PrepU 66

elevated 30 degrees

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?

CCP is low

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

Turn the client to the side. Provide verbal reassurance.

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.

Using a cervical collar

Which method is used to help reduce intracranial pressure?

Phenobarbital/phenytoin

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Avoiding flexion of the neck with use of a cervical collar

Which positions is used to help reduce intracranial pressure (ICP)?

Mannitol

osmotic diuretic A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Excessive urine output and decreased urine osmolality

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?

Increased ICP is 12 mm Hg.

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Keep a food diary. Maintain a headache diary.

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.

high protein/low carb diet

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

Altered respiratory patterns

Which is a late sign of increased intracranial pressure (ICP)?

"My children are at greater risk to develop this disease."

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?

Generalized

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?

Declining level of consciousness (LOC)

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?

Restricting fluid intake and hydration

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Decorticate.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

flaccid

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

diplopia

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:

damage to optic nerve

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?

Explaining hospice care and services

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Apply warm or cool cloths to the forehead or back of the neck

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client?

lethargy and stupor

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

decreased level of consciousness (LOC)

What is one of the earliest signs of increased ICP?

Rising blood pressure and bradycardia

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?

Decorticate

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Bradycardia Hypertension Bradypnea

Which signs are manifestations of the Cushing triad? Select all that apply.

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid

Reorient the client while gently holding their arms.

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?

generalized

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?

Administer medications at exact intervals ordered.

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?

Osteoporosis

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?

Check the equipment.

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?

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

Ineffective cerebral tissue perfusion

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?

Ensure access to a language board when communicating with the client. Establish a voiding time schedule. Encourage the client to walk with feet wide apart

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply.

increase the frequency of the catheterizations.

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

3

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

Decerebrate posturing and loss of corneal reflex

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?

Maintains a patent airway

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?

Bradycardia Bradypnea Hypertension

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.

unequal response

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

More than 200 mL/h

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?

Give stool softeners

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?

Verapamil (Calan)

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?

Monroe-Kellie

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

diminished responsiveness.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

carefully move the client to a flat surface and turn him on his side.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

Administering a stool softener as ordered

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)?

24-36 hrs

Cerebral edema peaks at which time point after intracranial surgery?

promote carbon dioxide elimination.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

Miasthenia gravis

The initial manifestation of MG usually involves the ocular muscles. Diplopia (double vision) and ptosis (drooping of the eyelids) are common. The majority of patients also experience weakness of the muscles of the face and throat, generalized weakness, and weakness of the facial muscles.

Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy

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.

Administer corticosteroids as ordered.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

drooping eyelids

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?

cluster

While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of 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?

an absence seizure

petite mal seizure The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

chewing

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

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.

Bradypnea Bradycardia Hypertension

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.

poor

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? (decerebrate posture)

brain tumor

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Vasopressin

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?

Hypocortisolism

Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition?