Week 5

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 1.A walker 2.Eyeglasses 3.A hearing aid 4.A bath thermometer

3 The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1.Unchanged weight 2.Shift intake 950 mL, output 900 mL 3.Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

4 After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O (285 to 295 mmol/kg). A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate overhydration or underhydration.

The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls? (Select all that apply.) a. Memory deficit b. Sensory deficit c. Motor function deficit d. Cranial and spinal nerves e. Reticular activation system f. Central nervous system changes

b, c, f Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Review laboratory results for changes in the white cell count. b. Give acetaminophen for the headache and fever before the procedure. c. Notify the provider if signs of increased intracranial pressure are present. d. Administer antibiotics before the procedure to treat the potential meningitis.

c A lumbar puncture should not be performed in a patient with possible increased intracranial pressure to avoid potential downward herniation of the brain when cerebrospinal fluid is drawn from the lumbar cistern.

A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication would the nurse give first? a. Codeine b. Phenytoin c. Ceftriaxone d. Acetaminophen

c Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

The nurse is admitting a patient with frontal lobe dementia. What functional problems would the nurse expect? a. Lack of reflexes b. Endocrine problems c. Higher cognitive function problems d. Respiratory, vasomotor, and cardiac dysfunction

c Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.

In planning long-term care for a patient after craniotomy, what would the nurse include in family and caregiver education? a. Seizures will develop within weeks or months. b. The family will be unable to cope with role reversals. c. There are often residual changes in personality and cognition. d. Referrals will be made to eliminate residual deficits from the damage.

c In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? a. High blood flow to the brain b. Normal intracranial pressure c. Impaired blood flow to the brain d. Adequate autoregulation of blood flow

c Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow, and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

How would the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? a. Ask the patient to close their eyes and slowly bring the tips of the index fingers together. b. Ask the patient to close their eyes and identify the presence of a common object on the forearm. c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance.

c The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes their eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. What action would the nurse take? a. Document the ICP reading in the chart. b. Determine if the patient has a headache. c. Assess the patient's level of consciousness. d. Position the patient with head elevated 60 degrees.

c The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

The nurse on the clinical unit is assigned to 4 patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. A patient with an acute stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale d. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting

c The patient with meningitis should be seen first. Patients with meningitis must be observed closely for manifestations of increased ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second. Although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nosebleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

Management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

c, e Nursing interventions should be based on a realistic appraisal of the patient's condition and prognosis after cranial surgery. The nurse should provide support and education to the caregiver and family about the patient's behavioral changes. The nurse should be prepared to manage seizures and teach the caregiver and family about antiseizure drugs and how to manage a seizure. An overall goal is to foster the patient's independence for as long as possible and to the highest degree possible. The nurse should decrease stimuli in the patient's environment to prevent increases in intracranial pressure.

A patient taking a drug that impairs function of the extrapyramidal system may have loss of a. sensations of pain and temperature. b. regulation of the autonomic nervous system. c. integration of somatic and special sensory inputs. d. automatic movements associated with skeletal muscle activity.

d A group of descending motor tracts carries impulses from the extrapyramidal system, which includes all motor systems (except the pyramidal system) concerned with voluntary movement. It includes descending pathways originating in the brainstem, basal ganglia, and cerebellum. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves.

The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder. b. instruct the patient about the risk for electric shock. c. ensure the patient has no metallic jewelry or metal fragments. d. teach the patient that pain may be experienced during the study.

d Electromyography (EMG) is used to assess electrical activity associated with nerves and skeletal muscles. Activity is recorded by insertion of needle electrodes to detect muscle andperipheral nerve disease. The nurse should tell the patient that pain and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

d Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

A patient with heart failure and type 1 diabetes is scheduled for a positron emission tomogram (PET) of the brain. Which medication would the nurse expect to administer before the study? a. Furosemide 20 mg IV b. Alprazolam 0.5 mg oral c. Ciprofloxacin 500 mg oral d. Regular insulin 6 units subcutaneous

d Patients with type 1 diabetes must receive insulin the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).

