prepu chapter 37

An older adult man has been diagnosed with Parkinson's disease and has begun treatment with levodopa and carbidopa. When providing health education about his new medication regimen, what should the nurse teach the man?

"This medication helps significantly but the benefits tend to decrease over time."

A client with head trauma is taken to surgery to insert an ICP monitor as signs and symptoms indicating increased ICP have continued to worsen. What increase in ICP (from a previous measurement) is cause for concern?

2 mm Hg

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

3

A client fell at home and sustained a head injury. The client exhibits signs and symptoms of head trauma with indications of increased ICP. What is the normal ventricular ICP?

5 to 15 mm Hg

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?

70 mm Hg

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?

Absence seizure

A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?

Administer morphine sulfate as prescribed.

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

Altered respiratory patterns

Which of the following medication classifications is utilized preoperatively to decrease risk of postop seizures?

Anticonvulsants

A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?

Assist the client to the floor, in a side-lying position, and protect him with linens.

The causes of acquired seizures include what? (Mark all that apply.)

Cerebrovascular disease Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?

Fluid restriction

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?

Generalized

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding?

It indicates an injury at the midbrain level.

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

Lethargy and stupor

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client?

Maintain head of bed (HOB) elevated at 30 to 45 degrees.

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

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Maintenance of a patent airway

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?

Meningitis

A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case?

Narcotic analgesics increase CSF pressure.

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Notify the physician of a possible cerebrospinal fluid leak.

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?

Safety

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches?

The client takes vasodilators for the treatment of angina.

Which client should the nurse assess for degenerative neurologic symptoms?

The client with Huntington disease.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?

The client's activities immediately prior to the seizure.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?

Turn the client to the side

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.

Turn the client to the side. Provide verbal reassurance.

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

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

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

promote carbon dioxide elimination.

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?

Respiratory function

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

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?

Restricting fluid intake and hydration

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?

Rising blood pressure and bradycardia

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge?

The patient should perform frequent physical activity but avoid becoming fatigued.

Which methods may be used by the nurse to maintain the peripheral circulation in a client with IICP? Select all that apply.

Use pressure-relieving pads or a similar type of mattress. Apply elastic stockings to lower extremities.

In the aggressive treatment for increased intracranial pressure, IV therapy can be an instrumental tool in decreasing ICP. What type of IV solution would a physician order to maintain cerebral tissue perfusion? Select all that apply.

normal saline lactated Ringer's

A client fell while snowboarding, sustaining a blow to the head resulting in a loss of consciousness. Upon arrival at the emergency department, the client regained consciousness within 1 hour. What signs are symptoms would indicate increased ICP? Select all that apply.

personality changes sleepiness

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?

Confusion

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Confusion

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

Ineffective cerebral tissue perfusion

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis?

Monitor serum electrolytes.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

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

3

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response?

Inform the care team and assess for further signs of possible increased ICP.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Parkinson's disease.

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?

unequal response

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Glasgow Coma scale

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 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.

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 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 Frequent oral care

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?

As soon as the client senses the onset of symptoms

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.

Death Permanent neurologic dysfunction Impaired cellular activity

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?

Declining level of consciousness (LOC)

A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?

Decreased muscle spasms in the lower extremities

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP?

Disorientation and restlessness

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?

Dyskinesia

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

Generalized seizure

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?

Loss of brain stem reflexes

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment?

Lumbar puncture

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?

Osteoporosis

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?

Phenytoin

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?

Place the client in a side-lying position.

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses?

Prepare an advance directive.

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:

Tremors and muscle rigidity

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

chewing

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

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

restricting fluid intake and hydration

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:

shivering in hypothermia can increase ICP.

A cliient is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because

shivering in hypothermia can increase ICP.