Chapter 61 Seizure
"My children are at greater risk to develop this disease."
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? · "My children are at greater risk to develop this disease." · "I will lose strength in my arms." · "I need to remain active for as long as possible." · "I will have progressive muscle weakness."
Impaired cellular activity Death · Permanent neurologic dysfunction · Seizures
A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options. · Impaired cellular activity · Insomnia · Death · Permanent neurologic dysfunction · Seizures
Urinary tract infection
A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? · Emotional apathy · Choreiform movements · Severe depression · Urinary tract infection
unknown.
A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: · vasodilating agents. -can trigger · unknown. · endocrine. · muscular.
Glasgow Coma Scale
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
vasodilation
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? · hypertension · vasodilation · increased PaO · vasoconstriction
Elevated 30 degrees
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? · Flat · Elevated no more than 10 degrees · Elevated 30 degrees · Turned onto the operative side
Turn the client to the side during a seizure and do not restrain movements - prevents aspiration of saliva or stomach contents
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? · Place a cooling blanket beneath the client - THIS IS FOR HYPERTHERMIA · Provide oxygen or anticonvulsants, whichever is available - REDUCES CHANCES OF SEIZURE (carbamazepine) · Turn the client to the side during a seizure and do not restrain movements - prevents aspiration of saliva or stomach contents · Suction the client's mouth and pharynx - AFTER A SEIZURE
Restricting fluid intake and hydration
A client with neurological 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 · Hyperoxygenation before and after tracheal suctioning · Administering prescribed antipyretics · Maintaining adequate hydration
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? · "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." · "In most people, epilepsy is usually synonymous with intellectual disability." · "Cases of epilepsy are often associated with intellectual level." · "For many people with epilepsy, the disorder is synonymous with mental illness."
3
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? · 3 · 6 · 9 · 12
Bradycardia · Hypertension · Bradypnea
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 · Tachycardia · Hypertension · Bradypnea · Pupillary constriction
Infection
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? · Coma · Infection · Apnea · High blood pressure
diminished responsiveness.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: · elevated temperature. · pupillary changes. - occur later · decreasing blood pressure. - increases blood pressure diminished responsiveness.
Vasopressin
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? · Furosemide (Lasix) · Mannitol · Vasopressin · Phenobarbital
Flaccid
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? · Rigid · Decorticate · Flaccid · Decerebrate
Diplopia.
A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of: · Dysphoria. · Generalized fatigue. · Diplopia. Double vision · Facial muscle weakness.
Side-lying, to facilitate drainage of oral secretions
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Pituitary carcinoma
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? · Esophageal carcinoma · Pituitary carcinoma · Laryngeal carcinoma · Colorectal carcinoma
Performing a lumbar puncture
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? · Elevating the head of his bed - can be done to relieve ICP · Performing a lumbar puncture - decompresses the nervous system · Giving him a barbiturate - ARE given to prevent seizure · Placing him on mechanical ventilation - may be required for breathing deteoration
Brain tumor
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? · Epilepsy · Brain tumor · Trigeminal neuralgia · Hypostatic pneumonia
dehydrate the brain and reduce cerebral edema.
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to · dehydrate the brain and reduce cerebral edema. · control shivering. · reduce cellular metabolic demand. · control fever.
Assess for a patent airway.
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 for a patent airway. · Assess Glasgow Coma Scale. · Assess vital signs. · Assess pupils.
24 hours
Cerebral edema peaks at which time point after intracranial surgery? · 12 hours · 24 hours · 48 hours · 72 hours
Gingival hyperplasia
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? · Ataxia · Diplopia · Alopecia · Gingival hyperplasia
Hypocortisolism
Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition? · Hyperglycemia · Hypercalcemia · Hypocortisolism · Hypoglycemia
promote carbon dioxide elimination.