The nurse is caring for a patient after a lumbar puncture. Which would be the nurse's priority action? a. Assess for drainage or bleeding from the puncture site. b. Monitor for bladder problems and bowel incontinence. c. Maintain bed rest until lower extremities move normally. d. Check for loss of muscle strength in the upper extremities.

a After a lumbar puncture, the nurse would monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.

A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. maintaining strict bed rest with the head of the bed slightly elevated. d. keeping the room dark and quiet to minimize environmental stimulation.

b Fever must be vigorously managed because it increases cerebral edema and the frequency of seizures. Neurologic damage may result from an extremely high temperature over a prolonged period. Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or tepid sponge baths with water, may be effective in lowering the temperature.

During the neurologic assessment, the nurse finds the patient has speech problems with weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery. b. left middle cerebral artery. c. right anterior cerebral artery. d. left posterior communicating artery.

b The left middle cerebral artery feeds the lateral frontal lobes. The motor strip in this distribution controls the contralateral arm, lower half of the face, and motor speech.

The nurse is alert to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression in increased ICP. They include decreasing level of consciousness and headache.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? a. Tonic spasms of the legs b. Curling in a fetal position c. Arching of the neck and back d. Resistance to flexion of the neck

d Nuchal rigidity is a manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1.PaO2 60 to 100 mm Hg, PaCo2 25 to 30 mm Hg 2.PaO2 60 to 100 mm Hg, PaCo2 30 to 35 mm Hg 3.PaO2 80 to 100 mm Hg, PaCo2 25 to 30 mm Hg 4.PaO2 80 to 100 mm Hg, PaCo2 35 to 38 mm Hg

4 The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect.

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."

B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity --------------------- A. The nurse should teach the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EE G readings. C. The nurse should teach the client that the procedure will take approximately 1 hr. D. The nurse should teach the client that normal activity can resume immediately following the procedure.

A patient suspected of having a brain tumor has memory deficits, visual changes, weakness of right upper and lower extremities, and personality changes. The nurse determines that the tumor is likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.

a A unilateral frontal lobe tumor may result in unilateral hemiplegia, seizures, memory deficit, personality and judgment changes, and visual changes. A bilateral frontal lobe tumor may cause symptoms associated with a unilateral frontal lobe tumor and an ataxic gait.

What nursing intervention would be implemented for a patient with increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status carefully. b. Position the patient in a high Fowler's position. c. Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation.

a Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically used in the treatment of ICP.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) a. Judgment b. Eye opening c. Abstract reasoning d. Best motor response e. Best verbal response f. Cranial nerve function

b, d, e The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the a. microglia. b. astrocytes. c. ependymal cells. d. oligodendrocytes.

d Glial cell types include oligodendrocytes, astrocytes, ependymal cells, and microglia, and each has specific functions. Oligodendrocytes are specialized cells that produce the myelin sheath of nerve fibers in the central nervous system (CNS). They are found mainly in the white matter of the CNS.

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1.Blood pressure 2.Motor response 3.Pupillary response 4.Level of consciousness

1 Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.

A patient's eyes jerk while the patient looks to the left. The nurse records this finding as a. nystagmus. b. CN VI palsy. c. ophthalmic dyskinesia. d. oculocephalic response.

a Nystagmus is defined as fine, rapid jerking movements of the eyes.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1.Confusion 2.Bradycardia 3.Sluggish pupils 4.A widened pulse pressure

1 Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? 1.Eye movements 2.Response to verbal stimuli 3.Affect, feelings, or emotions 4.Insight, judgment, and planning

1 Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How would the nurse document this finding? a. Ataxia b. Apraxia c. Anisocoria d. Anosognosia

a Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

The patient's magnetic resonance imaging (MRI) shows a brain tumor. The nurse anticipates which treatment modality? a. Surgery b. Chemotherapy c. Radiation therapy d. Biologic drug therapy

a Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? a. A 50-yr-old woman with lethargy from a drug overdose b. A 40-yr-old man with a complete lumbar spinal cord injury c. A 60-yr-old man with severe pain from trigeminal neuralgia d. A 30-yr-old woman with a high fever and bacterial meningitis

a The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.

