Question 1

A patient arrives in the emergency department with a bullet wound to the left frontal lobe. The patient is comatose on arrival. What is the nursing care priority at this time?

Accepted Answer

Maintaining an open airway is the priority in any comatose patient to ensure adequate oxygenation and ventilation. Once the airway is secured, other priorities such as evaluating neurological status and controlling fluid balance can be addressed. Maintaining body temperature is also important, but not as urgent as ensuring adequate oxygenation.

Question 2

A 17-year-old patient is admitted with a new onset of seizures and is diagnosed with epilepsy. Which of the following would the nurse include in the patient teaching?

Accepted Answer

Sudden withdrawal of anticonvulsants can lead to status epilepticus. Patients must continue to take anticonvulsants regularly to prevent seizures. Aspirin can interact with anticonvulsants, but this is not the most relevant piece of information for patient teaching. It is not advisable to discontinue anticonvulsant medication unless directed by a healthcare provider.

Question 3

The nurse administers an analgesic to a patient with a headache. What is the best way for the nurse to assess the patient's response to the medication?

Accepted Answer

Asking the patient to rate their pain on a scale of 0 to 10 is the best way for the nurse to assess the patient's response to the medication. This allows for a subjective measurement of pain relief and can help guide further pain management interventions. Although asking the patient to describe the pain and observing their behavior can be helpful, they do not provide a quantifiable measure of pain relief. Monitoring the patient's blood pressure and pulse is important for assessing the medication's side effects, but does not necessarily indicate pain relief.

Question 4

The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. What early signs of increased intracranial pressure (ICP) should the nurse be alert for?

Accepted Answer

A decreased level of consciousness is an early sign of increased ICP. Bradycardia and pinpoint pupils are later signs, while hypothermia is not typically associated with increased ICP.

Question 5

A patient is incontinent during a seizure and sleeps for several hours afterward. What type of seizure did the patient most likely have?

Accepted Answer

The patient most likely had a tonic-clonic seizure, also known as a grand mal seizure. Incontinence and post-seizure sleepiness are common symptoms of this seizure type. Absence seizures typically only last a few seconds and don't typically result in incontinence or prolonged sleep. Simple partial seizures typically don't cause loss of bladder or bowel control, and the patient would not sleep for several hours afterward. Status epilepticus is a medical emergency where seizures last longer than usual or occur in succession, and incontinence may be a symptom, but the patient would not likely sleep for several hours afterward.

Question 6

The nurse is caring for a patient in the emergency department with a severe headache due to viral meningitis. The patient requests an opioid analgesic. What explanation about opioids should the nurse provide?

Accepted Answer

Opioid analgesics can mask mental status changes, making it difficult to assess the patient's condition.

Question 7

The nurse is caring for a patient following surgery for a brain tumor. Three days after surgery, the LVN enters the room and finds the patient jerking rhythmically in the bed. The patient does not respond to the LVN's questions. What should the nurse do first?

Accepted Answer

The patient may be experiencing a seizure, which is a potential complication after brain surgery. The priority is to protect the patient from injury by removing any sharp objects from the bed and placing pillows around them. The nurse should also observe and document the sequence of events, including the time the seizure started and any characteristics of the seizure, such as the duration and type of movements. After protecting the patient, the nurse should notify the RN and physician as soon as possible. While holding the patient may be necessary to prevent injury, it is not the first action the nurse should take.

Question 8

A patient with a newly diagnosed seizure disorder is being prepared for discharge. What medication does the nurse anticipate the patient being discharged on to prevent recurrent seizures?

Accepted Answer

Gabapentin (Neurontin) is an anticonvulsant medication that is often prescribed as a first-line treatment to prevent recurrent seizures in patients with new-onset seizure disorders. Dexamethasone (Decadron) is a corticosteroid medication used to treat inflammation, and would not be indicated for seizure prevention. Haloperidol (Haldol) is an antipsychotic medication used to treat psychotic disorders and would not be indicated for seizure prevention. Selegiline (Eldepryl) is a medication used to treat Parkinson's disease and depression and would not be indicated for seizure prevention.

Question 9

The nurse is assisting with teaching a clinic patient who is diagnosed with tension headaches. Which explanation of tension headaches should the nurse provide?

Accepted Answer

Tension headaches are typically caused by stress and sustained muscle contraction of the head and neck, which can lead to pain and discomfort. Other potential triggers may include poor posture, eyestrain, fatigue, and emotional tension. Unlike migraines, tension headaches do not typically involve changes in cerebral blood flow or release of pain mediators in the periphery. Blood sugar fluctuations may play a role in some types of headaches, but they are not typically associated with tension headaches.

Question 10

The nurse is caring for a patient during a post-ictal period. The patient remembers smelling something like dead fish prior to the seizure. Which of the following responses by the nurse is best?

