Management of Patients With Neurologic Dysfunction
You are caring for a patient who has had transsphenoidal surgery. You know that when a patient has transsphenoidal surgery it is generally for a problem with what? A) Pituitary B) Thalamus C) Hypothalamus D) Foreamen ovale
ANS: A Transsphenoidal surgery is a surgical approach to the pituitary via the sphenoid sinuses.
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Mannitol
ANS: C If a brain tumor is the cause of the increased ICP, corticosteroids (eg, dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and mannitol, an osmotic diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.
What should the nurse suspect when hourly assessment of urine output on a postcraniotomy patient exhibits a urine output from a catheter of 1500 mL for 2 consecutive hours? A) Cushing's syndrome. B) Syndrome of inappropriate antidiuretic hormone C) Adrenal crisis. D) Diabetes insipidus.
ANS: D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
During the examination of an unconscious patient, the nurse notices that the patient's pupils are fixed and dilated. What is the clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.
ANS: D Pupils that are fixed and dilated indicate injury at the midbrain level.
A patient has developed diabetes insipidus after having increased ICP following head trauma. When developing a teaching plan for this patient the nurse should include information about which hormone, commonly lacking in patients with diabetes insipidus? A) Antidiuretic hormone (ADH) B) Thyroid-stimulating hormone (TSH) C) Follicle-stimulating hormone (FSH) D) Luteinizing hormone (LH)
ANS: A ADH is the hormone lacking in diabetes insipidus. The patient's TSH, FSH, and LH levels won't be affected.
Your patient is scheduled for intracranial surgery in the morning. You know that it is important that the patient has adequate preparation for surgery to reduce what? A) Postoperative complications B) Length of time under anesthesia C) Establishing expectations that are too high D) Length of time in the hospital
ANS: A Adequate preparation for surgery, with attention to the patient's physical and emotional status, can reduce the risk of anxiety, fear, and postoperative complications. Adequate preparation for surgery does not reduce the length of time under anesthesia or in the hospital and it does not establish expectations that are too high.
You have a patient with an altered level of consciousness. What would be your first action when assessing this patient? A) Assessing the verbal response B) Assessing if the patient follows commands C) Assessing whether the patient will open their eyes D) Assessing response to pain
ANS: A Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. Therefore options B, C, and D are incorrect.
When caring for a patient with a neurologic dysfunction, what complications must the nurse monitor for? (Mark all that apply.) A) Contractures B) Interrupted family processes C) Pressure ulcer D) DVT E) Pneumonia
ANS: A, C, D, E Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. Interrupted family processes is a nursing diagnosis, not a possible complication.
When the nurse observes that the post-craniotomy patient is unresponsive to and unaware of environmental stimuli, the nurse uses which of the following terms to describe the patient in his documentation? A) Unresponsive B) Comatose C) Demonstrating akinetic mutism D) In a persistent vegetative state
ANS: A Coma is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli, although nonpurposeful responses to painful stimuli and brainstem reflexes may be present. Persistent vegetative state is a condition in which the patient is described as wakeful but devoid of conscious content, without cognitive or affective mental function. In unresponsiveness, the patient is unresponsive to and unaware of environmental stimuli. Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes.
The nursing instructor is discussing increased intracranial pressure (ICP) with the senior nursing students. What would the instructor be correct in telling the students is an early clinical manifestation of ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex
ANS: A Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brainstem reflexes such as the corneal reflex.
When caring for a patient with a neurologic impairment and his or her family, what are the mutual goals? A) Achieve as high a level of function as possible. B) Enhance the quantity of life. C) Teach the family proper care of the patient. D) Provide community assistance.
ANS: A The goals are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. It is not a goal to enhance the quantity of the patient's life or provide community assistance. The scenario does not indicate that the patient needs to be taken care of by the family.
When caring for a patient with increased ICP the nurse must monitor for possible secondary complications. One possible complication of increased ICP is SIADH. What nursing interventions would the nurse initiate if the patient developed SIADH? A) Fluid restriction B) Fluid replacement C) Electrolyte replacement D) Electrolyte restriction
ANS: A The nurse also assesses for complications of increased ICP, including diabetes insipidus and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. You do not "restrict" electrolytes with patients, you monitor them. Diabetes insipidus requires fluid and electrolyte replacement.
