Question 1

A patient without a history of previous seizures experiences two tonic-clonic seizures in succession while the nurse is in the patient's room. List in priority order the actions the nurse should take.
A) Turn the patient on his or her side.
B) Protect the patient from environmental harm.
C) Start oxygen via face mask.
D) Reorient the patient to time, person, and place.

Accepted Answer

A,B,C,D

Question 2

A patient with increased intracranial pressure (ICP) is being repositioned. The nurse would incorporate which actions into this intervention?. Select all that apply.

Accepted Answer

A,D,E

Question 3

A patient is in the emergency department following a head injury. The nurse would assess for which sign indicating early increased intracranial pressure?

Accepted Answer

A decreasing level of consciousness is an early sign of increased intracranial pressure. Elevated diastolic blood pressure, decreasing respiratory rate, and tachycardia may all indicate other issues but are not early signs of increased intracranial pressure.

Question 4

The nurse is caring for a patient with an intracranial pressure monitoring device. What is the priority nursing diagnosis (NDX) for this patient?

Accepted Answer

The priority nursing diagnosis for a patient with an intracranial pressure monitoring device is Risk for Infection. The device is an entry point for potential infection, and any infection can lead to further complications, including increased intracranial pressure. Therefore, it is essential to maintain proper infection prevention measures, including frequent monitoring of the insertion site and sterile dressing changes. Ineffective Thermoregulation, Risk for Impaired Skin Integrity, and Impaired Physical Mobility are also potential nursing diagnoses for this patient, but they are not as high of a priority as preventing an infection.

Question 5

A patient is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. How would the nurse categorize this seizure?

Accepted Answer

The symptoms described (blank stare, unresponsiveness, and smacking of the lips) are all indicative of an absence seizure. The duration of less than a minute also supports this classification, as absence seizures are typically short-lived.

Question 6

Which nursing diagnosis is most applicable to a patient with new-onset seizures?

Accepted Answer

Anxiety is the most applicable nursing diagnosis to a patient with new-onset seizures as they may experience fear, uncertainty, and stress due to the sudden and unexpected nature of the seizures. They may also be anxious about the potential consequences and impact on their daily life.

Question 7

The patient was an unrestrained front-seat passenger in a motor vehicle crash and struck his forehead on the inside of the windshield. Diagnostic testing in the emergency department reveals coup-contrecoup injury. The nurse identifies which area as the contrecoup injury?

Accepted Answer

The contrecoup injury refers to the area of the brain opposite the site of impact. In this case, the patient struck his forehead on the inside of the windshield, resulting in a contrecoup injury in the posterior or occipital part of the brain.

Question 8

A 2-year-old child fell and sustained a scalp laceration that will require suturing. The parents ask the nurse, "How serious an injury is this?" How should the nurse respond?

Accepted Answer

The answer of A 2-year-old child fell and sustained a...

Question 9

The nurse anticipates that which medication will be ordered to halt status epilepticus in a patient?

Accepted Answer

Lorazepam (Ativan) IV is the medication of choice for halting status epilepticus as it has a rapid onset of action and is effective in suppressing seizure activity. Oral glucose (B) is used to treat hypoglycemia, not seizures. Phenytoin (Dilantin) (C) is used for long-term seizure prophylaxis and is not effective in stopping active seizure activity. Gabapentin (Neurontin) and lamotrigine (Lamictal) (D) are used for long-term seizure prophylaxis and are not effective in stopping active seizure activity.

Question 10

The patient was riding in a car that hit a tree. The head hit the windshield, and then the brain rebounded within the skull toward the opposite side. This injury represents which mechanism of injury?

Accepted Answer

An acceleration-deceleration injury (also known as a coup-contrecoup injury) occurs when the brain is accelerated forward and then rebounds within the skull, causing injury on the opposite side of impact. This is consistent with the mechanism of injury described in the scenario.

Question 11

The patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees. The nurse is observing for which finding?

