Module 11 -Intracranial Regulation
11. You're assessing a patient who recently experienced a focal type seizure (partial seizure). As the nurse, you know that which statement by the patient indicates the patient may have experienced a focal impaired awareness (complex partial) seizure? A. "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." B. "I remember having vision changes, but it didn't last long." C. "I woke up on the floor with my mouth bleeding." D. "After the seizure I was very sleepy, and I had a headache for several hours."
A
14. A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A. "Every morning I take this medication with a full glass of milk with my breakfast." B. "I know it is important to have my drug levels checked regularly." C. "I will report a skin rash immediately to my doctor." D. "This medication can lower my body's ability to clot and fight infection."
A
2) A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which interventions should the nurse prepare to implement? A) Assess airway, breathing, and circulation. B) Assess patency of the Foley catheter. C) Treat the client's pain. D) Get a complete history from the client.
A
7) The nurse is caring for a child with decreased level of consciousness secondary to increased intracranial pressure (IICP) from a head trauma. Which order from the healthcare provider should the nurse question? A) Passive range-of-motion exercises B) Elevating the head of the bed to 30° C) Vital signs and neuro checks every hour D) Administering oxygen at 2 L nasal cannula to keep saturation above 95%
A
6) The nurse makes a visit to the home of an adolescent recently discharged from the hospital for a seizure disorder. Which observations indicate that outcomes for care have been achieved? Select all that apply. A) The client is not driving. B) The client has not had a seizure for 1 month. C) The client is participating in the school basketball team. D) The client has bruises on both arms from seizure activity. E) The client has several episodes of constipation each week.
A, B, C
4) The nurse identifies the diagnosis Risk for Trauma as appropriate for a client with a seizure disorder. Which nursing interventions should be done if the client has a seizure? Select all that apply. A) Turn the client to a lateral position, if possible. B) Stay with the client. C) Insert a tongue blade into the client's mouth. D) Call for help. E) Restrain the client.
A, B, D
The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. A. Head tilt B. Vomiting C. Polydipsia D. Lethargy E. Increased appetite F. Increased pulse
A, B, D
2. You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.
A, B, D, E
5) The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. What actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Provide all care quickly at one time to provide periods of rest. E) Keep the room dark and quiet.
A, B, E
6) The nurse is planning care for an older client with a head injury sustained from a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Reflexes are less intense in an older client. C) Impulse transmission and reactions to stimuli are slower. D) The plantar and Achilles reflexes are hyperactive in this age group. E) Impairment in vision and hearing should be taken into consideration.
A, C, E
16. A patient who is having a tonic-clonic seizure is prescribed Phenobarbital. During administration of this drug, it is important the nurse monitors for: A. Respiratory depression B. Hypertension C. Disseminated intravascular clotting D. Hypotension E. Fever
A, D
12. You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions: A. Oxygen and suction at bedside B. Bed in highest position C. Remove all pillows from the patient's head D. Have restraints on stand-by E. Padded bed rails F. Remove restrictive objects or clothing from patient's body G. IV access
A, E, F, G
1) A 10-year-old loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 28 and irregular. What does this vital signs assessment indicate to the nurse? A) Typical for a sleeping child at this age B) A sign of increased intracranial pressure C) Normal for this child D) A sign that this child has a spinal cord injury
B
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
B
4) The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the neurosurgeon during morning rounds. Which diagnostic test results should be on the medication record for the physician's review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Complete blood count of the cerebrospinal fluid
B, C, D, E
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head of bed elevated 30 to 45 degrees B. Head mildline C. Head turned to the side D. Neck in neutral position
C
6) The nurse is providing care to prevent a client recovering from a head injury from developing increased intracranial pressure (IICP). Which assessment information suggests that nursing care has been successful? Select all that apply. A) Body temperature elevated 1 degree in 4 hours B) Absent gag reflex C) Pupils equal and reactive to light D) Oxygen saturation 93% via pulse oximetry E) Sluggish response to verbal stimuli
C, D
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure
D
8) The nurse is planning care for a client with a head injury and increased intracranial pressure (IICP) from a motor vehicle crash. Which intervention is a priority for this client? A) Ensuring adequate oxygenation B) Maintaining a calm environment C) Monitoring for nausea and vomiting D) Controlling pain
A
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases B. Pupils are 8 mm and nonreactive C. Systolic blood pressure remains at 150 mm Hg D. BUN and creatinine levels return to normal
A
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest B. Side-lying, with a pillow under the hip C. Prone, in a slight Trendelenburg's position D. Prone, with a pillow under the abdomen.
