Intracranial Regulation
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What action(s) should the nurse take? Select all that apply. Monitor neurologic status using the Glasgow Coma Scale. Encourage the client to cough to expectorate secretions. Elevate the head of the bed 30 degrees. Stimulate the client with active range-of-motion exercises. Contact the health care provider (HCP) if the ICP is higher than 28 mm Hg.
Elevate the head of the bed 30 degrees. Contact the health care provider (HCP) if the ICP is higher than 28 mm Hg. Monitor neurologic status using the Glasgow Coma Scale. Explanation: The nurse should maintain ICP by elevating the head of the bed 30 degrees and monitoring neurologic status. An ICP of 28 mm Hg with 20 to 25 mm Hg as the upper limit of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.
A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first? Notify the supervisor that an operating room is needed because the physician will want to insert a ventriculoperitoneal (VP) shunt. Call child protective services because of suspected child endangerment. Move the family to an area where an assessment can be completed and call for a physician. Assess the infant's vital signs in the triage area and instruct the family to wait until their names are called.
Move the family to an area where an assessment can be completed and call for a physician. Explanation: A head injury in an infant can be extremely serious. The nurse's priority should be to move the infant and family to an area where assessment and treatment can occur. Triaging the infant and having the parents wait for evaluation by a physician is inappropriate because of the potential seriousness of the injury. Although increased intracranial pressure can result from head trauma, it's unlikely that inserting a VP shunt would be the first treatment. The fact that the child was left unattended in an unsafe location is a significant safety issue, but notifying child protective services isn't a priority at this time.
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? sensory Jacksonian absence generalized
generalized Explanation: A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.
The nurse is completing a neurologic assessment on a client admitted with a contusion to the brain. Which finding does the nurse prioritize as requiring immediate action? The Glasgow Coma Scale score is 15. The client reports a mild headache. The client moves away from noxious stimuli. Pupils are equal with sluggish reaction to light.
Pupils are equal with sluggish reaction to light. Explanation: Assessing the pupillary response is an important consideration in a neurologic assessment. When pupils are sluggish to respond, this indicates neurologic impairment. A mild headache is an expected finding. If severe or accompanied by other symptoms, headache could be serious, but as stated, the change in pupil response is a more serious finding. The Glasgow Coma Scale (GCS) is used to assess the extent of neurologic impairment; a score of 15 is normal. Moving away from noxious stimuli is a normal and expected response.
A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond? "The client's ICP was elevated but now has returned to normal." "The client's ICP remains elevated." "The client's ICP is within normal limits." "The client's ICP has decreased to lower than normal limits."
"The client's ICP remains elevated." Explanation: A normal ICP is between 0 and 15 mm Hg. The documentation shows pressures greater than 15 mm Hg
The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.
Explanation: Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. For this client, pulse pressure is 170 - 80 = 90.
Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? Initiate oral feedings. Monitor head circumference. Provide age-appropriate diversionary activities. Allow the infant to rest undisturbed.
Monitor head circumference. Explanation: In the postoperative period, the nurse carefully monitored the head circumference to ensure it is not increasing or decreasing too rapidly. Feedings should start when the infant is fully awake. The infant will need to be disturbed to check vital signs and be repositioned. Age-appropriate activities are important but not until the infant is awake and less fussy.
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches their back (see figure). What action should the nurse take first? Pad the side rails of the crib. Notify the health care provider (HCP). Stroke the back to release the arching. Place the child prone.
Notify the health care provider (HCP). Explanation: The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the HCP immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the first action is to notify the HCP. Placing the child in a prone position will not relieve the herniation or release the arching.
The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply. The test may require removal of watches, bracelets, or earrings. It is necessary to report any known allergies to iodine or seafood prior to the procedure. Throat irritation and facial flushing may occur if contrast dye is used. All medications must be withheld for 12 hours prior to the procedure. A contrast dye may be given before the test. The CT scan is considered an invasive procedure, but not dangerous.
The test may require removal of watches, bracelets, or earrings. A contrast dye may be given before the test. Throat irritation and facial flushing may occur if contrast dye is used. It is necessary to report any known allergies to iodine or seafood prior to the procedure. Explanation: The nurse would inform the client who is scheduled to undergo a CT scan that a contrast medium may be administered before the procedure and that the dye can cause throat irritation and facial flushing. Because the dye is iodine based, it is essential for the client to report any known allergies to iodine or seafood before testing begins. Removal of watches, bracelets, or earrings or other metal objects may be needed if they interfere with the test. The CT scan is not invasive or dangerous. The client will not be able to take routine medications for 12 to 24 hours beforehand, depending upon the medication.
