PrepU chapter 61
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 associated with an organic cause, such as a brain tumor."
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 -Positioning the patient on his or her side with head flexed forward -Providing for privacy
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.
-Medication regimen -Appointments for chemotherapy or radiotherapy -Adverse effects of chemotherapy or radiation and techniques for managing them -Nutritional support
Cerebral edema peaks at which time point after intracranial surgery?
24 hours
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:
52 mm Hg.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
Administer corticosteroids as 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?
Administer medications at exact intervals ordered.
Which is a late sign of increased intracranial pressure (ICP)?
Altered respiratory patterns
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?
Apply warm or cool cloths to the forehead or back of the neck
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 Bradypnea Hypertension
Which signs are manifestations of the Cushing triad? Select all that apply.
Bradycardia Hypertension Bradypnea
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
Brain tumor
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 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
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 Seizures
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
High in protein and low in carbohydrate
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?
Increased ICP is 12 mm Hg.
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?
Infection
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure?
Keep the client on one side.
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
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 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?
Maintains a patent airway
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 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?
Monro-Kellie
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
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
Phenobarbital
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Pituitary carcinoma
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
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity.
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 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.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
Turn client to side-lying position.
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?
Vasopressin
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
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
decerebrate
What is one of the earliest signs of increased ICP?
decreased level of consciousness (LOC)
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise.
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?
poor
A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines?
seasonal changes
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 client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?
"There is a strong familial tendency."
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"You must avoid coughing, sneezing, and blowing your nose."
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.
A nurse is working in the neurologic intensive care unit and 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 the person in part B of the accompanying image. Which posturing is the patient exhibiting?
Decerebrate
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?
Decerebrate posturing and loss of corneal reflex
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?
Decorticate
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?
Drooping eyelids
A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed 30 degrees.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed.
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
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?
Glasgow Coma Scale
The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?
Heart failure
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
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?
Flaccid