A patient with a newly diagnosed seizure disorder is to be discharged home in the morning. You are preparing patient/family teaching and know that a priority to teach the family is what? A) Place the patient in a side-lying position. B) Pad the bed rails. C) Keep a bite block nearby at all times. D) Withhold medication after a seizure.
ANS: A To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. Most patients at home do not have bed rails; a bite block is no longer used in the care of seizure patients; you do not withhold medication from a seizure patient.
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? (Mark all that apply.) A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) EMG
ANS: A, B, C Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.
What diagnostic test is contraindicated in a patient exhibiting clinical manifestations of increased intracranial pressure? A) CT scan B) Lumbar puncture C) MRI D) Venous Doppler studies
ANS: B A lumbar puncture in a client with increased intracranial pressure (ICP) may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. A CT scan, MRI, and venous Doppler are considered noninvasive procedures and would not affect the intracranial pressure itself.
A nurse is caring for a patient admitted with cluster headaches. The nurse knows that in the early phase of a cluster headache what is required? A) Dim lighting B) Abortive medication therapy C) Quiet D) Rest
ANS: B A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Dim lighting, quiet, and rest are necessary for migraines; they are not required in the early phase of a cluster headache.
A clinic nurse is caring for a patient diagnosed with migraine headaches. When doing patient teaching, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about alcohol's effects? A) Alcohol causes hormone fluctuation. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.
ANS: B Alcohol causes vasodilation of the blood vessels. Alcohol has a depressant effect on the central nervous system (CNS). Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.
A school nurse is called to the playground where a 6-year-old girl has fallen off the slide. When the nurse gets to the playground the girl is exhibiting jerking motions in her left arm and leg. The girl is unconscious. How would the nurse document the girl's activity in her chart at school? A) Simple partial seizure B) Complex partial seizure C) Complex generalized seizure D) Simple generalized seizure
ANS: B In a simple partial seizure, consciousness remains intact, whereas in a complex partial seizure, consciousness is impaired.
While completing a health history on a newly diagnosed patient with generalized seizure disorder the nurse would assess for what characteristic associated with the post-ictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity
ANS: B In the post-ictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles which occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the emergency department. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The priority nursing evaluations, when assessing level of consciousness in this patient, would be based on what? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status exam
ANS: B Level of consciousness (LOC), a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Refer to Chart 63-4. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status exam would be part of the neurologic examination for this patient, but would not be the priority in evaluating level of consciousness.
When caring for an unconscious patient what nursing intervention takes highest priority? A) Inserting an indwelling urinary catheter B) Maintaining a patent airway C) Putting a nasogastric (NG) tube in place D) Administering an enema daily
ANS: B Maintaining a patent airway always takes top priority. An indwelling urinary catheter and NG tube can be inserted after airway patency has been established. Enemas should be avoided because of the danger of increasing intracranial pressure.
The nurse is caring for a patient on the neurologic unit who is in status epilepticus. What medications does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbitol (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)
ANS: B Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes intravenous diazepam (Valium) and intravenous lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbitol) are given later to maintain a seizure-free state.
In what position should the nurse place the patient following a craniotomy with a supratentorial approach? A) Position patient flat B) Maintain HOB elevated at 30 to 45 degrees C) Position patient in prone position D) Maintain bed in Trendelenburg position
ANS: B The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment.
The nurse is caring for a postop craniotomy patient. When writing the plan of care, the patient has a diagnosis of Deficient fluid volume related to fluid restriction related to osmotic diuretic use. What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated B) Monitor serum electrolytes C) Maintain NPO status D) Monitor arterial blood gas values
ANS: B The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Changing the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of Risk for imbalanced fluid volume.
