Chapter 66: Mgmt of Pt with Neurologic Dysfunction

13. 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? a. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure

A

6. A nurse caring for a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognize as the symptoms associated with Cushing triad? (Select all that apply.) a. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction

A, B, C

11. 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.) a. Loosening constrictive clothing b. Opening the patient's jaw and inserting a mouth gag c. Positioning the patient on their side with head flexed forward d. Providing for privacy e. Restraining the patient to avoid self-injury

A, C, D

4. The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? a. 8 to 15 mm Hg b. 0 to 10 mm Hg c. 20 to 30 mm Hg d. 25 to 40 mm Hg

B

7. What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a. A bounding pulse b. Bradycardia c. Hypertension d. Lethargy and stupor

D

2. A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 6 c. 9 d. 12

A

10. When educating a patient about the use of anticonvulsant medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a. Anemia b. Osteoarthritis c. Osteoporosis d. Obesity

C

12. The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? a. Low in fat b. Restricts protein to 10% of daily caloric intake c. High in protein and low in carbohydrate d. At least 50% carbohydrate

C

15. 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? a. Mannitol b. Furosemide (Lasix) c. Vasopressin d. Phenobarbital

C

3. 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? a. Decerebrate b. Decorticate c. Flaccid d. Rigid

C

5. A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a. 50 mm Hg b. 60 mm Hg c. 70 mm Hg d. 80 mm Hg

C

8. The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? a. Glycerin b. Isosorbide c. Mannitol d. Urea

C

1. The nurse is caring for a patient with an altered level of consciousness (LOC). What is the first priority of treatment for this patient? a. Assessment of pupillary light reflexes b. Determination of the cause c. Positioning to prevent complications d. Maintenance of a patent airway

D

14. A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a. Give the patient some mouthwash to gargle with b. Request an antihistamine for the postnasal drip c. Ask the patient to cough to observe the sputum color and consistency d. Notify the physician of a possible cerebrospinal fluid leak

D

9. A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a. 50 to 100 mL/h b. 100 to 150 mL/h c. 150 to 200 mL/h d. More than 200 mL/h

D