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:
hallucinations and delusions
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? · muscle fasciculations · depression · hallucinations and delusions · bradykinesia
Damage to the optic nerve
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 optic nerve · Damage to the vagal nerve · Damage to the olfactory nerve · Damage to the facial nerve
Airway clearance
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? · Risk of injury · Airway clearance · Risk for impaired skin integrity · Deficient fluid volume
Aspiration of a brain abscess
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 · Access for intravenous (IV) fluids · To assess visual acuity · Visualization of a hemorrhage
· Positioning the patient on his or her side with head flexed forward · Loosening constrictive clothing · Providing for privacy
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. · Positioning the patient on his or her side with head flexed forward · Loosening constrictive clothing · Opening the patient's jaw and inserting a mouth gag · Providing for privacy · Restraining the patient to avoid self inju
· Administer medications at exact intervals ordered.
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? · Assess client's reaction to new medication schedule. · Administer medications at exact intervals ordered. · Document medication given and dose. · Give client plenty of fluids with medications.
· Change in level of consciousness · Widening pulse pressure · Elevation of systolic blood pressure · Slowing of heart rate
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is · Change in level of consciousness · Widening pulse pressure · Elevation of systolic blood pressure · Slowing of heart rate
Oliguria and serum hyponatremia
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?
Increased ICP is 12 mm Hg.
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? · Increased ICP is 12 mm Hg. · Cerebral perfusion pressure (CPP) is 21 mm Hg. · The pupils are dilated and fixed. · The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP).
Explaining hospice care and services
The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?
· Cloudy cerebral spinal fluid · Purpura of hands and feet
The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. · Pain and stiffness of the extremities · Cloudy cerebral spinal fluid · Purpura of hands and feet · Low antidiuretic hormone (ADH) levels · Low white blood cell (WBC) count · Low red blood cell (RBC) count
Keep a food diary. Maintain a headache diary.
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. · Keep a food diary. · Sleep no more than 5 hours at a time. · Use St. John's Wort. · Exercise in a dark room. · Maintain a headache diary.
High in protein and low in carbohydrate
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? · Restricts protein to 10% of daily caloric intake · At least 50% carbohydrate · High in protein and low in carbohydrate · Low in fat
· Metabolic and toxic conditions · Drug and alcohol withdrawal · Hyponatremia · Cerebrovascular disease · Brain tumor
The nurse recognizes that causes of acquired seizures include what? Select all that apply. · Metabolic and toxic conditions · Drug and alcohol withdrawal · Hyponatremia · Cerebrovascular disease · Brain tumor
An absence seizure
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 tonic-clonic seizure · A complex seizure · An absence seizure · A partial seizure
minimize exposure to bright lights and noise.
To meet the sensory needs of a client with viral meningitis, the nurse should: · promote an active range of motion. · increase environmental stimuli. · avoid physical contact between the client and family members. · minimize exposure to bright lights and noise.
Lethargy and stupor
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? · Bradycardia · Hypertension · Lethargy and stupor · A bounding pulse
decreased level of consciousness (LOC)
What is one of the earliest signs of increased ICP? · decreased level of consciousness (LOC) · Cushing triad · coma · headache
Rising blood pressure and bradycardia
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 · Hypotension and bradycardia · Hypertension and narrowing pulse pressure
Osteoporosis
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? · Anemia · Obesity · Osteoarthritis Osteoporosis
Avoiding flexion of the neck with use of a cervical collar
Which positions is used to help reduce intracranial pressure (ICP)? · Extreme hip flexion, with the hip supported by pillows · 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
Decorticate
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
· Bradycardia · Hypertension · Bradypnea
Which signs are manifestations of the Cushing triad? Select all that apply. · Tachycardia · Bradycardia · Hypertension · Bradypnea
Herniation
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? · Autoregulation · Cushing response · Herniation · Monro-Kellie hypothesis
5 mm Hg
Which value indicates a normal intracranial pressure (ICP)? · 5 mm Hg · 17 mm Hg · 20 mm Hg · 27 mm Hg
seasonal changes
A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? · medications · seasonal changes · reproductive hormone fluctuations · specific food chemicals
"A secondary headache is associated with an organic cause, such as a brain tumor."