Accepted Answer

The smell of dead fish may be an aura, which is a signal that a seizure is coming. The nurse should educate the patient to seek help immediately if they experience this smell again. Option A is not helpful as it does not address the patient's concern. Option B assumes that the patient is hallucinating without any evidence, which could cause the patient to feel disregarded or invalidated. Option D is also not helpful as it addresses a different sensory experience (seeing a flash of light) and does not address the patient's concern about the smell of dead fish.

Question 11

The nurse is assessing a patient who just had a tonic-clonic seizure. Which finding most indicates a need for immediate nursing intervention?

Accepted Answer

Frothy sputum in the pharynx and gurgling respirations could indicate a compromised airway and a risk for aspiration. Immediate nursing intervention, such as suctioning or positioning, may be necessary to maintain adequate breathing and prevent further complications. The other options (difficulty arousing, incontinence, and belligerent behavior) may require nursing intervention but are not as immediately life-threatening as airway compromise.

Question 12

The nurse is caring for a patient who has had a seizure and is crying, saying life is over, and that working and driving will no longer be possible. Which response by the nurse is most appropriate?

Accepted Answer

This response provides accurate information and reassures the patient that there is hope for the future. It also encourages the patient to focus on improving seizure control with the help of their healthcare team. Option A provides a helpful suggestion to involve a social worker, but does not directly address the patient's concerns about working and driving. Option B suggests that public transportation may be an option, but does not address the patient's worry that they may never be able to work and drive again. Option D is incorrect and provides dangerous advice, as discontinuing seizure medication without medical guidance can be life-threatening.

Question 13

The nurse concludes that a patient's meningitis is improving when the patient can perform which of the following activities?

Accepted Answer

Touching the chin to the chest indicates a reduction in neck stiffness, which is a common symptom of meningitis. Improvement in this symptom suggests that the patient's condition is getting better.

Question 14

The nurse is walking a patient to the bathroom when the patient begins a generalized tonic-clonic seizure. What should the nurse do first?

Accepted Answer

During a seizure, the most important thing to do is to maintain the patient's airway. The nurse should quickly assist the patient to the floor or a safe surface, protect the patient's head, and loosen any restrictive clothing around the neck. Once the seizure has ended, the nurse can then perform a neurological assessment, maintain the patient's privacy, and reduce external stimuli.

Question 15

A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. What would be the most important function of the nurse at this time?

Accepted Answer

Having the patient's next of kin sign a consent form is crucial before the emergency surgery can be performed. It is important to obtain informed consent from a legal guardian or next of kin before performing any invasive medical procedure. This should be the nurse's priority at this time. The other options (bathing the patient, sending belongings home, finding out how the accident happened) are less urgent and can be addressed at a later time.

Question 16

The nurse is caring for a patient admitted to the emergency department with massive trauma to the right frontal lobe of the brain. Which data should the nurse collect related to the location of the injury?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 17

The nurse is caring for a patient admitted to the hospital with a fractured femur and possible head injury. Vital signs on admission were blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Four hours after admission, the nurse is checking vital signs as part of the hourly assessment. Which of the following vital signs most likely indicate the presence of increased intracranial pressure (ICP)?

Accepted Answer

The vital signs in option A (Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min) indicate the presence of Cushing's triad: widened pulse pressure, bradycardia, and irregular respirations, which are classic signs of increased intracranial pressure (ICP).

Question 18

The nurse is caring for a patient with a cerebral injury with increased intracranial pressure (ICP). Which intervention can help prevent further increasing intracranial pressure?

Accepted Answer

Spacing nursing care at intervals allows the patient to rest and can help prevent further increasing intracranial pressure. Providing too much care at one time can be overwhelming for the patient and increase stress, while avoiding touching the patient altogether can limit necessary interventions that may be needed. Providing constant stimulation such as radio and television can also be overwhelming for the patient and increase stress, contributing to increased intracranial pressure.

Question 19

A student is under a great deal of stress, develops a severe tension headache, and goes to a school clinic. What strategy can the nurse teach the student for dealing with the onset of headaches in the future?

Accepted Answer

Relaxation exercises, such as deep breathing, progressive muscle relaxation, and visualization, can help reduce muscle tension and overall stress levels, which can prevent or reduce the severity of tension headaches. Distraction techniques, such as listening to music or reading, may provide temporary relief but do not address the underlying cause of the headache. Vitamin C and zinc supplementation may be beneficial for preventing colds and other infections but have not been shown to prevent tension headaches. Aerobic exercise can also help reduce stress and tension, but it may not be feasible or practical for a student in the midst of a hectic school schedule.

Question 20

The nurse is caring for a patient being seen at a walk-in clinic for an acute migraine headache. The patient winces every time the light is turned on in the examining room. The patient is unable to identify what triggered the headache. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches?

Accepted Answer

Keeping a headache diary can help the patient identify potential triggers and patterns in their headaches, which can guide the development of a plan of care. Avoiding sugar and caffeine, avoiding bright light and noise, and avoiding taking analgesics until the cause has been determined may all be components of a plan of care, but they should not be the first step in determining a plan.

Quiz 48: Nursing Care of Patients With Central Nervous System Disorders