The nurse is assessing a client for potential subdural hematoma development after a head injury. Which manifestation does the nurse anticipate seeing first? alteration in level of consciousness raccoon eyes and battle sign slurred speech bradycardia
alteration in level of consciousness Explanation: The first sign of possible subdural hematoma is a change in level of consciousness. Raccoon eyes (bruising around the eyes) and battle sign (bruising behind the ears) are seen with a basilar skull fracture. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia occurs later if the condition isn't treated.
A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication? use of the standing position to void lateral rotation of the head and neck nonproductive cough clear yellowish fluid on the dressing
clear yellowish fluid on the dressing Explanation: Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? unequal pupil size decreasing body temperature decreasing systolic blood pressure tachycardia
unequal pupil size Explanation: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply. wrist pronation. stiff extension of the arms and legs. plantar flexion of the feet. opisthotonos. flexion of the arms and wrists with internal rotation
wrist pronation. stiff extension of the arms and legs. plantar flexion of the feet. opisthotonos. Explanation: Decerebrate posture, which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.
A new parent asks, "When will the soft spot near the front of my baby's head close?" When should the nurse tell the parent the soft spot will close? 2 to 3 months 12 to 18 months 6 to 8 months 9 to 10 months
12 to 18 months Explanation: Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniosynostosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months.
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? Encourage coughing and deep breathing. Administer stool softeners. Position the client with the head turned toward the side of the brain tumor. Provide sensory stimulation.
Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the partial pressure of arterial carbon dioxide (PaCO2) between 25 and 29 mm Hg and the partial pressure of arterial oxygen (PaO2) between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal? Decrease intracranial pressure. Ensure a patent airway. Produce hypoxia. Lower the arousal level.
Decrease intracranial pressure. Explanation: Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.
The nurse is planning care for a client with Parkinson disease who is experiencing freezing of gait with difficulty initiating movement. Which action should the nurse take? Tell the client to march in place. Have the client remain still. Instruct the client to use a wheelchair. Pull the client forward to initiate walking.
Tell the client to march in place. Explanation: When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.
Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury? widened pulse pressure atonic urinary bladder hyperactive reflexes flaccid paralysis
hyperactive reflexes Explanation: Spinal shock causes a loss of reflex activity below the level of the injury, resulting in bladder atony and flaccid paralysis. When the reflex arc returns, it tends to be overactive, resulting in spasticity. The reflexes and bladder become hypertonic during this phase of spinal shock resolution; sensation does not return. A widened pulse pressure is not associated with resolution of spinal shock.
A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention? increasing the rate of IV fluids contacting the physician reassessing vital signs in 15 minutes inserting a Foley catheter to monitor urine output
contacting the physician Explanation: The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.
A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention? reassessing vital signs in 15 minutes increasing the rate of IV fluids contacting the physician inserting a Foley catheter to monitor urine output
contacting the physician Explanation: The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.
The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test? changes in certain body chemicals, which are altered in depression cortisol levels after the system is challenged the amount of dexamethasone in the system cortisol levels before and after the system is challenged with a synthetic steroid
cortisol levels before and after the system is challenged with a synthetic steroid Explanation: The dexamethasone suppression test measures cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test does not measure dexamethasone or body chemicals altered in depression. Dexamethasone is used to challenge the cortisol level.
A client has sustained a head injury and is to receive mannitol by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find: increased cerebral circulation causing increase in mental alertness. decreased cerebral edema. increased lung expansion and ease of breathing. decreased cardiac workload.
decreased cerebral edema. Explanation: Mannitol, an osmotic diuretic, is used to decrease cerebral edema in clients with head injuries. The other choices are not correct results of mannitol.
