Question 1

The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized?

Accepted Answer

The overarching goals of care are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. This goal encompasses family and community participation.

Question 2

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

Accepted Answer

Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patients ability to explain the seizure is not clinically relevant.

Question 3

The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient?

Accepted Answer

Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patients orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

Question 4

The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.

Accepted Answer

Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

Question 5

The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?

Accepted Answer

If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

Question 6

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

Accepted Answer

Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering bronchodilators are insufficient responses, even though these actions may later be ordered.

Question 7

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

Accepted Answer

Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

Question 8

A patient 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?

Accepted Answer

Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonicclonic contraction). This pattern of rigidity does not occur in patients who experience unclassified, absence, or focal seizures.

Question 9

When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?

Accepted Answer

The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

Question 10

The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What
Diagnostic procedures might be included in this patients admission orders? Select all that apply.

Accepted Answer

Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumors blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

Question 11

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

Accepted Answer

The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain.

Question 12

A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure?

Accepted Answer

The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus.

Question 13

A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding?

Accepted Answer

Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. As such, there is not necessarily any need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage.

Question 14

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

Accepted Answer

Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

Question 15

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?

Accepted Answer

The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

Question 16

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

Accepted Answer

Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.

Question 17

A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?

Accepted Answer

To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

Question 18

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

Accepted Answer

A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.

Question 19

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

Accepted Answer

Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

Question 20

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply?

Accepted Answer

Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.

Quiz 65: Management of Patients With Neurologic Dysfunction