Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter 66 Exam: Management of Patients with Neurologic Dysfunction || With Questions & 100% Accurate Answers

Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter 66 Exam: Management of Patients with Neurologic Dysfunction || With Questions & 100% Accurate Answers Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter 66 Exam: Management of Patients with Neurologic Dysfunction || With Questions & 100% Accurate Answers A patient who has been on longterm phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient's plan of care? - Monitoring of pulse oximetry -Administration of a lowprotein diet -Administration of thorough oral hygiene -Fluid restriction as ordered - ANSWER - Administration of thorough oral hygiene Feedback: Gingival hyperplasia (swollen and tender gums) can be associated with longterm phenytoin (Dilantin) use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring. A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? -Rizatriptan (Maxalt) -Naratriptan (Amerge) - Sumatriptan succinate (Imitrex) - Zolmitriptan (Zomig) - ANSWER - Sumatriptan succinate (Imitrex) Feedback: Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches. The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? -Copes with sensory deprivation. -Registers normal body temperature. - Pays attention to grooming. -Obeys commands with appropriate motor responses. - ANSWER - Obeys commands with appropriate motor responses. Feedback: An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of "disturbed sensory perception." The outcome of "registers normal body temperature" relates to the diagnosis of "potential for ineffective thermoregulation." Body image disturbance would have a potential outcome of "pays attention to grooming." A patient exhibiting an altered level of consciousness (LOC) due to bluntforce trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool?