspicion of multiple sclerosis (MS). Which assessment finding correlates with this diagnosis? Select all that apply. Cognitive declines Vision loss Contractures Personality changes Difficulty in coordination
Difficulty in coordination Vision loss
The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Decreased pulse and respirations Loss of corneal reflex Projectile vomiting Disorientation and restlessness
Disorientation and restlessness
The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply. Displacing or shifting cerebral spinal fluid (CSF) Increasing the absorption of CSF Decreasing cerebral perfusion Decreasing cerebral blood volume Shifting brain tissue
Displacing or shifting CSF; Increasing the absorption of CSF; Decreasing cerebral blood volume
The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa for 7 years. For what common side effect should the nurse assess this client? Diarrhea Dyskinesia Lactose intolerance Pruritus
Dyskinesia
A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? Pathologic bone fractures Metastasis Risk for stroke Emotional and personality changes
Emotional and personality changes
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field? Place patient in a room near the nursing station. Ensure a clutter-free walkway. Instruct on adaptive plates with rims. Announce yourself when approaching the client.
Ensure a clutter-free walkway.
Bell palsy is a disorder of which cranial nerve? Trigeminal (V) Vagus (X) Facial (VII) Vestibulocochlear (VIII)
Facial (VII)
The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? Electrolyte restriction Transfusion of fresh frozen plasma (FFP) Fluid restriction Transfusion of platelets
Fluid restriction
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Absence seizure Focal seizure Unclassified seizure Generalized seizure
Generalized seizure
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Unclassified seizure Absence seizure Focal seizure Generalized seizure
Generalized seizure
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? Cranial nerve function Monro-Kellie hypothesis Glasgow Coma scale Mental status examination
Glasgow Coma scale
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition? Hemorrhagic stroke Visual loss Hearing loss Thyroid disorders
Hemorrhagic stroke
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? At least 50% carbohydrate Low in fat High in protein and low in carbohydrate Restricts protein to 10% of daily caloric intake
High in protein and low in carbohydrate
A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? Impaired Home Maintenance Disturbed Sleep Pattern Altered Nutrition Hopelessness
Hopelessness
A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? Bowel incontinence Impaired urinary elimination Chronic confusion Impaired verbal communication
Impaired verbal communication
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? Infection Increase in cerebral perfusion pressure Exacerbation of uncontrolled hypertension Increased ICP
Increased ICP
The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? Intravenous phenobarbital Intravenous diazepam Oral lorazepam Oral phenytoin
Intravenous diazepam
The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's? Requip Permax Levodopa Symmetrel
Levodopa
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Place client in high Fowler position. Restrain the client to prevent injury. Loosen the client's restrictive clothing. Open the client's jaws to insert an oral airway.
Loosen the client's restrictive clothing.
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? Loss of brain stem reflexes Dry mucous membranes Hemiplegia Signs of internal bleeding
Loss of brain stem reflexes
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Computed tomography (CT) scan Venous Doppler studies Magnetic resonance imaging (MRI) Lumbar puncture
Lumbar puncture
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
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? Spironlactone Furosemide Mannitol Hydrochlorothiazide
Mannitol
A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Meningitis Catheter occlusion Encephalitis Cerebral spinal fluid leak
Meningitis
The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Maintain NPO status. Change the client's position as indicated. Monitor serum electrolytes. Monitor arterial blood gas (ABG) values.
Monitor serum electrolytes.
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Numbness and tingling in the lower extremities Inability to stand with eyes closed and arms extended without swaying Neck flexion produces flexion of the knees and hips Pain upon ankle dorsiflexion of the foot
Neck flexion produces flexion of the knees and hips
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Cafergot Dexamethasone Phenytoin Prednisone
Phenytoin
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? Reassure the client and family members. Administer antianxiety medications as ordered. Place the client in a side-lying position. Pad the client's bed rails.
Place the client in a side-lying position.
A client presents to the clinic reporting a headache and stiffness in the neck. Which other indication(s) of meningeal irritation would be an expected finding? Select all that apply. Sensitivity to light Positive Kernig sign Hyperpatellar reflex Positive Brudzinski sign Sluggish pupil reaction
Positive Kernig sign Positive Brudzinski sign Sensitivity to light
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. Opening the patient's jaw and inserting a mouth gag Providing for privacy Positioning the patient on his or her side with head flexed forward Restraining the patient to avoid self injury Loosening constrictive clothing
Providing for privacy Positioning the patient on his or her side with head flexed forward Loosening constrictive clothing
A 35-year-old client with a history of traumatic brain injury has been admitted to the emergency department for a recent change in cognition. The client is steadily walking across the room, intermittently laughing loudly, and crying hysterically. What is the most likely condition associated with these signs?