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 associated with an organic cause, such as a brain tumor." · "A migraine headache is an example of a secondary headache." · "A secondary headache is located in the frontal area." · "A secondary headache is one for which no organic cause can be identified."
Parkinson disease.
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: · multiple sclerosis. · Parkinson disease. · Huntington disease. · seizure disorder.
· supine position with the head slightly elevated. 30 degrees
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. · Trendelenburg position. · supine position with the head slightly elevated. 30 degrees · dorsal recumbent position.
decerebrate.
When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as · flaccid. · decerebrate. · decorticate. · normal.
Enemas
Which activity should be avoided in clients with increased intracranial pressure (ICP)? · Suctioning - should not last longer than 15 sec · Minimal environmental stimuli · Enemas · Position changes
Altered respiratory patterns
Which is a late sign of increased intracranial pressure (ICP)? · Altered respiratory patterns · Irritability - first signs · Headache - first signs · Slow speech - first signs
· Headache
Which of the following is an early sign of increasing intracranial pressure (ICP)? · Decerebrate posturing · Headache · Vomiting · Loss of consciousness
Appointments for chemotherapy or radiotherapy Nutritional support Adverse effects of chemotherapy or radiation and techniques for managing them Medication regimen
A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. Appointments for chemotherapy or radiotherapy Electromyography Nutritional support Adverse effects of chemotherapy or radiation and techniques for managing them Medication regimen
Compliance with the prescribed medication regimen
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? · The type of anticonvulsant prescribed to manage the epileptic condition · Compliance with the prescribed medication regimen · Recent stress level · Recent weight gain and loss
Lethargy
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? · Periorbital edema - more for fluid overload · Blood pressure 100/60 mm Hg · Nausea - vomiting signifies increased ICP · Lethargy - same thing for decreasing LOC
· Avoid rotation of the neck. · Prevent compression of the jugular veins. · Elevate the head 30 to 45 degrees. · Keep head midline.
A client is diagnosed with a traumatic brain injury. Which action will the nurse take to reduce this client's risk of increasing intracranial pressure (ICP)? Select all that apply. · Avoid rotation of the neck. · Prevent compression of the jugular veins. · Elevate the head 30 to 45 degrees. · Assist to keep a position of hip flexion. · Keep head midline.
Lactated Ringer's
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? · Half-normal saline (0.45% NSS) - hypotonic · Lactated Ringer's - hypertonic · One-third normal saline (0.33% NSS) -hypotonic · Dextrose 5% in water (D5W) -hypotonic
Shivering
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? · Shivering · Cool, dry skin · Urine output of 100 mL/hr · Capillary refill of 2 seconds
Administer hydromorphone and/or sumatriptan medications for relief.
A client is returning to the medical unit after surgery and has a history of migraines. Which intervention would the nurse prioritize for the overall treatment of this client? · Obtain a scheduled order for ondansetron or trimethobenzamide. · Administer hydromorphone and/or sumatriptan medications for relief. · Maintain a clear liquid diet and administer intravenous fluids for hydration. · Elevate the head of the bed 90 degrees and provide task lighting in a quiet enviroment.
carefully move the client to a flat surface and turn him on his side.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: · place an oral airway in the client's mouth to maintain an open airway. · allow the client to remain in the chair but move all objects out of his way. · carefully move the client to a flat surface and turn him on his side. · hold the client's arm still to keep him from hitting anything.
Administering a stool softener as ordered
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 · Elevating the head of the bed 90 degrees · Administering a stool softener as ordered · Suctioning the client once each shift
Declining level of consciousness (LOC)
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? · Declining level of consciousness (LOC) · Pupillary asymmetry · Involuntary posturing · Irregular breathing pattern
"You must avoid coughing, sneezing, and blowing your nose."
