Management Of Patients With Neurologic Dysfunction

Question 1

A patient has a lesion affecting the pons, resulting in paralysis and the inability to speak, but has vertical eye movements and lid elevation, This patient is suffering from

Answer 1

Locked-in syndrome

Question 2

Three major potential complications in a patient with a depressed level of consciousness (LOC) are

Answer 2

Pneumonia
Aspiration
Respiratory Failure

Question 3

The earliest sign of increased ICP is

Answer 3

A change in the level of consciousness (LOC)

Question 4

Three primary complications of increased ICP are

Answer 4

Brain stem herniation
Diabetes Insipidus
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Question 5

The primary lethal complication of ICP is

Answer 5

Brain herniation resulting in death

Question 6

Nursing postoperative management includes detecting and reducing ______, relieving ________, preventing _________, and monitoring ________, and ___________.

Answer 6

Cerebral edema
Pain
Seizure
Increased ICP
Neurologic status

Question 7

The leading cause of seizures in the older adult is

Answer 7

Cerebrovascular disease

Question 8

A major potential complication of epilepsy is

Answer 8

Status Epilepticus

Question 9

It is present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.

Answer 9

Altered level of consciousness

Question 10

It is gauged on a continuum, with a normal state of alertness and full cognition on one end and coma on the other end

Answer 10

Level of Consciousness

Question 11

The five potential collaborative problems for a patient with an altered LOC.

Answer 11

Respiratory Distress
Pneumonia
Aspiration
Pressure Ulcer
Deep Vein Thrombosis (DVT)

Question 12

What should be included when a nurse performs neurologic examination?

Answer 12

Evaluation of Mental status
Cranial nerve function
Cerebellar function
Reflexes
Motor and sensory function
Score of Glasgow Coma Scale (GCS)

Question 13

If a patient with a altered LOC requires suctioning, what intervention is a priority for the nurse to provide?

Answer 13

Before and after suctioning, the patient is adequately ventilated to prevent hypoxia.

Question 14

What is the optimal way to determine the level of a patient’s alertness?

Answer 14

Alertness is measured by the patient’s ability to open the eyes spontaneously or in response to a vocal o noxious stimulus (pressure or pain).

Question 15

A neurologic dysfunction that involves an assist with daily active or passive range of motion as its nursing intervention

Answer 15

Foot drop & Paralyzed Extremity

Question 16

A neurologic dysfunction that involves elevating the head of the bed 30 degrees as its nursing intervention

Answer 16

Impaired cough reflex & Paralyzed Diaphragm

Question 17

A neurologic dysfunction that involves instituting a bowel-training program as its nursing intervention

Answer 17

Incontinence

Question 18

A neurologic dysfunction that involves maintaining dorsiflexion to affected area as its nursing intervention

Answer 18

Foot drop

Question 19

A neurologic dysfunction that involves placing the patient in a lateral position as its nursing intervention

Answer 19

Impaired cough reflex

Question 20

Alex, a 32-year old male, was riding his motorcycle without a helmet through the woods ad hit a large log, ejecting him over the handlebars and into a tree. He was unconscious when his friends found him and called the rescue squad. He has had a craniotomy to relieve an epidural hematoma and is in the neurologic intensive care unit (ICU).

In order to optimize cerebral perfusion pressure (CPP) and decrease intracranial pressure (ICP), in wht position should the nurse maintain alex?

Answer 20

Proper positioning helps reduce ICP.

1. Head is kept in a neutral (midline ) position, maintained with the use of a Cervical collar if necessary;
2. Elevation of the head is maintained at 30-45 degrees unless contraindicated
3. Extreme rotation of the neck ad flexion of the neck are avoided, because the compression or distortion of the jugular veins increases ICP.
4. Extreme flexion of the hip is also avoided, because this position causes an increase in intra-abdominal and thoracic pressures, which can produce an increase in ICP.

Question 21

What intervention can the nurse provide to avoid having Alex perform the Valsalva maneuver?

Answer 21

1. Stool softeners may be prescribed.
2. When Alex is awake and alert, a high-fiber diet may be indicated.
   - Abdominal distention, which increases intra-abdominal and intra-thoracic pressure and ICP, should be noted
3. Enemas and cathartics are avoided if possible.
4. When moving or being turned in bed, ask Alex to exhale (which opens the glottis) to avoid the valsalva maneuver.

