NUR 4770- Exam 1: PrepU Ch. 66 Managment of Pts w/neurologic Dysfunction
15. A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "I will have progressive muscle weakness." "My children are at greater risk to develop this disease." "I will lose strength in my arms." "I need to remain active for as long as possible."
"My children are at greater risk to develop this disease." Explanation: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
27. Cerebral edema peaks at which time point after intracranial surgery? 12 hours 24 hours 48 hours 72 hours
24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.
26. Which value indicates a normal intracranial pressure (ICP)? 5 mm Hg 17 mm Hg 20 mm Hg 27 mm Hg
5 mm Hg Explanation: ICP is usually measured in the lateral ventricles. Pressure measuring 0 to 10 mm Hg is considered normal. The other values are incorrect.
5. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: 48 mm Hg. 88 mm Hg. 52 mm Hg. 68 mm Hg.
52 mm Hg. Explanation: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP) In this case MAP = 60 mm Hg + 1/3(90 mm Hg - 60 mm Hg) = 70 mm Hg CPP = MAP - ICP CPP = 70 mm Hg - 18 mm Hg = 52 mm Hg
1. 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? Administer medications at exact intervals ordered. Give client plenty of fluids with medications. Assess client's reaction to new medication schedule. Document medication given and dose.
Administer medications at exact intervals ordered. Explanation: The nurse 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.
29. The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? Damage to the optic nerve Damage to the vagal nerve Damage to the facial nerve Damage to the olfactory nerve
Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.
11. The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? Sensitivity to bright light Drooping eyelids Muscle spasms Shortness of breath
Drooping eyelids Explanation: Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.
6. A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? Excessive urine output and decreased urine osmolality Oliguria and decreased urine osmolality Oliguria and serum hyperosmolarity Excessive urine output and serum hypo-osmolarity
Excessive urine output and decreased urine osmolality Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.
7. The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? Explaining hospice care and services Managing muscle weakness Offering family support groups Optimizing nutrition
Explaining hospice care and services Explanation: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
10. Which of the following is an early sign of increasing intracranial pressure (ICP)? Decerebrate posturing Vomiting Loss of consciousness Headache
Headache Explanation: A headache that is constant or increases in intensity is considered an early sign of increasing intracranial pressure (ICP). Loss of consciousness, projectile vomiting, and decerebrate posturing are all later signs of increasing ICP.
24. The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. Keep a food diary. Maintain a headache diary. Use St. John's Wort. Sleep no more than 5 hours at a time. Exercise in a dark room.
Keep a food diary. Maintain a headache diary. Explanation: The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.
31. A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? Lethargy Blood pressure 100/60 mm Hg Nausea Periorbital edema
Lethargy Explanation: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.
3. A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Attains desired fluid balance Demonstrates optimal cerebral tissue perfusion Maintains a patent airway Displays no signs or symptoms of infection
Maintains a patent airway Explanation: Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.
18. 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? Excessive urine output and serum hyponatremia Oliguria and serum hyponatremia Excessive urine output and decreased urine osmolality Oliguria and serum hyperosmolarity
Oliguria and serum hyponatremia 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.
4. Which of the following drugs may be used after a seizure to maintain a seizure-free state? Ativan Valium Phenobarbital Cerebyx
Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.
25. A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? Apply oxygen via nasal cannula. Place the client in wrist restraints. Administer lorazepam per orders. Reorient the client while gently holding their arms.
Reorient the client while gently holding their arms. Explanation: Some clients during the postictal phase will become confused and agitated. This reaction is not intentional, and most clients do not later remember becoming agitated. The nurse should attempt to calm and reorient the client, while also gently holding the arms to prevent the client from hitting, thereby preventing the client from doing injury to self or others. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.
21. When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? Hypotension and tachycardia Hypotension and bradycardia Rising blood pressure and bradycardia Hypertension and narrowing pulse pressure
Rising blood pressure and bradycardia Explanation: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.
19. A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. Physically restrain the client's movements. Provide verbal reassurance. Turn the client to the side. Inspect the oral cavity and teeth.
Turn the client to the side. Provide verbal reassurance. Explanation: Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.
12. 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? Furosemide (Lasix) Phenobarbital Mannitol Vasopressin
Vasopressin 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.
22. A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? smelling tasting swallowing chewing
chewing Explanation: Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.
30. When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as decorticate. normal. flaccid. decerebrate.
decerebrate. Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.
8. While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? Tension Migraine Sinus Cluster
Cluster Explanation: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed.
2. A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. Bradycardia Tachycardia Pupillary constriction Hypertension Bradypnea
Bradycardia Bradypnea Hypertension Explanation: At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.
23. A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. Electromyography Appointments for chemotherapy or radiotherapy Adverse effects of chemotherapy or radiation and techniques for managing them Nutritional support Medication regimen
Medication regimen Appointments for chemotherapy or radiotherapy Adverse effects of chemotherapy or radiation and techniques for managing them Nutritional support Explanation: The nurse should include the medication regimen, appointments for chemotherapy and radiotherapy, adverse effects of chemotherapy or radiation and techniques for managing them, and nutritional support as components of the discharge teaching for this client. Electromyography is used in amyotrophic lateral sclerosis (ALS) to validate weakness in the affected muscles and should not be included for the client being discharged after surgery for a brain tumor.
14. A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate. The CPP is high.
The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.
13. 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. Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Positioning the patient on his or her side with head flexed forward Providing for privacy Restraining the patient to avoid self injury SUBMIT ANSWER
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward 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.
16. A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered high. inaccurate. low. within normal limits.
low. Explanation: Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.
28. A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? Diet containing extra sodium Fluid restriction Vasopressin therapy Hypertonic saline solution
Vasopressin therapy Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity. Treatment consists of administration of fluids, electrolyte replacement, and vasopressin therapy. 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. Treatment consists of fluid restriction (less than 800 mL/day with no free water). In severe cases, careful administration of a 3% hypertonic saline solution may be therapeutic.
20. 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? Verapamil (Calan) Metoprolol (Lopressor) Amiodarone (Cordarone) Carvedilol (Coreg)
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 channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.
32. Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Elevating the head of the bed to 90 degrees Frequent oral care
Administering prescribed antipyretics. Maintaining aseptic technique with an intraventricular catheter. Frequent oral care. Explanation: Controlling fever is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate to control a fever. 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 client 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 client with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated to 30 to 45 degrees and in a neutral position to allow for venous drainage.
9. 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? Check the equipment. Document the reading because it reflects that the treatment has been effective. Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time.
Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.
17. The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). The pupils are dilated and fixed. Cerebral perfusion pressure (CPP) is 21 mm Hg. Increased ICP is 12 mm Hg.
Increased ICP is 12 mm Hg. Explanation: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage.
