Intracranial Regulation Assessment
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
Position the child side-lying.
A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?
"Implement a schedule to include periods of rest."
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
"Move objects away from the client."
A nurse is preparing to administer clonazepam 1.5 mg PO in 3 equally divided doses every 8 hr for a client who has seizures. The amount available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer per dose?
1
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to Take: - Implement seizure precautions - Dim the light's in the clients room Potential Condition: - Meningitis Parameters to Monitor: - Neurological status -Temperature
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to Take: - Keep infant NPO - Initiate seizure precautions Potential Condition: - Tonic-clonic seizures Parameters to Monitor: - Level of consciousness - Motor ability
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
Assess the cranial nerves.
A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects?
Difficulty voiding
A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?
Dilated scalp veins
A nurse at a rehabilitation center is planning care for a client who has a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Establish the ability to communicate effectively.
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?
Evaluate the client's neurological status.
A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?
Inability to recognize his family members
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?
Increase fluid intake.
The client is at highest risk for developing ________ as evidenced by the _________
Intracranial hemorrhage, Glasgow Coma Scale
A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?
Intracranial pressure (ICP) 18 mm Hg
A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?
Minimize environmental stimuli.
A nurse is caring for a client who has a head injury. The client states they fell off a ladder while painting approximately 2 hr ago and los consciousness for 45 min according to their partner. The nurse should determine that the client is experiencing which of the following classifications of traumatic brain injury?
Moderate
A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medication prescriptions should the nurse include under Schedule II?
Morphine
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Perform a Romberg's test.
A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?
Provide client supervision.
A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?
Pushes painful stimulus away.
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
Reduce edema of the brain.
A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?
Reduce stimuli.
A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Remind the client to look for food on the left side of the tray.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Severe headache
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
Speak to the client about one idea at a time.
A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
Systolic blood pressure changed from 140 mm Hg to 120 mm Hg
A nurse is admitting a client who has dementia related to a traumatic brain injury. Which of the following findings should indicate to the nurse that the client's condition is worsening?
Visual field cuts
A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following nursing interventions should the nurse implement?
Encourage exhaling through mouth during defecation.
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?
Encourage the client to take small bites.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
Manifestations preceded by a severe headache
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Place suction equipment at the client's bedside.
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Place the client on his side.
A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
Supplements via nasogastric tube
A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?
Cheddar cheese
A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?
"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?
"Have you had a recent influenza infection?"
A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching?
"I'll splint my incision with a pillow to cough."
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate withe the client. Which of the following responses by the nurse is appropriate?
"Incorporate nonverbal cues in the conversation."
A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
"The purpose of this device is to immobilize the cervical spine."
A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching?
"Use the pain scale to determine if you need to self-administer."
A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?
"What do you think your spouse would have wanted?"
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP?
- Bradycardia - Nonreactive dilated pupils
A nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning the client?
- Elevate the bed to waist height - Face the direction of movement when positioning the client - Stand with feet wide apart - Remove pillows prior to repositioning
A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)?
- Headache - Slurred speech - Pupillary changes - Disorientation
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- Loosen restrictive clothing - Place a pillow under the client's head
The nurse should determine the assessment findings are consistent with which of the following disease processes?
- Mood: Bacterial meningitis - Location of pain: Bacterial meningitis, Encephalitis - Body temperature: Bacterial meningitis, Encephalitis - GI manifestations: Bacterial meningitis, Encephalitis - Reaction to pupil assessment: Bacterial meningitis, Encephalitis - Neck range of motion: Bacterial meningitis. Encephalitis - CSF analysis: Bacterial meningitis
A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect?
- Muscle distortion - Pain behind the ear - Impaired taste
For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, or multiple sclerosis. Each finding can support more than 1 disease process.
- Orientation status: Parkinson's Disease, Stroke, and Multiple Sclerosis. - Ambulation pattern: Parkinson's Disease - Muscle movements: Parkinson's Disease - Speech: Parkinson's Disease, Stroke, Multiple Sclerosis. - Facial rigidity: Parkinson's Disease
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take?
- Place the client in a side-lying position. - Remove objects from the client's bed. - Assess the client's airway patency.
A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include?
- Provide a suction setup at the bedside. - Elevate the side rails near the head when the client is in bed. - Place the bed in the lowest position. - Keep an oxygen setup at bedside.
A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan?
- Provide oral fluids - Monitor for nausea - Check level of consciousness - Check sensation in the toes
A nurse is caring for a client who has a seizure disorder.
- Time the duration of the seizure. - Administer supplemental oxygen to the client. - Turn the client to the side.
A nurse is preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is valproic acid 250 mg/5mL. How many mL should the nurse administer per dose?
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A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?
A change in the Glasgow Coma Scale from 13 to 11
A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?
A lucid period followed by an immediate loss of consciousness.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to Take: - Prepare the client for a STAT CT - Place the client on seizure precautions Potential Condition: - Hemorrhagic Stroke Parameters to Monitor: - PT/ INR - Blood pressure
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to Take: 1- Ensure oxygen and suctioning equipment are readily available. 2- Place the client on droplet precautions. Potential Condition: Bacterial Meningitis Parameters to Monitor: 1- Level of conciousness 2- WBC count
A nurse on the intensive care unit is caring for a client who has a severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?
Adjust the client's head of bed.
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Allow the drainage to drip onto a sterile gauze pad.
A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?
Alternating periods of alertness and unconsciousness
A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside?
Bag-valve-mask device
A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?
Bradykinesia
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?
Brudzinski's sign
A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?
Check the display on the PCA pump.
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?
Check the drainage for glucose.
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
Code status
A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take?
Encourage oral fluids.
A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?
Decreased tremors.
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Elevate the head of the bed.
The nurse should first address the client's ________ followed by the client's __________
Drowsiness, Right shoulder pain
A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?
Hold the infant's chin to his chest and knees to his abdomen during the procedure.
A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect?
Hyporeflexia
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?
Instruct the client to look up and down without moving his head.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
Irritability
A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?
Levodopa/ carbidopa
A nurse is assessing a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test corneal reflexes?
Lightly touch the eyes with a wisp of cotton.
A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?
Maintain the client on absolute bed rest.
A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?
Measure head circumference every shift.
A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take?
Notify emergency management services.
A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?
Obtain IV access.
A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?
Oliguria
A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
Place a pillow under the client's head.
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?
Plantar flexion of the legs.
A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?
Respiratory status
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
Restlessness
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?
Restlessness
The client is at risk for developing ____________ due to _____________.
Seizure, Phenytoin level
A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?
Sensitivity to light
A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?
Small drops of clear fluid in the left ear.
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Suction saliva from the client's mouth.
A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?
The client has a paralytic ileus.
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
The client needs total nursing care.
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coms Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
The client opens his eyes when spoken to.
A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include?
The nurse may serve as a witness to informed consent for organ donation.
A nurse is in a client's room when the client begins having tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side.
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?
Use log rolling to reposition the client.
A nurse is assessing a client who has an acoustic neuroma. Which of the following manifestations should the nurse expect?
Vertigo
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
Widened pulse pressure
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
a self-report pain rating scale