The nurse is administering a thrombolytic drug to a client who has had a stroke. What is the expected outcome of this drug? prevention of hemorrhage vasoconstriction increased vascular permeability dissolved blood clot
dissolved blood clot Explanation: Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
The nurse is planning care for a client with a head injury who is at risk for increased intracranial pressure (ICP). Which activity should the nurse instruct the client to avoid? deep-breathing exercises vigorous coughing passive range-of-motion (ROM) exercises turning
vigorous coughing Explanation: Vigorous coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. If the client has a cough, the nurse can consider requesting a prescription for a cough suppressant. The client can continue deep-breathing exercises. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? dilated, fixed pupils decrease in the pulse rate widening pulse pressure decrease in the level of consciousness (LOC)
decrease in the level of consciousness (LOC) Explanation: A decrease in the client's LOC is an early indicator of the deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, a decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated
The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor? protecting the visitor's head with a pad to prevent injury restraining the visitor to prevent harm placing an object between the teeth to prevent airway obstruction laying the visitor on the back
protecting the visitor's head with a pad to prevent injury Explanation: Protect the head with a pad to prevent injury from striking hard surfaces during the seizure. After the visitor begins to have a seizure, nothing should be attempted to be inserted into the mouth. Broken teeth and injury to the mucosa may result. The visitor should be placed on the side if at all possible to facilitate drainage of saliva and mucus.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? dilated, fixed pupils decrease in the level of consciousness (LOC) widening pulse pressure decrease in the pulse rate
pupil size and response Explanation: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, though it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for a client with a thrombotic stroke without heart problems.
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client 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? irregular breathing pattern involuntary posturing pupillary asymmetry declining level of consciousness (LOC)
declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include diminished responsiveness. pupillary changes. decreasing blood pressure. elevated temperature.
diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage? head elevated on two pillows head of the bed elevated to 30 degrees side-lying on the left side flat with the head turned to the right
head of the bed elevated to 30 degrees Explanation: The head of the bed should be elevated 30 degrees to promote venous drainage and decrease intracranial pressure. The client's head should be in a midline, or neutral, position. Clients with supratentorial surgery should be positioned on the nonoperative side to prevent displacement of the cranial contents by gravity.
A full-term neonate is suspected of having hydrocephalus. The nurse collects what assessment finding to best assist in confirming the diagnosis? decreased level of consciousness increased body temperature increasing occipital frontal circumference evidence of seizure activity
increasing occipital frontal circumference Explanation: Hydrocephalus is an increase in cerebrospinal fluid in the ventricles of the brain. The nurse should assess the infant's head circumference and note any increases. Hydrocephalus is associated with an increased occipitofrontal diameter. When palpated, the head has widened sutures with wide, open fontanels. Typically the fontanels will feel tense and bulging. Other, less specific signs of hydrocephalus include poor feeding, "setting sun" eyes, vomiting, lethargy, prominent veins, and seizure activity due to increased intracranial pressure. Meningitis can develop and result in fever.
A client is receiving intravenous mannitol for treatment of a brain tumor. The client's intracranial pressure before administration of the mannitol was 14 mm Hg. Which assessment finding indicates that the medication is attaining a therapeutic effect? intracranial pressure of 10 mm Hg systolic blood pressure of 90 mm Hg decreased peripheral edema decreased agitation
intracranial pressure of 10 mm Hg Explanation: An expected finding with this osmotic diuretic is an intracranial pressure of 5-15 mm Hg. The medication is not administered to decrease agitation, lower systolic blood pressure, or decrease peripheral edema. The main therapeutic effect in brain tumor management is to decrease intracranial pressure.
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? hypotension and tachycardia hypertension and narrowing pulse pressure hypotension and bradycardia rising blood pressure and bradycardia
rising blood pressure and bradycardia Explanation: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready
The emergency department nurse has admitted an infant with bulging fontanelles, setting sun eyes, and lethargy. Which diagnostic procedure would be contraindicated in this infant? computerized tomography scan magnetic resonance imaging arterial blood draw lumbar puncture
lumbar puncture Explanation: The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk for herniation. Magnetic resonance imaging and a computerized tomography scan are indicated in children with suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP, such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client. However, there is no contraindication for performing an arterial blood draw on a child with increased ICP.
An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority? monitor oxygenation and temperature monitor intracranial pressure maintain the head in a neutral position maintain normoglycemia and normotension
monitor intracranial pressure Explanation: Increased intracranial pressure (ICP) contributes to increasingly severe pathology, including potential for brain stem herniation, so monitoring and maintaining stable intracranial pressure is the priority. Systemic parameters and intracranial parameters are both essential though. The nurse takes actions to keep the intracranial pressure low by controlling factors that can cause elevated ICP; these action include monitoring for changes in oxygenation, temperature, glucose, blood pressure, and heart rhythm and rate. Maintaining the head in a neutral position is essential to keeping ICP within the desired limits.