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 avoid coughing, sneezing, and blowing your nose." · "You must restrict your fluid intake." · "You must report ringing in your ears immediately." · "You must lie flat for 24 hours after surgery."
increase the frequency of the catheterizations.
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. · place the client on fluid restrictions. · increase the frequency of the catheterizations. · use a condom catheter instead of an invasive one.
Decerebrate posturing and loss of corneal reflex
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 · Mental confusion and pupillary changes · Decerebrate posturing and loss of corneal reflex · Loss of gag reflex and mental confusion
Vasopressin therapy
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? · Fluid restriction · Hypertonic saline solution · Diet containing extra sodium · Vasopressin therapy
· Maintains a patent airway
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 · Demonstrates optimal cerebral tissue perfusion · Maintains a patent airway · Attains desired fluid balance
place the client on his side, remove dangerous objects, and protect his head.
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 protect his head. · place the client on his back, remove dangerous objects, and hold down his arms. · place the client on his side, remove dangerous objects, and insert a bite block. · place the client on his back, remove dangerous objects, and insert a bite block.
Keep the client on one side.
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? · Pry the client's mouth open to allow a patent airway. · Place a cooling blanket beneath the client. · Keep the client on one side. · Help the client sit up.
The CPP is low.
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.
The CPP is low.
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 reading is inaccurate. · The CPP is low. · The CPP is high.
Administer stool softeners.
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? · Provide sensory stimulation. · Position the client with the head turned toward the side of the brain tumor. · Encourage coughing and deep breathing. · Administer stool softeners.
chewing
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
chewing
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? · tasting · smelling · chewing · swallowing
Monro-Kellie
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? · Dawn phenomenon · Hashimoto's disease · Cushing's · Monro-Kellie
"There is a strong familial tendency."
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? · "No familial tendency has been demonstrated." · "There is a very weak familial tendency." · "Only secondary migraine headaches show a familial tendency." - migraines are primary · "There is a strong familial tendency."
Change in level of consciousness
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is · Change in level of consciousness · Widening pulse pressure · Elevation of systolic blood pressure · Slowing of heart rate
· Administer acetaminophen per orders.
The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action? · Assess for signs and symptoms of infection. · Provide ventriculostomy care. · Administer acetaminophen per orders. · Inspect the ICP monitor to ensure it is working properly.
Heart failure
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 · Diabetes insipidus · Heart failure · Kidney failure
Increased ICP
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 · Increase in cerebral perfusion pressure · Exacerbation of uncontrolled hypertension · Infection
Administer corticosteroids as ordered.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis (inflammation that can cause rupture to the vessel). What is the priority nursing intervention? · Administer corticosteroids as ordered. - prevents vision loss or vessel rupture · Give acetaminophen per orders. · Assess for weight loss. · Document signs and symptoms of inflammation.
Drooping eyelids
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 · Shortness of breath · Muscle spasms · Drooping eyelids
Check the equipment.
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? · Check the equipment. · Continue the assessment because no actions are indicated at this time. · Contact the physician to review the care plan. · Document the reading because it reflects that the treatment has been effective.
Maintaining aseptic technique with an intraventricular catheter · Frequent oral care · Administering prescribed antipyretics
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. · Maintaining aseptic technique with an intraventricular catheter · Frequent oral care · Encouraging deep breathing and coughing every 2 hours · Administering prescribed antipyretics · Elevating the head of the bed to 90 degrees
Using a cervical collar
Which method is used to help reduce intracranial pressure? · Rotating the neck to the far right with neck support · Extreme hip flexion, with the hip supported by pillows · Keeping the head of bed flat · Using a cervical collar
· 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.
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. · Encourage the client to walk with feet wide apart. · Obtain daily weights to monitor weight gain.
Cluster
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? · Sinus · Cluster · Migraine · Tension