A
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A. Ataxia and confusion B. Sodium depletion C. Tonic-clonic seizure D. Urinary incontinence
A
5) While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. What are appropriate interventions for the nurse to teach the family member? Select all that apply. A) The head of the bed should be elevated to 30 degrees. B) The client should remain in a supine position. C) The family should use slow, gentle movements when repositioning the client. D) The client should be repositioned as needed. E) Patients with ICP should remain in a stationary position.
A, C, D
7) A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which classifications of medications should the nurse prepare to administer to this client? Select all that apply. A) Loop diuretics B) Antibiotics C) Anticonvulsants D) Histamine H2 antagonists E) Antipyretics
A, C, D, E
1) The nurse observes a school-age child have an absence seizure. How would the nurse describe this seizure in the client's medical record? A) "Pulled arms in toward the body and flexed hands over the chest. This lasted 2 minutes." B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes." C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes." D) "Sat very still and was unresponsive with a blank stare for 2 minutes."
D
5) The nurse is planning discharge teaching for a child with epilepsy prescribed phenytoin (Dilantin). Which information is important for the nurse to include in these instructions? A) Brush teeth less frequently. B) Take the medication with milk. C) Increase fluid intake. D) Increase vitamin D intake.
D
6. A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-clonic D. Absence
D
8) The nurse is caring for a 1-year-old who starts to have a tonic-clonic (grand mal) seizure while in a crib in the hospital. The child's jaws are clamped shut. What is the most appropriate nursing action? A) Place a tongue blade between the child's jaws. B) Restrain the child to prevent injury. C) Prepare the suction equipment. D) Stay with the child to observe for complications.
D
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: A. 88 mm Hg B. 68 mm Hg C. 48 mm Hg D. 52 mm Hg
D
A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. Phenytoin (Dilantin) B. Mannitol (Osmitrol) C. Furosemide (Lasix) D. Lidocaine (Xylocaine)
D
The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP? A. Decreased systolic blood pressure B. Dilated pupils that don't react to light C. Inability to wake the patient with noxious stimuli D. Headache and vomiting
D
Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg
A
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion
A
10. You're developing discharge instructions to the parents of a child who experiences atonic seizures. What information below is important to include in the teaching? A. "This type of seizure is hard to detect because the child may appear like he or she is daydreaming." B. "Be sure your child wears a helmet daily." C. "It is common for the child to feel extremely tired after experiencing this type of seizure." D. "Avoid high fat and low carbohydrate diets."
B
15. The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? A. Narcan B. Flumazenil C. Calcium Chloride D. Idarucizumab
B
2) A 4-year-old client with myoclonic seizures has been on a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided abdominal pain. Which complication of the ketogenic diet should the nurse suspect the client is experiencing? A) Bowel obstruction B) Renal calculi C) Urinary tract infection D) Appendicitis
B
2) The nurse is caring for a client in the neurological ICU with head trauma. The client is being monitored for increased intracranial pressure (IICP). Using the Monroe-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "There is nothing that can be done." B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." C) "The pressure in the brain is increasing because the brain is shrinking." D) "Because there is more pressure in the brain, the blood flow is also increasing."
B
3) The nurse is caring for an 8-year-old child who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for IICP. The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child develops sunset eyes, it will be important to call the doctor."
B
3) The nurse provides teaching about phenytoin (Dilantin) to the mother of a school-age child with a seizure disorder. Which statement made by the mother indicates that teaching has been effective? A) "I will give his medicine on an empty stomach so he will absorb it better." B) "I will check his gums and increase visits to the dentist." C) "I will use a carbonated beverage to dilute his medication." D) "I will let him chew his tablet."
B
3. A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? A. Assess the patient for a rash B. Initiate seizure precautions C. Hold the next dose of Phenytoin D. Continue to monitor the patient
B
4) The nurse identifies the diagnosis of Interrupted Family Processes for a child who sustained a brain injury during an automobile accident. Which intervention would support this diagnosis? A) Teach the family the importance of using seat belts. B) Encourage the family to express feelings. C) Refer the family to support services in the community. D) Explain rules for visiting in the Intensive Care Unit.
