Neurological Exam part 3
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? 1. Semi-Fowler's 2. Prone 3. High-Fowler's 4. Supine
ANSWER: 1. Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon's eyes and Battle sign.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
Take daily weights.
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
The client has cerebral spinal fluid (CSF) leaking from the ear.
A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number ONLY.
97.5143 lbs/2.2 = 65 kg. 65 kg x 1.5 = 97.5 grams.
Which signs are manifestations of the Cushing triad? Select all that apply. A. Hypertension B. Bradycardia C. Bradypnea D. Tachycardia
ANSWER: A. Hypertension B. Bradycardia C. Bradypnea
Which is a late sign of increased intracranial pressure (ICP)? A. Slow speech B. Headache C. Altered respiratory patterns D. Irritability
ANSWER: C. Altered respiratory patterns
The nurse reviews the physician's emergency department progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign. The nurse knows that the physician observed which clinical manifestation?
An area of bruising over the mastoid bone
Which are risk factors for spinal cord injury (SCI)? Select all that apply.- A. Drug abuse B.-Alcohol use - C,Female gender - D. Young age - E.Caucasian ethnicity
Answer: -D, Young age- B. Alcohol use- A. Drug abuse The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.
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. Oliguria and serum hyponatremia C. Oliguria and serum hyperosmolarity D. Excessive urine output and decreased urine osmolality
ANSWER: C. Oliguria and serum hyponatremia
Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?- A. Extradural hematoma - B. Epidural hematoma - C. Subdural hematoma - D. Intracerebral hemorrhage
ANSWER: C. Subdural hematoma
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified -A. subacute - B. intracerebral - C. acute - D. chronic
ANSWER: C. acute Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury
The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? A. Limit the diet to clear liquids given through a straw B. Keep the patient on NPO status until swallowing is assessed C. Monitor the patients weight D. Sit with the patient while the patient eats and observe for swallowing difficulties
Answer: B. Keep the patient on NPO status
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?- A. Sterilization is best; it would be difficult to care for a baby in your condition. - B. Birth via surrogate is best because your baby can be implanted in another woman. - C. Conception is not impaired; the birth process is determined with the physician.
Answer: C. Conception is not impaired; the birth process is determined with the physician.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
Elevated 30 degrees
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?
Increased ICP
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
Increased intracranial pressure (ICP)
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care?
Ineffective airway clearance related to altered LOC
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?
Maintenance of a patent airway
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol(Osmitrol) With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling
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?
More than 200 mL/h
The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate?
Place patient in supine position with head slightly elevated.
A client has sustained a traumatic brain injury, with involvement of the hypothalamus. The healthcare team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
Record intake and output.
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?
Restricting fluid intake and hydration
A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate
Shivering
Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane?
Subdural hematoma
A patient with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered
low The normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?- A. Restlessness - B. Change in level of consciousness (LOC) - C. Seizures - D. Pupil changes
ANSWER: B. Change in level of consciousness (LOC
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?
Administer stool softeners.
The nurse who is providing care postoperative for a patient who hasd a craniotomy immediately notifies the surgeon of which assessment finding? A. Drainage in the Jackson-Pratt container of 45ml/8 hrs. B. Intracranial pressure of 15 mm Hg C. Pco2 level of 35 mm Hg D. Serum sodium of 117 mEq/L
Answer: D. Serum sodium level
Following a left hemisphere stroke, the patient has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? A. Repeat the names of objects on a routine basis B. face the patient and speak slowly and clearly c. Obtain a whiteboard with an erasable marker D. Develop a picture board that has objects and activities
Answer: D. develop a picture board that has objects and activities
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA)
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulnessExplanation:
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following reasons?
To dehydrate the brain and reduce cerebral edema The initial sign of increasing ICP includes decreased level of consciousness.
Which of the following is accurate regarding a hemorrhagic stroke? 1. It is caused by a large-artery thrombosis. 2. Main presenting symptom is an "exploding headache." 3. One of the main presenting symptoms is numbness or weakness of the face. 4. Functional recovery usually plateaus at 6 months.
ANSWER: .2. Main presenting symptom is an "exploding headache."
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as A. decerebrate. B. normal. C. flaccid. D. decorticate.
ANSWER: A. decerebrate.