The nurse is caring for a patient admitted for surgical removal of a brain tumor. Which complications will the nurse monitor for? (Select all that apply.) a. Seizures b. Vision loss c. Cerebral edema d. Pituitary dysfunction e. Parathyroid dysfunction f. Focal neurologic deficits

a, b, c, d, f Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

Stimulation of the parasympathetic nervous system results in (select all that apply) a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. d. increased blood glucose levels. e. relaxation of the urinary sphincters.

a, b, c, e Stimulation of the parasympathetic nervous system results in pupil constriction, decreased heart rate, increased saliva secretion, and relaxation of the urinary sphincter with stimulation of urination. Stimulation of the sympathetic nervous system results in increased blood glucose levels.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. disrupting the blood-brain barrier. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

b Vasogenic cerebral edema occurs mainly in the white matter. It results from disruption of the blood-brain barrier. This allows large molecules (protein, blood products) to enter brain tissue.

A patient sustained a diffuse axonal injury from a traumatic brain injury. What would the nurse explain to the family is the reason enteral nutrition is being started? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be better avoided with feedings. d. Malnutrition promotes continued cerebral edema.

d A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Nutrition replacement should meet caloric needs by at least day 5 after injury. Malnutrition promotes continued cerebral edema. Fluid and electrolytes will be monitored to maintain balance with the enteral nutrition. Excess intravenous fluid administration will also increase cerebral edema.

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How would the nurse document this finding? a. Athetosis b. Hypotonia c. Hemiparesis d. Pronator drift

d Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What would the nurse consider as a sign of improvement? a. Serum sodium of 120 mEq/L b. Urine specific gravity of 1.001 c. Fasting blood glucose of 80 mg/dL d. Serum osmolality of 290 mOsm/kg

d Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood glucose levels occur with diabetes.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response

1 Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1.Reduce environmental noise. 2.Allow visitors as desired by the client and family. 3.Awaken the client every 2 to 3 hours to monitor mental status. 4.Cluster nursing activities to reduce the number of interruptions.

1 Nursing interventions to control ICP include maintaining a calm, quiet, and restful environment. Environmental noise should be kept at a minimum. Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1.Sounds will not be heard clearly unless they are loud. 2.Obtain assistance with ambulation if the client is lightheaded. 3.Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed.

1 The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? 1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX)

1 The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign 4.A Glasgow Coma Scale score of 15

3 Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

The nurse is completing an assessment for a newly admitted patient. How would the nurse assess cognitive function? a. Ask the patient a question such as, "Who were the last 3 presidents?" b. Evaluate level of consciousness, body posture, and facial expressions. c. Observe for signs of agitation, anger, or depression during the health check. d. Request that the patient mimic rapid alternating movements with both hands.

a Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination. It may include testing rapid alternating movements of the upper and lower extremities.

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment of a. airway patency. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a The nurse's initial priority in the emergency management of a patient with a severe head injury is to ensure that the patient has a patent airway.

The nurse is caring for a patient with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? a. Tachypnea b. Bradycardia c. Hypotension d. Narrowing pulse pressure

b Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? a. Place packing in the patient's nares. b. Apply a loose gauze pad under the patient's nose. c. Place the patient in a modified Trendelenburg position. d. Ask the patient to gently blow the nose to clear the drainage.

b Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the provider immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and the patient should not sneeze or blow the nose.

When assessing the muscle strength of an older adult, the nurse cannot compare the findings with those of a younger adult because a. nutrition status is better in young adults. b. muscle tone and strength decrease in older adults. c. muscle strength should be the same for all adults. d. most young adults exercise more than older adults.

b Changes associated with aging include decreases in muscle strength and agility in relation to decreased muscle bulk.

During neurologic testing, the patient can perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense. b. patellar reflexes. c. temperature perception. d. heel-to-shin movements.

c If pain sensation is intact, assessment of temperature sensation may be omitted because both sensations are transmitted by the same ascending pathways.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1.It is possible the client can hear the family. 2.The family needs immediate crisis intervention. 3.The client might have wanted a visit from the hospital chaplain.

