Chapter 54

The three components of Cushing's response are:

Widened pulse pressure. Bradycardia Increased systolic blood pressure.

loss of the ability to recognize familiar objects or people through sensory stimulation. This condition is called

agnosia.

The best nursing intervention for restlessness in a patient with a head injury is

assessing for pain or distended bladder.

A ___________ is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space and is similar to a lumbar puncture.

myelogram

The ____ connects the midbrain to the medulla oblongata. The word means "bridge." It is the origin of cranial nerves 5 and 8.

pons

the rest period after a tonic-clonic seizure is called a

postictal period

A therapeutic measure to reduce increased intracranial pressure is

reduce fluid intake.

A 39-year-old has a 6-year history of multiple sclerosis. During planning, the nurse remembers this is a degenerative neurological disease that

results from demyelination of the nerve sheath.

When the seriousness of craniocerebral trauma is assessed, it is important to remember that

signs and symptoms may not occur until several days after the trauma.

The cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions is the

vagus nerve.

Before the patient undergoes computed tomographic (CT) scanning with a contrast medium, the nurse should

verify that the patient is not allergic to seafood or iodine.

When obtaining a health history from a patient with a neurological problem, the nurse is likely to elicit the most valid response from the patient with which question?

"Can you describe the sensations you are having in your head?"

Which test should not be done if there is an indication of ICP?

A lumbar puncture (contraindicated in patients who might have increased ICP, because the withdrawal of fluid may cause the medulla oblongata to herniate downward)

A patient has a head injury and is presenting with signs and symptoms of ICP. Which intervention would be helpful in reducing this pressure?

Place the neck in a neutral position to promote venous drainage.

which would best describe the patient's inability to assess spatial position of his body?

Proprioception

Which body system would the nurse choose to closely monitor in a patient diagnosed with Guillain-Barré syndrome?

Respiratory

If a patient with a head injury has drainage from the nose or ears, which nursing intervention would be appropriate?

Allow the patient to wipe the nose or ears, but not blow the nose or place anything in the external ear.

What is the most significant sign of increased intracranial pressure?

Decrease in the level of consciousness

A patient's neurological status deteriorates over hours, and a craniotomy is performed to evacuate the hematoma. Which nursing intervention is indicated to help decrease the threat of increased ICP?

Elevate the head of the bed 30 degrees.

A patient who has recently suffered a stroke has problems with choking, especially when she drinks thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?

Instructing her to tuck her chin when swallowing

before a myelogram

Obtain an allergy history

Migraine headaches are unusual in that there are prodromal [early signs and symptoms of a developing condition or disease] signs and symptoms that occur

before the acute attack.

A patient, age 27, has been admitted to the neurological department because of seizures of unknown cause. The nurse should take precautions by

being certain padded side rails are present.

A patient has a spinal cord injury resulting in paraplegia. She manifests signs and symptoms of autonomic dysreflexia, which is frequently triggered by

bladder distention.

When planning care for a patient with aphasia, the nurse should

consider the type of aphasia that the patient has and adapt communication methods accordingly.

The earliest sign of increased intracranial pressure is

decreasing level of consciousness.

The Glasgow coma scale is a screening tool used to assess level of consciousness in three major areas. They are

eye opening. best motor response. best verbal response.

An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him

from the left side.

A patient, age 69, is being evaluated by a neurologist for signs of muscle rigidity, masklike face (area from forehead to chin), and propulsive gait. These signs are often characteristic of

Parkinsonism.

A patient, age 52, is brought to the emergency department by ambulance after she hit her head on her bathroom sink and fell unconscious to the floor. Which assessment should the nurse perform first?

Patency of airway