B
4. You're educating a 25-year-old female about possible triggers for seizures. Which statement requires you to re-educate the patient about the triggers? A. "I'm at risk for seizure activity during my menstrual cycle." B. "I will limit my alcohol intake to 2 glasses of wine per day." C. "It's important I get plenty of sleep." D. "I will be sure to stay hydrated, especially during hot weather."
B
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply). A Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B Administer phenytoin (Dilantin) 200 mg PO daily. C Teach patient about the need for good oral hygiene. D Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
B
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues B. Intracranial pressure (ICP) is increased C. The client needs mechanical ventilation D. Blood is anticipated in the cerebralspinal fluid (CSF)
B
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern? A. Signs of sleepiness at 10 PM. B. Repeated vomiting C. Bulging Anterior Fontanel D. Inability to read short words from a distance of 18 inches
B
For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg B. Promote carbon dioxide elimination C. Prevent respiratory alkalosis D. Lower arterial pH
B
Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure? A. Polydipsia B. Increased restlessness C. Tachypnea D. Intermittent tachycardia
B
Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A. Congenital anatomic abnormality of the meninges B. Lack of acquired resistance to the various etiologic organisms C. Occlusion or narrowing of the CSF pathway D. Natural affinity of the CNS to certain pathogens
B
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A. Bladder infection B. Middle ear infection C. Fractured clavicle D. Septic arthritis
B
Whether Mr Snyder's tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except: A. Obvious motor deficits B. Increased pulse rate, drop in blood pressure C. Headache, nausea, and vomiting D. Papilledema, dizziness, mental status changes
B
Which of the following pathologic processes is often associated with aseptic meningitis? A. Ischemic infarction of cerebral tissue B. Childhood diseases of viral causation such as mumps C. Brain abscesses caused by a variety of pyogenic organisms D. Cerebral ventricular irritation from a traumatic brain injury
B
Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? A. Bradycardia B. Restlessness and confusion C. Widened pulse pressure D. Large amounts of very dilute urine
B
Which of the following types of drugs might be given to control increased intracranial pressure (ICP)? A. Histamine receptor blockers B. Barbiturates C. Carbonic anhydrase inhibitors D. Anticholinergics
B
13. You're patient is scheduled for an EEG (electroencephalogram). As the nurse you will: A. Keep the patient nothing by mouth. B. Hold seizure medications until after the test. C. Allow the patient to have coffee, milk, and juice only. D. Wash the patient's hair prior to the test. E. Administer a sedative prior to the test.
B, D
1. Neurons in the brain are tasked with handling and transmitting information. There are different types of neurons, such as excitatory and inhibitory. Excitatory neurons release the neurotransmitter _____________, while inhibitory neurons release the neurotransmitter ________________. A. GABA, glutamate B. Norepinephrine, GABA C. Glutamate, GABA D. Dopamine, glutamate
C
17. An 8-year-old child, who is not responding to anti-seizure medications, is prescribed to start a ketogenic diet. This diet will include: A. High carbohydrates and high fat B. Low fat, high salt, and high carbohydrates C. High fat and low carbohydrates D. High glucose, high fat, and low carbohydrates
C
7) A 78-year-old client is experiencing a tonic-clonic (grand mal) seizure exceeding 10 minutes in length. Which medication should the nurse prepare to administer to this client? A) Intramuscular injection of diazepam B) 5% dextrose solution IV C) Intravenous diazepam slowly over several minutes D) Intravenous bolus of 10% dextrose
C
7. Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Continue assisting the patient to the restroom and let them sit down. B. Initiate the emergency response system. C. Lay the patient down on their side with a pillow underneath the head. D. Assess the patient's medication history.
C
8. Keeping the previous question in mind, the patient is now experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Suction the patient C. Initiate the emergency response system D. Restrain the patient to prevent further injury
C
9. Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness
C
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure B. To prevent acute tubular necrosis C. To promote osmotic diuresis to decrease ICP D. To draw water into the vascular system to increase blood pressure
C
Later signs of increased intracranial pressure (ICP) later include which of the following? A. Decreased blood pressure B. Increased pulse rate C. Projectile vomiting D. Narrowed pulse pressure
C
A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when: A. Client refuses dinner because of anorexia B. Blood pressure is decreased from 160/90 to 110/70 C. Pulse is increased from 88-96 with occasional skipped beat. D. Client is oriented when aroused from sleep, and goes back to sleep immediately
D