Question 22

When the nurse plans Alex’s care, how can his needs be met in order to prevent a rise in ICP and a decrease in CPP?

Answer 22

1. Space activities to avoid stress and strain.
2. Maintain a calm atmosphere and decrease environmental stimuli

Question 23

It increases intra-abdominal and intra-thoracic pressure, as well as ICP

Answer 23

Abdominal distention

Question 24

The nurse is caring for a patient with an altered level of consciousness (LOC). What is the first priority of treatment for this patients?

A. Assessment of pupillary light reflexes
B. Determination of the cause
C. Positioning to prevent complications
D. Maintenance of a patent airway

Answer 24

D. Maintenance of a patent airway

Question 25

A nurse assesses the patient’s LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic funtion? A. 3 B. 6 C. 9 D. 12

Answer 25

A. 3

Question 26

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? A. Decerebrate B. Decorticate C. Flaccid D. Rigid

Answer 26

C. Flaccid

Question 27

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the optimal range of ICP for this patient? A. 8 t 15 mmHg B. 0 to 10 mmHg C. 20 to 30 mmHg D. 25 to 40 mmHg

Answer 27

B. 0 to 10 mmHg

Question 28

A patient is admitted to the hospital with an ICP reading of 20 mmHg and a mean arterial pressure of 90 mmHg. What would the nurse calculate the CPP to be? A. 50 mmHg B. 50 mmHg C. 70 mmHg D. 80 mmHg

Answer 28

C.70 mmHg

Question 29

A nurse caring or a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognize as the symptoms associated with Cushing triad? (Select all that apply) A. Bradycardia B. Bradypnea C. Hypertension D. Tachycardia E. Pupillary constriction

Answer 29

A. Bradycardia B. Bradypnea C. Hypertension

Question 30

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A. A bounding pulse B. Bradycardia C. Hypertension D. Lethargy and Stupor

Answer 30

D. Lethargy and Stupor

Question 31

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? A. Glycerin B. Isosorbide C. Mannitol D. Urea

Answer 31

C. Mannitol

Question 32

A nurse is assessing a patient’s urinary output as an indicator of diabetes insipidus related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? A. 50 to 100 mL/hr B. 100 to 150 mL/hr C. 150 to 200 mL/hr D. More than 200 mL/hr

Answer 32

D. More than 200 mL/hr

Question 33

When educating a patient about the use of anticonvulsant medication, what should the nurse inform the patient is a result of long-term use of the medication in women? A. Anemia B. Osteoarthritis C. Osteoporosis D. Obesity

Answer 33

C. Ostoporosis

Question 34

The nurse is called to tend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? (Select all that apply) A. Loosening constrictive clothing B. Opening the patient’s jaw and inserting a mouth gag C. Positioning the patient on their side with head flexed forward D. Providing for privacy E. Restraining the patient to avoid self-injury

Answer 34

A. Loosening constrictive clothing C. Positioning the patient on their side with head flexed forward D. Providing for privacy

Question 35

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. Low in fat B. Restricts protein to 10% of daily caloric intake C. High in protein and low in carbohydrate D. At least 50% carbohydrate

Answer 35

C. High in protein and low in carbohydrate

Question 36

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient’s blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? A. Increased ICP B. Exacerbation of uncontrolled hypertension C. Infection D. Increase in cerebral perfusion pressure

Answer 36

A. Increased ICP

Question 37

A patient 3 days postoperative from a craniotomy informs the nurse, “I feel something trickling down the back of my throat and I taste something salty.” What priority intervention does the nurse initiate? A. Give the patient some mouthwash to gargle with B. Request an antihistamine for the postnasal drip C. Ask the patient to cough to observe the sputum color and consistency D. Notify the physician of a possible cerebrospinal fluid leak

Answer 37

D. Notify the physician of a possible cerebrospinal fluid leak

Question 38

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? A. Mannitol B. Furosemide (Lasix) C. Vasopressin D. Phenobarbital

Answer 38

C. Vassopressin