H&I 3 EAQ: intracranial regulation

A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record?

1) Anomia rationale: Clients with anomia cannot remember names of objects. Clients with apraxia cannot use objects properly or complete sequential movement. Clients with dysarthria know what they want to say but cannot speak clearly because there is motor impairment caused by a central or peripheral nervous system injury. Clients with dysphagia have difficulty swallowing; they do not have a speech problem.

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

1) Assess the client's airway. rationale: Ensuring an airway is the first action in an emergency response to any client. Placing pads on the side rails during the procedure is too late; protecting the airway and client are priority. The healthcare provider will be notified as soon as the nurse ensures the client's safety and has a patent airway. The nurse should not leave the client during a seizure.

Which lobe of the cerebrum includes the client's Broca's speech center?

1) Frontal lobe rationale: Broca's speech center is located in the frontal lobe and is responsible for the formation of words into speech. The parietal lobe aids in processing of spatial awareness and receiving and processing information about temperature, taste, and touch. The primary visual center is in the occipital lobe. The auditory center for interpreting sound is present in the temporal lobe.

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion?

1) Positive Kernig sign Meningitis may occur secondary to surgical procedures on the brain. It is highly probable when Kernig sign is positive. The Glasgow coma scale is used as a reliable way of recording the conscious state of the client, but it is not used to diagnose meningitis. A meningitis diagnosis is highly probable with a positive Brudzinski sign and the presence of nuchal rigidity (e.g., stiff neck).

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?

1) Pulse 50 bpm and BP 140/60 mm Hg. rationale: Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate. Pulse 56 bpm and BP 130/110 mm Hg, pulse 60 bpm and BP 126/96 mm Hg, and pulse 120 bpm and BP 80/60 mm Hg do not meet these criteria.

A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask a nurse, "How much longer will my child need to take the medication?" What is the best response by the nurse?

2) "It is important that the medications be gradually decreased." rationale: A predesigned protocol is used to wean a child off anticonvulsants gradually because abrupt removal of the drug can result in a seizure. Anticonvulsants are discontinued gradually after a child is seizure free for 2, not 3, years and has an EEG within expected limits. Anticonvulsants cannot be stopped abruptly at the 2-year follow-up visit, but the discontinuation process may be started. The statement that seizure disorders are lifelong problems that require ongoing medications may or may not be true; this is determined on an individual basis.

Which part of the client's brain is primarily associated with life support and basic functions of the body?

2) Brain stem rationale: The brainstem, which connects the brain to the CNS, is concerned primarily with life support and basic functions, such as breathing and movement. The cerebrum controls intelligence, creativity, and memory. The cerebellum is concerned with coordination of movement. The cerebral cortex is part of the cerebrum, which is involved with almost all of the higher functions of the brain.

Which part of the client's brain primarily regulates muscle functioning and coordinates movement?

2) Cerebellum rationale: The cerebellum regulates motor movements resulting in smooth and balanced muscular activity. The cerebrum is associated with higher brain functions, such as thought and action. The epithalamus acts as a connection between the motor pathways and regulates emotions. The hypothalamus regulates the body temperature and secretions of the endocrine gland.

The nurse asks the client to shrug the shoulders and to run the head against passive resistance. Which cranial nerve is involved in this action?

2) Cranial nerve XI rationale: Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders. Cranial nerve II (optic nerve) is a sensory nerve for visual acuity. Cranial nerve VI (abducens nerve) is a motor nerve that coordinates the lateral movement of eyeballs. Cranial nerve VII or (auditory nerve) is a sensory nerve which coordinates the hearing sense.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply.

2) These seizures increase the risk of injuries due to fall. 3) These seizures are most resistant to drug therapy. rationale: Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by post ictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to drug therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.

A nurse is teaching an epileptic child's mother about epilepsy care. Which statements of the mother indicate effective education? Select all that apply.

3) "I should keep a medical journal of my child's treatment." 4) "I should use a graduated device for dose measurement." 5) "I should encourage my child to wear a medical alert bracelet." rationale: Parents should keep a medical journal with a record of the signs and symptoms before and after treatment with an antiepileptic drug because this information will help the primary healthcare provider. Using a graduated device or syringe to measure oral medicines is highly recommended. An epileptic child should be encouraged to wear a medical alert bracelet or necklace with information about his or her diagnosis, drug therapy, and any drug allergies. Parents are advised to stop the medicine and contact the primary healthcare provider if the child is having allergic reactions. Certain medicines such as valproic acid should not be mixed with milk because the drug may dissolve early and may cause stomach irritation.

