Prep U Ch 61

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 3 6 9 15

3

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? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg

70 mm Hg

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? Pupillary asymmetry Irregular breat

Declining level of consciousness (LOC)

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? Lamictal Lamisil Labetalol Lomotil

Lamictal

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A bounding pulse Bradycardia Hypertension Lethargy and stupor

Lethargy and stupor

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure began at 1300 hours. The client cried out before the seizure began. Seizure was 1 minute in duration including tonic-clonic activity. Sleeping quietly after the seizure

Seizure was 1 minute in duration including tonic-clonic activity.

A client is having a tonic-clonic seizure. What should the nurse do first? Elevate the head of the bed. Restrain the client's arms and legs. Place a tongue blade in the client's mouth. Take measures to prevent injury.

Take measures to prevent injury.

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements? "A secondary headache is one for which no organic cause can be identified." "A secondary headache is located in the frontal area." "A secondary headache is associated with an organic cause, such as a brain tumor." "A migraine headache is an example of a secondary headache."

"A secondary headache is associated with an organic cause, such as a brain tumor."