Med Surg II - Chapt 66 - Management of Pts with Neurologic Dysfunction
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a) 70 mm Hg b) 60 mm Hg c) 50 mm Hg d) 80 mm Hg
A) 70 mm Hg Explanation: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a) Increased ICP b) Exacerbation of uncontrolled hypertension c) Increase in cerebral perfusion pressure d) Infection
A) Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a) Lethargy and stupor b) Hypertension c) Bradycardia d) A bounding pulse
A) Lethargy and stupor Correct Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? (Select all that apply.) a) Loosening constrictive clothing b) Providing for privacy c) Restraining the patient to avoid self injury d) Positioning the patient on his or her side with head flexed forward e) Opening the patient's jaw and inserting a mouth gag
A) Loosening constrictive clothing D) Positioning the patient on his or her side with head flexed forward B) Providing for privacy Explanation: During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. 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. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a) Notify the physician of a possible cerebrospinal fluid leak. b) Give the patient some mouthwash to gargle with. c) Ask the patient to cough to observe the sputum color and consistency. d) Request an antihistamine for the postnasal drip.
A) Notify the physician of a possible cerebrospinal fluid leak. Correct Explanation: Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.
The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS? a) Oligoclonal bands b) IV administration of edrophonium c) An elevated acetylcholine receptor antibody titer d) Episodes of muscle fasciculations
A) Oligoclonal bands Correct Explanation: Electrophoresis of the CSF, a technique for electrically separating and identifying proteins, demonstrates abnormal immunoglobulin G bands, described as oligoclonal bands. An elevated acetylcholine receptor antibody titer and IV administration of edrophonium are diagnostic of Mysthenia Gravis. Episodes of muscle fasciculations are characteristic of ALS.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? a) Vasopressin b) Furosemide (Lasix) c) Mannitol d) Phenobarbital
A) Vasopressin Correct Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.
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? a) Absence b) Generalized c) Jacksonian d) Sensory
B) Generalized Correct 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 client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? a) Change in level of consciousness b) Vector bites c) Seizures d) Vomiting
B) Vector bites Explanation: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in LOC, vomiting, and seizures are all symptoms of increased ICP and due not assist in the differentiating of cause, diagnosis, or establishing nursing care.
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? a) Amiodarone (Cordarone) b) Verapamil (Calan) c) Metoprolol (Lopressor) d) Captopril (Coreg)
B) Verapamil (Calan) Explanation: Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channels blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and captopril aren't used to treat migraines.
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a) 12 b) 6 c) 3 d) 9
C) 3 Correct Explanation: 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 (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? a) Document medication given and dose. b) Assess client's reaction to new medication schedule. c) Administer medications at exact intervals ordered. d) Give client plenty of fluids with medications.
C) Administer medications at exact intervals ordered. Correct Explanation: He or she must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? a) The type of anticonvulsant prescribed to manage the epileptic condition b) Recent weight gain and loss c) Compliance with the prescribed medication regimen d) Recent stress level
C) Compliance with the prescribed medication regimen Correct Explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a) 100 to 150 mL/h b) 50 to 100 mL/h c) More than 200 mL/h d) 150 to 200 mL/h
C) More than 200 mL/h Explanation: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? a) Excessive urine output and serum hyponatremia b) Excessive urine output and decreased urine osmolality c) Oliguria and serum hyponatremia d) Oliguria and serum hyperosmolarity
C) Oliguria and serum hyponatremia Correct Explanation: SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute. (less)
A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a) Maintaining adequate hydration b) Administering prescribed antipyretics c) Restricting fluid intake and hydration d) Hyperoxygenation before and after tracheal suctioning
C) Restricting fluid intake and hydration Correct Explanation: Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients. A patient with neurological infection should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratory distress
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? a) 20 to 30 mm Hg b) 8 to 15 mm Hg c) 25 to 40 mm Hg d) 0 to 10 mm Hg
D) 0 to 10 mm Hg Explanation: ICP is usually measured in the lateral ventricles, with the normal pressure being 0 to 10 mm Hg, and 15 mm Hg being the upper limit of normal (Hickey, 2009).
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child? a) A tonic-clonic seizure b) A complex seizure c) A partial seizure d) An absence seizure
D) An absence seizure Correct Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? a) Loss of gag reflex and mental confusion b) Mental confusion and pupillary changes c) Complaints of headache and lack of pupillary response d) Decerebrate posturing and loss of corneal reflex
D) Decerebrate posturing and loss of corneal reflex Correct Explanation: Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood presure and temperature, widened pulse pressure, Chenyne-Stokes breathing, projectile vomiting, heimplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he 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? a) Irregular breathing pattern b) Pupillary asymmetry c) Involuntary posturing d) Declining level of consciousness (LOC)
D) Declining level of consciousness (LOC) Correct 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.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a) Obesity b) Osteoarthritis c) Anemia d) Osteoporosis
D) Osteoporosis Correct Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
Which of the following positions should be utilized after supratentorial intracranial surgery? a) Body and head aligned b) Bed rest with a firm mattress and bed board c) Sitting position d) Supine position with head slightly elevated
D) Supine position with head slightly elevated Correct Explanation: After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. Bed rest with a firm mattress and bed board is used for patients with a lumbar herniated disk. Sitting position and body and head aligned are the correct positions to place the patient after the surgery.
Which interventions are appropriate for a patient with increased ICP? Select all that apply. a) Administering prescribed antipyretics b) Frequent oral care c) Elevating the head of the bed at 90 degrees d) Encouraging deep breathing and coughing every 2 hours e) Maintaining aseptic technique with the intraventricular catheter
Which interventions are appropriate for a patient with increased ICP? Select all that apply. You selected: A) Administering prescribed antipyretics B) Frequent oral care E) Maintaining aseptic technique with the intraventricular catheter Correct Explanation: Controlling a fever is an important intervention for a patient with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate for control of fevers. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the patient is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a patient with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated at 30 to 45 degrees and in a neutral position to allow for venous drainage.