A patient with increased intracranial pressure (ICP) has a ventriculostomy for monitoring their ICP. The patient is now exhibiting nuchal rigidity and photophobia. What would the nurse be correct in suspecting has become a complication? A) Encephalitis B) CSF leak C) Meningitis D) Clotted catheter
ANS: C Complications of a ventriculostomy include ventricular infection meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis. Therefore options A, B, and D are incorrect
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to your unit. You would be correct in assessing for what adverse effect of this therapy? A) Bradycardia B) Diarrhea C) Gingivival hyperplasia D) Weight gain
ANS: C Gingivival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Bradycardia, diarrhea, and weight gain are not associated with dilantin therapy. Adverse effects noted with dilantin therapy are tachycardia, constipation, and weight loss
A priority in postoperative management of a patient who has had intracranial surgery is what? A) Reducing pain B) Reducing periorbital edema C) Monitoring ICP D) Preserving seizures
ANS: C Ongoing postoperative management is aimed at detecting and reducing cerebral edema, relieving pain and preventing seizures, and monitoring ICP and neurologic status.
A nurse is admitting a patient with a severe migraine headache. The patient has a history of myocardial infarction in the past year. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)
ANS: C Sumatriptan may cause chest pain and is contraindicated in patients with ischemic heart disease. Adverse effects of sumatriptan succinate include angina, chest pressure, and chest tightness. None of the triptan medications should be taken concurrently with medications containing ergotamine (vascular headache suppressant) due to the potential for a prolonged vasoactive reaction. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.
You have admitted a patient to the Neurolog Intensive Care Unit with a brainstem herniation. The patient is now exhibiting an altered level of consciousness. The nurse has determined that the patient's mean arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values? A) Normal B) High C) Low D) Compensating
ANS: C The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion.
A patient is being admitted to the Neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medications to reduce cerebral edema? A) Hydrochlorothiazide (HydroDIURIL) B) Lasix (Furosemide) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)
ANS: C The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reduces the volume of brain and extracellular fluid. Spirolactone, Lasix, and Hydrochorothiazide are used in the treatment of CHF and hypertension.
During their pathophysiology class the nursing students study seizures. How might the instructor best describe the cause of a seizure? A) Uncontrolled normal electrical charges throughout the brain B) A dysrhythmia in the motor strip of the brain C) A dysrhythmia in the nerve cells in one section of the brain D) Abnormal, recurring, controlled electrical charges in the brain
ANS: C The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by normal electrical charges throughout the brain or controlled electrical charges in the brain. Option B could be correct, but not all seizures arise in the motor strip of the brain.
A patient with a seizure disorder is presenting having a generalized seizure. An appropriate nursing intervention during the seizure would include what? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.
ANS: D An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of Ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.
ANS: D An expected outcome of the diagnosis of Ineffective tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of Disturbed sensory perception. The outcome of Registers normal body temperature relates to the diagnosis of Potential for ineffective thermoregulation. Body image disturbance would have a potential outcome of Pays attention to grooming.
You are discharging a patient home after supratentorial removal of a pituitary mass. What medication would you expect to have ordered prophylactically for this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phentoin
ANS: D Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after these procedures. Prednisone and dexamethasone are steroids. Cafergot is used in the treatment of migraines.
A patient is considered terminal after being involved in a motor vehicle accident in which they received massive trauma to the head. As the patient's ICP increases and condition worsens, the family asks you what indications of approaching death will there be. What would be your best response? A) "There is a change in the pattern of their respirations." B) "Projectile vomiting and hemiplegia usually occur just before death." C) "Posturing may develop as pressure on the brainstem increases." D) "Loss of brainstem reflexes is a sign of approaching death."
ANS: D As ICP increases, the patient's condition worsens, as manifested by the following signs and symptoms: the LOC continues to deteriorate until the patient is comatose. The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne-Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brainstem increases. Bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death.
How does the nurse help the patient and family gain control of their lives? A) By providing educational resources in the community B) By offering referrals to community social clubs C) By introducing the patient to other neurologically impaired people in the community D) By collaborating with other members of the health care team
ANS: D The nurse collaborates with other members of the health care team to provide essential care, offer a variety of solutions to problems, help the patient and family gain control of their lives, and explore the educational and supportive resources available in the community. The nurse does not provide educational resources in the community, provide introductions to others who are neurologically impaired, or refer patients to social clubs
The causes of acquired seizures include what? (Mark all that apply.) A) Cerebrovascular disease B) Metabolic and toxic conditions C) Hypernatremia D) Brain tumor E) Drug and alcohol addiction
ANS: D The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies.
