PrepU Patho Ch 37
The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom?
Stupor The most frequent sign of brain dysfunction is an altered level of consciousness such as stupor. Pupils that react to light, wheezing, and chest pain are not symptoms of brain function.
The spouse of a client diagnosed with Alzheimer disease asks the nurse why the client often neglects to take a shower. The spouse states that the client was always diligent with hygiene in the past; however, over the past few months that has not been the case. What is the nurse's best response?
"You should remind the client to shower." The client should be reminded to shower because most likely he or she has difficulty remembering to do so. In the moderate stage of Alzheimer disease, which can last for several years, it is not unusual for hygiene to be neglected because the person may just not remember if he or she showered. There is no information in the question to support the remaining responses.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?
Assess for other signs/symptoms of increased intracranial pressure. The tumor may be causing increased intracranial pressure. Vomiting, with or without nausea, is a common symptom of increased intracranial pressure and/or brain stem compression. The nurse's first action is to assess for other signs/symptoms of increased intracranial pressure. Once the assessment is completed, the nurse should contact the physician if indicated by the findings.
A client has an abrupt onset of mental slowing and depression. Which conditions in the client's history would indicate vascular dementia as a cause of these changes? Select all that apply.
Cerebrovascular accident Cardiac dysrhythmias Cigarette smoking The hallmarks of vascular dementia are mental slowing and depression. They usually occur as a result of brain injury from hemorrhage or occlusion. Common disorders associated with this diagnosis are cerebrovascular accident, cardiac dysrhythmias, cigarette smoking, hypertension, hyperlipidemia, diabetes mellitus, and autoimmune disorders.
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following?
Encephalitis Less frequent causes of encephalitis include ingesting toxic substances such as lead. People experience neurologic disturbances such as lethergy, disorientation, seizures, focal paralysis, delirium and coma. Bacterial and viral meningitis are caused by bacterial and viral infections. Meningiomas are a type of brain tumor that are seen in the middle or later years of life.
A client who is diagnosed with seizures describes feeling confused after experiencing a seizure. The family members report that the client has been smacking his lips prior to having a seizure. The client most likely experienced which type of seizure?
Focal Focal seizures with impairment of consciousness sometimes referred to as psychomotor seizures are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common. The other seizures do not display these manifestations.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:
Lumbar puncture The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be that:
bruising on the surface of the brain occurred. Contusions represent bruising on the surface of the brain, and lacerations are a tearing of brain tissue. A cerebral concussion is a transient neurogenic dysfunction caused by mechanical force to the brain. Hypoxia usually is seen in conditions such as exposure to reduced atmospheric pressure, carbon monoxide poisoning, severe anemia, and failure of the lungs to oxygenate the blood.
The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced:
generalized seizure. When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.
Cognition Level of consciousness Motor function Sensory function Brain injuries can cause changes in level of consiousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a client with a traumatic brain injury should assess for changes in these areas.