1 Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. In addition, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client. The remaining options are incorrect interpretations.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1.The intracranial pressure reading is normal. 2.The intracranial pressure reading is elevated. 3.The intracranial pressure reading is borderline. 4.An intracranial pressure reading of 8 mm Hg is low.

1 The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1, 2, 3 Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1.Normal 2.Abnormal 3.Insignificant 4.Inconclusive

2 In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? 1.Sternal rub 2.Nailbed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2 Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? 1.Prone in semi-Fowler's position 2.Supine in semi-Fowler's position 3.Prone with a small pillow under the abdomen 4.Lateral with the head slightly lower than the rest of the body

3 After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. The remaining options are incorrect.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1.Insert nasal packing. 2.Document the findings. 3.Contact the primary health care provider (PHCP). 4.Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3 Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the PHCP because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation.

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the primary health care provider (PHCP)? 1.Backache 2.Headache 3.Neck stiffness 4.Feelings of fatigue

3 Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may occur because of the positions required for the procedure.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1.Dilated pupils 2.Lumbar trauma 3.A cervical cord injury 4.Altered level of consciousness

3 In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1.Brain death 2.A cerebral lesion 3.A temporal lesion 4.An intact brainstem

4 Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1.Cerebrum 2.Cerebellum 3.Hippocampus 4.Hypothalamus

4 Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? 1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure

4 Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect.

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1.5 mm Hg 2.8 mm Hg 3.14 mm Hg 4.22 mm Hg

4 Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (Select all that apply.) A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

A. CORRECT: The nurse should report the client's statement of possible pregnancy to the provider because the contrast media can place the fetus at risk. B. CORRECT: The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography D. CORRECT: The nurse should report a client's report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast media. E. CORRECT: The nurse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hr prior to the procedure. ---------------- C. There is no contraindication related to cerebral angiography for a client who is taking antihypertensive medication.

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

B. CORRECT: The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain. --------------- A. The calculation is incorrect. E2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. C. The client's score is calculated incorrectly. E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands. D. The client's score is calculated incorrectly. E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. E. Instruct the client to perform deep breathing and coughing exercises.

B. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. C. CORRECT: The nurse should administer an opioid medication for a client's report of headache pain. D. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. --------------------- A. The Glasgow Coma Scale is used to assess a client's level of consciousness and is not necessary following a lumbar puncture. E. Coughing can increase ICP, which can result in an increase in the client's headache.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

B. CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life‑threatening condition, which can result in meningitis. ---------------- A. The nurse should monitor a client who has increased ICP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy. C. The nurse should monitor a client who has increased ICP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy. D. The nurse should monitor a client who has increased ICP for hypertension, but this is not a complication directly related to the ventriculostomy.

The nurse is performing a neurologic assessment. When assessing the accessory nerve, what action would the nurse take? a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Have the patient say "ah" while noting elevation of soft palate. d. Ask the patient to push the tongue to either side against resistance.

b The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.

A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient reports double vision when looking down. During the neurologic assessment, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a. a basal skull fracture. b. an injury to CN VI on both sides. c. a stiff neck from the hyperextension injury.

b Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle, the main muscle responsible for lateral eye movement, is innervated by cranial nerve VI. A hyperextension injury, which can occur in diving accidents or rear-end motor vehicle crashes, can stretch these nerves bilaterally.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position

b The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevation in ICP. Elevating the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the venous system and jugular veins, and decreases the vascular congestion that can cause cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic BP. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? a. Administer IV mannitol as ordered. b. Ventilator use to hyperoxygenate the patient. c. Use strict aseptic technique with dressing changes. d. Be aware of changes in ICP related to cerebrospinal fluid leaks.

c The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The nurse is preparing the patient for an electromyogram (EMG). What would the nurse include in teaching the patient before the test? a. The patient will be tilted on a table during the test. b. It is noninvasive, and there is no risk of electric shock. c. The pain that occurs is from the insertion of the needles. d. The passive sensor does not make contact with the patient.

c With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.