Pseudobulbar affect
A 35-year-old client with a history of traumatic brain injury has been admitted to the emergency department for a recent change in cognition. The client is steadily walking across the room, intermittently laughing loudly, and crying hysterically. What is the most likely condition associated with these signs? Pseudobulbar affect Absence seizure Status epilepticus Dementia
Pseudobulbar affect
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? Rapid, jerky, involuntary movements Dysphagia and dysphonia Slow, shuffling gait Dementia
Rapid, jerky, involuntary movements
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. Place the client in wrist restraints. Administer lorazepam per orders.
Reorient the client while gently holding their arms.
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? Suction the client's mouth and pharynx Provide oxygen or anticonvulsants, whichever is available Turn the client to the side during a seizure and do not restrain movements Place a cooling blanket beneath the client
Turn the client to the side during a seizure and do not restrain movements
A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? Riluzole Dantrolene sodium Baclofen Diazepam
Riluzole
A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? Riluzole Diazepam Baclofen Dantrolene sodium
Riluzole
A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing? Cluster headache Paroxysmal hemicranias Cranial arteritis Secondary headache
Secondary headache
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Cool, dry skin Urine output of 100 mL/hr Shivering Capillary refill of 2 seconds
Shivering
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Suggest applying cool compresses on the face several times a day to tighten the muscles. Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Inform the patient that the muscle function will return as soon as the virus dissipates. Tell the patient to smile every 4 hours.
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
A nurse is providing care to a client recently diagnosed with a brain tumor. When planning this client's care, the nurse anticipates which therapy as providing the best outcome for the client? Chemotherapy Immunotherapy Radiation therapy Surgery
Surgery
A client is having a tonic-clonic seizure. What should the nurse do first? Restrain the client's arms and legs. Place a tongue blade in the client's mouth. Take measures to prevent injury. Elevate the head of the bed.
Take measures to prevent injury.
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 reading is inaccurate. The CPP is within normal limits.
The CPP is low.
The nurse is writing a discharge care plan for a client diagnosed with brain metastases. The nurse decides that the client is experiencing anxiety related to lack of control over the health circumstances. In establishing this plan of care for the client, the nurse should include what intervention? The client's family will be instructed on planning the client's care. The client will begin intensive therapy with the goal of distraction. The client will be encouraged to utilize available resources to help maintain independence. The client will receive antianxiety medications every 4 hours.
The client will be encouraged to utilize available resources to help maintain independence.
Which client should the nurse assess for degenerative neurologic symptoms? The client with Huntington disease. The client with Paget disease. The client with osteomyelitis. The client with glioma.
The client with Huntington disease.
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 exercises that are brief but high-intensity. 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 frequent physical activity but avoid becoming fatigued.
The patient should perform frequent physical activity but avoid becoming fatigued.
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. Cerebral angiography Electromyography (EMG) Transcranial Doppler flow study Cranial radiography MRI
Transcranial Doppler flow study Cerebral angiography MRI
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?
Uneven, labored respirations
A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? When the client is participating in occupational therapy When the client is preparing his or her meal tray to eat When the client is resting When the client is ambulating
When the client is resting
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Within 24 hours after exposure Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 72 hours after exposure Within 48 hours after exposure
Within 24 hours after exposure
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? tasting swallowing smelling chewing
chewing
What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC) Cushing triad headache coma
decreased level of consciousness (LOC)
What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC) headache Cushing triad coma
decreased level of consciousness (LOC)
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: diminished responsiveness. pupillary changes. elevated temperature. decreasing blood pressure.
diminished responsiveness.
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 malaria. hypothermia can cause death to the client. hypothermia is indicative of severe meningitis. shivering in hypothermia can increase ICP.
shivering in hypothermia can increase ICP.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the dorsal recumbent position. prone position with the head turned to the unaffected side. Trendelenburg position. supine position with the head slightly elevated.
supine position with the head slightly elevated.