A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for?

3) Decrease in the level of consciousness. rationale: Decreasing level of consciousness [1] [2] occurs because of the brain's acute sensitivity to hypoxia. The respirations usually are depressed because of brainstem compression. The systolic pressure increases, and the diastolic pressure decreases, resulting in a widening, not narrowing, pulse pressure. The peripheral vascular resistance is decreased when hypoxia occurs, thereby decreasing, not increasing, the diastolic blood pressure.

Which antiepileptic drug is used as the first-line treatment for absence seizures?

3) Valproic acid rationale: Valproic acid is used as the first-line treatment for absence seizures. Phenytoin is used to treat partial, secondary, and generalized tonic-clonic seizures. Diazepam is used to treat status epilepticus. Acetazolamide is used as an adjunct drug for the treatment of absence seizures.

The nurse is monitoring a client with severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative if increasing intracranial pressure?

3) increased restlessness rationale: Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. Urine output is not related to increased intracranial pressure. The respiratory rate will decrease. The pulse will be slow and bounding.

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). Which outcome would the nurse anticipate?

4) Decreased urine output rationale: ADH causes water retention, resulting in decreased urine output. Blood volume may increase, causing dilution of nitrogenous wastes in the blood. The client is overhydrated so that serum sodium is decreased, producing a dilutional hyponatremia. ADH acts on nephrons to cause water to be reabsorbed from glomerular filtrate, leading to an increased specific gravity of urine.

A client with a cerebrovascular accident ("brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem?

4) Effective communication rationale: Clients with dysarthria have difficulty communicating verbally, and an alternate means of communication may be indicated. Routine hygiene, liquid formula diet, and prevention of aspiration are important aspects of care, but they are not related to dysarthria. Dysphagia can lead to aspiration.

A 6-year-old child with Reye syndrome is receiving an intravenous solution of 10% glucose and mannitol to reduce cerebral edema. For which complication of this therapy does the nurse monitor the child?

4) Hypovolemic shock rationale: Both hypertonic glucose and mannitol cause diuresis; the child should be monitored for excessive fluid loss. Hypertonic glucose and mannitol will cause fluid loss, not gain. Seizure activity is not anticipated as a result of this infusion. An increased fluid volume can lead to heart failure; however, hypertonic glucose and mannitol cause fluid loss, not gain.

A nurse is caring for a client who is admitted to the hospital with a severe head injury. Which action is priority?

4) Maintain respiratory exchange and ventilation. rationale: The brain requires continuous, large quantities of oxygen to function; maintaining the airway and ensuring respiratory exchange and ventilation are the priorities. The supine position does not facilitate respirations; the semi-Fowler position promotes venous return, prevents venous stasis, and aids ventilation. Although avoiding contractures and deformities is a concern, preventing contractures and deformities is not the priority at this time. Although monitoring the blood pressure is done because a widening pulse pressure may indicate increasing intracranial pressure, it is not the priority.

Four clients who sustained head injuries are presented below. Which client has the least score on the Glasgow coma scale?

C) able to open eyes to pain stimulus, has normal flexion and an inappropriate verbal response. rationale: The Glasgow coma scale is used to establish baseline data in eye opening, motor response, and verbal response in acute care settings. According to the Glasgow coma scale: Eye opening: spontaneous-4, to sound-3, to pain-2, never-1. Motor answer: obeys commands-6, localizes pain-5, normal flexion (withdrawal) -4, abnormal flexion-3, extension-2, none-1. Verbal answer: oriented-5, confused conversation-4, inappropriate words-3, incomprehensible sounds-2, none-1. Based on this scale, the score in client C is 9, while the score in client A is 14, client B is 12, and client D is 11. Lower the score, the lower the client's neurological function. Therefore client C has the least neurological function.

A healthcare provider prescribes mannitol for a client with a head injury. The nurse concludes that the purpose of the medication is to relieve cerebral edema by which mechanism?

Drawing fluid from the brain cells into the bloodstream. rationale: Mannitol, an osmotic diuretic, pulls fluid from the white cells of the brain to relieve cerebral edema. Mannitol's diuretic action does not decrease the production of cerebrospinal fluid. Mannitol does not affect brain metabolism; rest and lowered body temperature reduce brain metabolism. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium, not mannitol.