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective if the client does not develop which complication?
seizures Explanation: Generalized seizures may occur on the second or third day of withdrawal from barbiturates. Without treatment, the seizures may be fatal.Psychosis is a possibility but is not fatal and will not be prevented by the pentobarbital sodium regimen.Orthostatic hypotension is possible but is unlikely to be fatal; it is also not treatable by the pentobarbital sodium regimen.Hyperthermia, rather than hypothermia, occurs during withdrawal
A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of their lorazepam and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. What should the nurse do in order of priority from first to last? All options must be used. 1Place seizure pads on the cart rails. 2Record the time, duration, and nature of the seizures. 3Ask the friend about the client's medical history and current medications. 4Obtain a stat prescription for diazepam.
Obtain a stat prescription for diazepam. Place seizure pads on the cart rails. Record the time, duration, and nature of the seizures. Ask the friend about the client's medical history and current medications. Explanation: The nurse should first obtain a stat prescription for diazepam and administer it to stop the status epilepticus. The nurse should next prevent injury by using seizure pads. Recording the time, duration, and nature of the seizures will be important for ongoing treatment. Finally, the nurse can attempt to obtain information about medication use and abuse history from the friend until the client is able to do so for themself.
A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? Check vital signs and level of consciousness; then place the client in a quiet area with a family member. Monitor the level of agitation and, when the client calms down, refer to the community addiction team. Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Notify the emergency physician and request a telephone order for sedation. Administer the medication and place the client in a quiet place for monitoring.
Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Explanation: This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.
The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise? padded side rails oxygen mask and bag system at bedside lorazepam for seizure lasting longer than 5 minutes padded tongue blade at the bedside
padded tongue blade at the bedside Explanation: The nurse should revise a care plan that includes padded tongue blades. Nothing should be placed in the mouth during a seizure. Padded side rails will protect the child from injury during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do not, then a dose of lorazepam can be administered. The healthcare provider will prescribe the correct dosage for weight and the parameters for administering.
The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise? padded side rails padded tongue blade at the bedside oxygen mask and bag system at bedside lorazepam for seizure lasting longer than 5 minutes
padded tongue blade at the bedside Explanation: The nurse should revise a care plan that includes padded tongue blades. Nothing should be placed in the mouth during a seizure. Padded side rails will protect the child from injury during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do not, then a dose of lorazepam can be administered. The healthcare provider will prescribe the correct dosage for weight and the parameters for administering.
The nurse is planning care for a client in the first 24 hours after admission for a thrombotic stroke. Which assessment is a priority for the nurse to make during this time? pupil size and response echocardiogram bowel sounds cholesterol level
pupil size and response Explanation: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, though it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for a client with a thrombotic stroke without heart problems.
A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?
15 Explanation: The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points.
Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? hyperbilirubinemia hyperactivity bulging fontanelles increased muscle tone
Explanation: A common finding of IVH is a bulging fontanelle. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe.
An 8-month-old infant is brought to the emergency department following a fall from a high chair and a possible head injury. The parents are distressed because the infant is crying and irritable. The mother asks if she can try to breastfeed the infant. What is the nurse's best response? "We can put you in a private area to feed, but we will need to reassess frequently." "Yes, we recommend calming the child to reduce any increased pressures in the brain." "We can provide a bottle of water because clear fluids are best right now." "Until assessments are complete, we should not give your child anything by mouth."
"Until assessments are complete, we should not give your child anything by mouth." Explanation: The infant should be kept NPO until the possibility of a head injury with increased intracranial pressure is ruled out. The risk for aspiration still exists with providing bottled fluids. It would be inappropriate for the nurse to mention "increased pressures in the brain" in this scenario.
The nurse is teaching a client with seizures to recognize an aura. What should the nurse instruct the client to notice as indicating the onset of an aura? a symptom that occurs just before a seizure a hallucination that occurs during a seizure a feeling of relaxation as the seizure begins to subside a postictal state of amnesia
a symptom that occurs just before a seizure Explanation: An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? infection high blood pressure coma apnea
infection Explanation: The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? occipital parietal frontal temporal
occipital Explanation: The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.
A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating? Assist the client in learning to eat with the left hand. Continue feeding the client until the hemiplegia resolves. Have a family member assist with feeding at mealtimes. Request a diet of thickened liquids that can be taken through a straw.
Assist the client in learning to eat with the left hand. Explanation: It is important to involve the client in care. The client will need to learn to eat with the non-dominant hand. Promoting independence and supporting attainment of this skill will help the client positively meet the goal of rehabilitation. Feeding the client or having the family feed the client does not promote independence. The client is not having difficulty chewing or swallowing, so a thickened liquid diet is not needed.