The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP?- A. Administer enemas, as needed - B. Position the client in the supine position - C. Restrain the client, as indicated - D. Maintain cerebral perfusion pressure from 50 to 70 mm Hg
ANSWER: D. Maintaining cerebral perfusion pressure from 50 to 70 mm Hg
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?- A. Systolic blood pressure less than or equal to 185 mm Hg B. Intracranial hemorrhage - C. Ischemic stroke - D. Age 18 years or older
ANSWER: E. Intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
Which interventions for a patient with a left hemisphere stroke should a nurse use? Select all that apply: A. Teach the patient to wash both sides of the face B. Place pictures and familiar objects around the patient C. Reorient the patient freqently D. Repeat names of commonly used objects E. Approach the patient from the unaffected side F. Establish a structured routine for the patient
Answer: B,C,D,F
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? 1. Every 30 minutes 2. Every hour 3. Every 45 minutes 4. Every 15 minutes
ANSWER: 4. Every 15 minutes
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? A. Flat Supine, with the head of the bed elevated 30 degrees B. Flat, except for logrolling as needed C. A head elevation of 90 degrees to prevent cerebral swelling
ANSWER: B. Flat, except for logrolling as needed
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?- A. An extradural hematoma - B. An intracerebral hematoma - C. A subdural hematoma - D. An epidural hematoma
ANSWER: B. An intracerebral hematoma
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? 1. Anticoagulant therapy 2. Monthly prothrombin levels 3. Cholesterol-lowering drugs 4. Carotid endarterectomy
ANSWER: 1. Anticoagulant therapy
You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? A. -Paraplegia - B. Tetraplegia - C. Autonomic dysreflexia - D. Areflexia
ANSWER: C. Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
At which level of cord injury does a patient have full head and neck control?- A. C2 - B .C4 - C .C5 - D. C3
ANSWER: C. C5 At level C5, there is full head and neck control. At C1 there is little or no sensation or control of the head and neck. At C2 to C3 there is head and neck sensation and some neck control. At C4 there is good head and neck sensation and motor control.
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:
ANSWER: Loss of motor power and sensation in the upper extremities.
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A. 30-degree head elevation - B. Flat - C. Trendelenburg's - D. Side-lying
ANSWER: A. 30-degree head elevation
Which are characteristics of autonomic dysreflexia?
ANSWER: severe hypertension, slow heart rate, pounding headache, sweatingAutonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? A. -Basilar skull fracture - B. Occipital skull fracture - C. Frontal skull fracture - D. Temporal skull fracture
ANSWER: A. Basilar skull fracture
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- A. Decerebrate - B. Flaccid - C. Normal - D. Decorticate
ANSWER: A. DECEREBRATE
Which of the following is not a manifestation of Cushing's Triad? A. -Bradypnea - B. Tachycardia - C. Hypertension - D. Bradycardia
ANSWER: B. Tachycardia Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
The most important nursing priority of treatment for a patient with an altered LOC is to:- A. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. - B. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. - C. Position the patient to prevent injury and ensure dignity. - D. Maintain a clear airway to ensure adequate ventilation.
ANSWER: D. Maintain a clear airway to ensure adequate ventilation.
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?- A. Edema to the head with bruising of the mastoid process - B. Edema to the head and a blackened eye - C. Edema to the head with fixed pupils - D. Edema to the head with a large scalp laceration
ANSWER: Edema to the head with bruising of the mastoid process
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?- A. Pregabalin (Lyrica)- B. Diphenhydramine (Benadryl)- C. Heparin- D. Lioresal (Baclofen)
ANSWER: Lioresal (Baclofen)
The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury?- A. Cardiogenic shock - B. Tetraplegia - C. Spinal shock - D. Paraplegia
ANSWER: Spinal shock
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as ordered
Which symptoms indicate that a patient's stroke has affected the right hemisphere? Select all that apply: A. Loss of depth perception B. Aphasia C. Denies illness D. Cannot recognize faces e. Loss of hearing F. Depression
Answer: A, C, D, E
The nurse is caring for an intubated patient with increased ICP. If the patient needs to be suctioned, which nursing action does the nurse take to avoid further aggravating the increased ICP? A. Manually hyperventilate with 100% oxygen before passing the catheter B. Maintain strict sterile technique when performing endotracheal suctioning C. Perform oral suctioning frequently, but do not perform endotracheal suctioning D. Obtain an order for an arterial blood gas before suctioning the patient
Answer: A. Hyperventialate with oxygen
A patient has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? A. Nimodipine (Nimotop) B. Phenytoin (dilantin) C. Dexamethasone (Dilantin) D. Clopidogrel (Plavix)
Answer: A. Nimodipine
A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? A. Sinus bradycardia B. Atrial Fibillation C. Sinus tachycardia D. First-degree heart block
Answer: B. A-fib
The nurse is caring for a patient at risk for increased ICP related to ischemic stroke. For what purpose does the nurse place the patient's head in a midline neutral position? A. Provide comfort for the patient B. Protect the cervical spine C. Facilitate venous drainage from the brain D. Decrease pressure from cerebrospinal fluid
Answer: C. Facilitate venous drainage from the brain
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?- A. Examine the rectum for a fecal mass. - B. Examine the skin for any area of pressure or irritation. - C. Empty the bladder immediately. - D. Raise the head of the bed and place the patient in a sitting position.