Accepted Answer

The nurse is observing for Brudzinski sign, which is the passive flexion of the neck causing the flexion of the hips and knees. This is a sign of meningeal irritation, which can occur in conditions such as meningitis or subarachnoid hemorrhage. Doll's eyes reflex is a neurological test for brainstem function, Babinski reflex is a test for upper motor neuron function, and Kernig's sign is another sign of meningeal irritation that is elicited by flexing the hip and knee and then extending the knee, causing pain in the back.

Question 12

A 25-year-old female is diagnosed with tic douloureux. How should the nurse describe this disorder to the patient?. Select all that apply.

Accepted Answer

The answer of A 25-year-old female is diagnosed with tic...

Question 13

A patient comes to the clinic complaining of repetitive episodes of sudden severe pain on the right side of the face. The nurse anticipates additional testing for which disorder?

Accepted Answer

The symptoms mentioned indicate trigeminal neuralgia, which is a disorder characterized by sudden, severe, and brief attacks of facial pain that are often triggered by touch or movement. Additional testing such as MRI, CT scan, or nerve conduction studies may be done to confirm the diagnosis. Parkinson's disease, Bell's palsy, and myasthenia gravis do not typically present with sudden severe facial pain as a primary symptom.

Question 14

A patient at risk for increased intracranial pressure (ICP) is likely to experience involuntary compensatory mechanisms. The nurse would monitor this patient for signs of which involuntary compensation?. Select all that apply.

Accepted Answer

The answer of A patient at risk for increased intracranial...

Question 15

Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness; the patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. The nurse prepares to care for this patient based on which evaluation of this assessment?

Accepted Answer

The patient's symptoms suggest an epidural hematoma, which is a medical emergency that requires immediate surgical intervention to relieve pressure on the brain. The dilated pupil on the same side as the hematoma is a sign of increased intracranial pressure, which can be life-threatening if not treated promptly. The seizure also indicates the severity of the head injury.

Question 16

A patient has experienced a subarachnoid hemorrhage and is at risk for increased intracranial pressure (ICP) due to the initiation of the vasodilatory cascade. The nurse plans care for this patient to avoid which primary initiating factor?

Accepted Answer

Cerebral tissue ischemia is a primary initiating factor for increased intracranial pressure (ICP) following a subarachnoid hemorrhage. It can lead to a cycle of worsening conditions, including the vasodilatory cascade, which further increases ICP.

Question 17

The patient sustains a subdural hematoma after falling. How would the nurse explain this injury to the patient's family?

Accepted Answer

A subdural hematoma occurs when blood collects between the brain and its outermost covering, which is known as the dura mater. This explanation accurately describes the location of the bleeding in a subdural hematoma.

Question 18

A patient has just been diagnosed with trigeminal neuralgia. What would the nurse teach this patient about treatment for this disorder?

Accepted Answer

Trigeminal neuralgia is typically treated with antiseizure medications, such as carbamazepine, phenytoin, and valproic acid. These drugs are effective in reducing the severity and frequency of the pain associated with this disorder. Antiviral drugs are not used to treat trigeminal neuralgia, and there is no evidence to suggest that gargling with salt water would be an effective means of reducing pain associated with this condition. Supporting respiratory function would not be a primary treatment focus for trigeminal neuralgia.

Question 19

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which position?

Accepted Answer

Decerebrate posturing is characterized by hyperextension and hyperpronation of the arms and legs, and indicates severe brain damage affecting the brainstem. The other options do not describe decerebrate posturing.

Question 20

A patient with a right temporal lobe hematoma is displaying Cheyne-Stokes respirations. How should this nurse interpret this assessment finding?

Accepted Answer

Cheyne-Stokes respirations are a sign of increased intracranial pressure, which can be caused by a hematoma. Surgical decompression of the brain is a necessary intervention in this case to relieve pressure and prevent further damage. The other options (A, B, and D) are not accurate interpretations of the assessment finding.

Quiz 21: Caring for the Patient With an Acute Brain or Cranial Nerve Disorder