The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which sign(s) or symptom(s)? Select all that apply. mood swings emesis headache bulging fontanelle irritability
irritability bulging fontanelle emesis Explanation: Irritability, bulging fontanelle, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? tachycardia decreasing body temperature unequal pupil size decreasing systolic blood pressure
unequal pupil size Explanation: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
A 5-year-old child has been placed on phenytoin for tonic-clonic seizures. The child weighs 42 lb (19.1 kg), and the maintenance dose prescribed for this child is 7.5 mg/kg per day. How many milligrams should the child receive each day? (Round to the nearest whole number.) mg/day
143 Explanation: Determine the dose by multiplying the child's weight by the dose prescribed: 19 kg × 7.5 mg/kg/day = 143 mg/day
The nurse is administering a thrombolytic drug to a client who has had a stroke. What is the expected outcome of this drug? vasoconstriction dissolved blood clot increased vascular permeability prevention of hemorrhage
dissolved blood clot Explanation: Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
The nurse is planning care for a client with a head injury who is at risk for increased intracranial pressure (ICP). Which activity should the nurse instruct the client to avoid? vigorous coughing deep-breathing exercises turning passive range-of-motion (ROM) exercises
vigorous coughing Explanation: Vigorous coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. If the client has a cough, the nurse can consider requesting a prescription for a cough suppressant. The client can continue deep-breathing exercises. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.
Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma? disorientation, increasing blood pressure, bradycardia, and bradypnea presence of the corneal blink response, drooling, tachycardia, and tachypnea eye opening response when spoken to, verbal response, and spontaneous purposeful movements verbal and motor responses, reactive constricting pupils, and hypoventilation
disorientation, increasing blood pressure, bradycardia, and bradypnea Explanation: Alterations in consciousness and disorientation over the past 2 hours are indicative of increased intracranial pressure. Vital sign changes also indicate the vasomotor control centers in the brain are affected, resulting in increased pulse pressure and bradycardia. Bradypnea indicates that the respiratory center is also affected. Each of the other choices represents normal findings on a Glasgow coma scale, except for hypoventilation.
A nurse is caring for an infant with meningitis. Which assessment finding would provide the most accurate confirmation of increased intracranial pressure (ICP)? brisk accommodation of pupils evidence of opisthotonic posturing bulging fontanels when crying inconsolable crying while being held
evidence of opisthotonic posturing Explanation: Opisthotonic posturing is decerebrate posturing where the neck and back are arched posteriorly. An infant lying in an opisthotonic position is exhibiting a sign of increased ICP. This position alleviates discomfort associated with meningitis. Fontanels may be bulging with increased ICP, but fontanels may also bulge when the infant cries under normal circumstances, so this not a definitive sign. Inconsolable crying while being held may indicate an increase in ICP, but it is not definitive, as this could also be indicative of gastric distress or other discomfort. Pupillary reaction is expected to be brisk and is a normal finding.
An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority? Monitor oxygenation and temperature. Maintain normoglycemia and normotension. Monitor intracranial pressure. Maintain the head in a neutral position.
Monitor intracranial pressure. Explanation: Increased intracranial pressure contributes to increasingly severe pathology, including potential for brain stem herniation, so monitoring and maintaining stable intracranial pressure is priority. Systemic parameters and intracranial parameters are both essential, though. The nurse takes actions to keep the intracranial pressure low by controlling factors that can cause elevated ICP such as monitoring for changes in oxygenation, temperature, glucose, blood pressure, and heart rhythm and rate. Maintaining the head in a neutral position is essential to keeping ICP within the desired limits.
A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first? Assess the infant's vital signs in the triage area and instruct the family to wait until their names are called. Notify the supervisor that an operating room is needed because the physician will want to insert a ventriculoperitoneal (VP) shunt. Move the family to an area where an assessment can be completed and call for a physician. Call child protective services because of suspected child endangerment.
Move the family to an area where an assessment can be completed and call for a physician. Explanation: A head injury in an infant can be extremely serious. The nurse's priority should be to move the infant and family to an area where assessment and treatment can occur. Triaging the infant and having the parents wait for evaluation by a physician is inappropriate because of the potential seriousness of the injury. Although increased intracranial pressure can result from head trauma, it's unlikely that inserting a VP shunt would be the first treatment. The fact that the child was left unattended in an unsafe location is a significant safety issue, but notifying child protective services isn't a priority at this time.