Answer: D. Raise the head of the bed and place the patient in a sitting position. Raise the head of the bed and place the patient in a sitting position.The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? 1. A ruptured arteriovenous malformation will cause deficits until it is stopped. 2. Thrombolytic therapy has a time window of only 3 hours. 3. A ruptured intracranial aneurysm must quickly be repaired. 4. Intracranial pressure is increased by a space-occupying bleed.
ANSWER: 2. . Thrombolytic therapy has a time window of only 3 hours.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? 1. Cardiogenic emboli 2. Large artery thrombosis 3. Cerebral aneurysm 4. Small artery thrombosis
ANSWER: 2. Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? 1. Monitoring for seizure activity 2. Maintaining a patent airway 3. Elevating the head of the bed to 30 degrees 4. Administering a stool softener
ANSWER: 2. Maintaining a patent airway
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? 1. Phenytoin (Dilantin) 2. Methyldopa (Aldomet) 3. Heparin sodium 4. Dexamethasone (Decadron)
ANSWER: 3. Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? 1. Decreased level of consciousness (LOC) 2. Elevated blood pressure 3. Increased urine output 4. Decreased heart rate
ANSWER: 3. Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? 1. Completed Stroke 2. Right-sided cerebrovascular accident (CVA) 3. Left-sided cerebrovascular accident (CVA) 4. Transient ischemic attack (TIA)
ANSWER: 3. Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? 1. Slow, cautious behavior 2. Aphasia . Altered intellectual ability 4. Left visual field deficit
ANSWER: 4. Left visual field deficit A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke
The ED nurse is receiving a patient-handoff report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestation?- A. An area of bruising over the mastoid bone - B. A bloodstain surrounded by a yellowish stain on the head dressing C. Escape of cerebrospinal fluid from the client's nose - D. Escape of cerebrospinal fluid from the client's ear
ANSWER: A. An area of bruising over the mastoid bone
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. Decerebrate posturing and loss of corneal reflex B. Loss of gag reflex and mental confusion C. Complaints of headache and lack of pupillary response D. Mental confusion and pupillary changes
ANSWER: A. Decerebrate posturing and loss of corneal reflex
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?- A. Ecchymosis over the mastoid - B. Drainage of cerebrospinal fluid from the nose - C. Drainage of cerebrospinal fluid from the ears - D. Bruising under the eyes
ANSWER: A. Ecchymosis over the mastoid
A client with quadriplegia is in spinal shock. What finding should the nurse expect?- A. Hyperreflexia along with spastic extremities - B. Absence of reflexes along with flaccid extremities - C. Spasticity of all four extremities - D. Positive Babinski's reflex along with spastic extremities
ANSWER: B. Absence of reflexes along with flaccid extremities
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? A. Contact the physician to review the care plan. B. Check the equipment. C. Continue the assessment because no actions are indicated at this time. D. Document the reading because it reflects that the treatment has been effective.
ANSWER: B. Check the equipment.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? A. Excessive urine output and serum hypo-osmolarity B. Excessive urine output and decreased urine osmolality C. Oliguria and serum hyperosmolarity D. Oliguria and decreased urine osmolality
ANSWER: B. Excessive urine output and decreased urine osmolality
A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?- A. Assess for a wing sign - B. Assess for bloody drainage - C. Assess for a halo sign - D. Assess for crepitus around the nose
ANSWER: C. Assess for a halo sign
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?- A. Keep the head of the client's bed flat. - B. Avoid sedation. - C. Keep the client's neck in a neutral position (no flexing). - D. Cluster all procedures together.
ANSWER: C. Keep the client's neck in a neutral position (no flexing)
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?- A. Increased intracranial pressure (ICP) B. -Hypertension - C. Headache - D. Bleeding
ANSWER: D. Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.