Chapter 66: Management of Patients With Neurologic Dysfunction 4
Elevate the head of the bed.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Restricting fluid intake and hydration
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
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?
Ineffective airway clearance related to altered LOC
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?
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?
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?
decreased level of consciousness (LOC)
What is one of the earliest signs of increased ICP?
decerebrate.
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
