Management of Patients with Neurologic Dysfunction Flashcards
The nurse is caring for a patient with an altered level of consciousness
(LOC). Which is the first priority of treatment for this patient?
a. Assessment of pupillary light reflexes
b. Determination of the cause
c. Positioning to prevent complications
d. Maintenance of a patent airway
d. Maintenance of a patent airway
A nurse assesses the patient’s LOC using the Glasgow Coma Scale.
Which score indicates severe impairment of neurologic function?
a. 3
b. 6
c. 9
d. 12
a. 3
A patient has a severe neurologic impairment from a head trauma.
Which 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
c. Flaccid
The nurse is caring for a patient in the neurologic ICU who sustained
head trauma in a physical altercation. Which optimal range does the
nurse identify for this patient?
a. 8 to 15 mm Hg
b. 0 to 10 mm Hg
c. 20 to 30 mm Hg
d. 25 to 40 mm Hg
b. 0 to 10 mm Hg
A patient is admitted to the hospital with an ICP reading of 20 mm Hg
and a mean arterial pressure of 90 mm Hg. Which is the calculated
cerebral perfusion pressure?
a. 50 mm Hg
b. 60 mm Hg
c. 70 mm Hg
d. 80 mm Hg
c. 70 mm Hg
A nurse caring for a patient with head trauma will be monitoring the
patient for Cushing triad. Which are the identified symptoms associated
with Cushing triad that the nurse documents? (Select all that apply.)
a. Bradycardia
b. Bradypnea
c. Hypertension
d. Tachycardia
e. Pupillary constriction
a. Bradycardia
b. Bradypnea
c. Hypertension
The nurse is caring for a patient with a traumatic brain injury (TBI).
Which does the nurse identify 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
d. Lethargy and stupor
The nurse is caring for a patient with increased ICP. As the pressure
rises, what osmotic diuretic does the nurse prepare to administer as
prescribed?
a. Glycerin
b. Isosorbide
c. Mannitol
d. Urea
c. Mannitol
A nurse is assessing a patient’s urinary output as an indicator of diabetes
insipidus related to a traumatic brain injury. The nurse identifies that an
hourly output of which 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
d. More than 200 mL/hr
When educating a patient about the use of anticonvulsant medication,
what will 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
c. Osteoporosis
The nurse is called to attend to a patient having a tonic-clonic seizure in
the waiting area. Which nursing interventions are provided for this
patient? (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
a. Loosening constrictive clothing
c. Positioning the patient on their side with head flexed forward
d. Providing for privacy
The nurse is educating a patient with a seizure disorder. Which
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
c. High in protein and low in carbohydrate
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, and crackles in the bases of the lungs.
Which situation does the nurse suspect is occurring?
a. Increased ICP
b. Exacerbation of uncontrolled hypertension
c. Infection
d. Increase in cerebral perfusion pressure
a. Increased ICP
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.” Which priority action 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 health care provider of a possible cerebrospinal fluid leak.
d. Notify the health care provider of a possible cerebrospinal fluid leak.
A patient had a small pituitary adenoma removed by the transsphenoidal
approach and has developed diabetes insipidus. Which pharmacologic
therapy will the nurse be administering to this patient as prescribed to
control symptoms?
a. Mannitol
b. Furosemide (Lasix)
c. Vasopressin
d. Phenobarbital
c. Vasopressin