The emergency department nurse has admitted an infant with bulging fontanelles, setting sun eyes, and lethargy. Which diagnostic procedure would be contraindicated in this infant? arterial blood draw magnetic resonance imaging computerized tomography scan lumbar puncture
lumbar puncture Explanation: The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk for herniation. Magnetic resonance imaging and a computerized tomography scan are indicated in children with suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP, such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client. However, there is no contraindication for performing an arterial blood draw on a child with increased ICP.
The parents of an 8-month-old infant have brought the child to the emergency department after falling from the high chair. The nurse takes immediate actions for increased intracranial pressure (ICP) based on what assessment finding? depressed fontanel and raccoon eyes bradycardia and pupils that are 3+ in size irritability and increased respiratory rate lethargy and sluggish pupils
lethargy and sluggish pupils Explanation: With increased ICP, the child would have changes in behavior such as inconsolable irritability, an increase in sleepiness or lethargy, a cry that is shrill or high-pitched, vomiting, and pupils that are sluggish to react or nonreactive. An increased respiratory rate combined with irritability could be stress-related and is not as strong an indicator of increased ICP compared to the combination of lethargy and sluggish pupils. A depressed fontanel is indicative of dehydration; raccoon eyes suggest a skull fracture. A 3+ pupil size could be considered normal. The child could have tachycardia or bradycardia depending on the degree of increase in ICP.
A charge nurse is educating a new nurse on antipsychotic medications. The charge nurse knows teaching has been effective when the new nurse makes which statement? "Antipsychotic medication binds to opiate receptors in the central nervous system and alters the response to pain." "Antipsychotic medication stops the breakdown of monoamine neurotransmitters, which keep the brain's concentration of neurotransmitters steady." "Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine." "Antipsychotic medication blocks the effect of acetylcholine at the myoneural junction."
"Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine." Explanation: Antipsychotic medications, also known as neuroleptic medications, work by blocking the transmission of dopamine and the reuptake of norepinephrine and serotonin. Monoamine oxidase inhibitor antidepressants work by stopping the breakdown of monoamine neurotransmitters. Neuromuscular-blocking agents block the effect of acetylcholine at the myoneural junction, and opioids bind to receptors and alter the pain response.
Which statement indicates that a client understands the nurse's teaching about phenytoin for the diagnosis of seizures? "This medication can help reduce my anxiety." "This medication may keep me awake." "I will only be on this type of medication for a short while." "This medication will not cure my disease."
"This medication will not cure my disease." Explanation: Phenytoin is an antiseizure medication and it will not cure seizures. Most clients are on antiseizure medications for a lifetime, and one of the side effects of phenytoin is drowsiness. Phenytoin does not reduce anxiety.
A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The parent questions pain medication for home. Which response by the nurse is most appropriate? "Pain medication is avoided after a head injury to avoid hiding a worsening condition." "Your child has a mild concussion; acetaminophen can be given." "Opioid medications may lead to vomiting, which increases the intracranial pressure (ICP)." "Maybe the health care provider will prescribe ibuprofen for the head pain."
"Your child has a mild concussion; acetaminophen can be given." Explanation: Following MRI of the brain, it is confirmed that there is no bleeding on the brain; thus, pain medication may be administered. The mother asks for medication for a headache. The most appropriate response is that acetaminophen may be given. Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP); therefore, it would not be given. Also, this level of analgesia is not typically given for mild concussions. Ibuprofen is a common over-the-counter pain reliever; however, ibuprofen is a nonsteroidal anti-inflammatory medication, which reduces the ability of the blood to clot.
After the nurse explains to a primiparous client the causes of her neonate's cranial molding, which statement by the client indicates the need for further instruction? "The molding will usually disappear in a couple of days." "The molding was caused by an overlapping of the baby's cranial bones during my labor." "The amount of molding is related to the amount and length of pressure on the head." "Brain damage may occur if the molding does not resolve quickly."
"Brain damage may occur if the molding does not resolve quickly." Explanation: The parent needs further instruction if they say the molding can result in brain damage. Brain damage is highly unlikely. Molding occurs during vaginal birth when the cranial bones tend to override or overlap as the head accommodates to the size of the birth parent's birth canal. The amount and duration of pressure on the head influence the degree of molding. Molding usually disappears in a few days without any special attention.
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the partial pressure of arterial carbon dioxide (PaCO2) between 25 and 29 mm Hg and the partial pressure of arterial oxygen (PaO2) between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal? Produce hypoxia. Decrease intracranial pressure. Ensure a patent airway. Lower the arousal level.
Decrease intracranial pressure. Explanation: Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.
