1
1
neurological disorders nclex
The nurse witnesses a patient with a seizure disorder as the patient suddenly
jerks the arms and legs, falls to the floor, and regains consciousness
immediately. It will be most important for the nurse to
_________________ - answer-assess the patient for a possible head injury.
rational: The patient who has had a myoclonic seizure and fall is at risk for
head injury and should be evaluated and treated for this possible
complication first. Documentation of the seizure, notification of the seizure,
and administration of antiseizure medications also are appropriate actions,
but the initial action should be assessment for injury.
When family members ask the nurse about the purpose of the
ventriculostomy system being used for intracranial pressure monitoring for a
patient, which response by the nurse is best? - answer-"The monitoring
system helps show whether blood flow to the brain is adequate."
rational: Short and simple explanations should be given to patients and
family members. The other explanations are either too complicated to be
easily understood or may increase the family member's anxiety.
A patient with a head injury has admission vital signs of blood pressure
128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1
hour after admission, will be of most concern to the nurse? - answer-Blood
pressure 156/60, pulse 55, respirations 12
rational: Systolic hypertension with widening pulse pressure, bradycardia,
and respiratory changes represent Cushing's triad and indicate that the
intracranial pressure (ICP) has increased, and brain herniation may be
imminent unless immediate action is taken to reduce ICP. The other vital
signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
When the nurse applies a painful stimulus to the nail beds of an unconscious
patient, the patient responds with internal rotation, adduction, and flexion of
the arms. The nurse documents this as _____________ - answer-decorticate
posturing.
rational: Internal rotation, adduction, and flexion of the arms in an
unconscious patient is documented as decorticate posturing. Extension of
the arms and legs is decerebrate posturing. Because the flexion is
generalized, it does not indicate localization of pain or flexion withdrawal.
[Type here]
, 1
1
Which parameter is best for the nurse to monitor to determine whether the
prescribed IV mannitol (Osmitrol) has been effective for an unconscious
patient? - answer-Intracranial pressure
rational: Mannitol is an osmotic diuretic and will reduce cerebral edema and
intracranial pressure. It may initially reduce hematocrit and increase blood
pressure, but these are not the best parameters for evaluation of the
effectiveness of the drug. Oxygen saturation will not directly improve as a
result of mannitol administration.
A patient with a head injury opens the eyes to verbal stimulation, curses
when stimulated, and does not respond to a verbal command to move but
attempts to remove a painful stimulus. The nurse records the patient's
Glasgow Coma Scale score as _______ - answer-11
rational: The patient has a score of 3 for eye opening, 3 for best verbal
response, and 5 for best motor response.
Following a head injury, an unconscious 32-year-old patient is admitted to
the emergency department (ED). The patient's spouse and children stay at
the patient's side and constantly ask about the treatment being given. What
action is best for the nurse to take? - answer-Allow the family to stay with the
patient and briefly explain all procedures to them.
rational: The need for information about the diagnosis and care is very high
in family members of acutely ill patients, and the nurse should allow the
family to observe care and explain the procedures. A pastor or counseling
service can offer some support, but research supports information as being
more effective. Asking the family to stay in the waiting room will increase
their anxiety.
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will
be included in the plan of care? - answer-Keep the head of the bed elevated
to 30 degrees.
rational: The patient with increased intracranial pressure (ICP) should be
maintained in the head-up position to help reduce ICP. Flexion of the hips
and knees increases abdominal pressure, which increases ICP. Because the
stimulation associated with nursing interventions increases ICP, clustering
interventions will progressively elevate ICP. Coughing increases intrathoracic
pressure and ICP.
[Type here]
1
neurological disorders nclex
The nurse witnesses a patient with a seizure disorder as the patient suddenly
jerks the arms and legs, falls to the floor, and regains consciousness
immediately. It will be most important for the nurse to
_________________ - answer-assess the patient for a possible head injury.
rational: The patient who has had a myoclonic seizure and fall is at risk for
head injury and should be evaluated and treated for this possible
complication first. Documentation of the seizure, notification of the seizure,
and administration of antiseizure medications also are appropriate actions,
but the initial action should be assessment for injury.
When family members ask the nurse about the purpose of the
ventriculostomy system being used for intracranial pressure monitoring for a
patient, which response by the nurse is best? - answer-"The monitoring
system helps show whether blood flow to the brain is adequate."
rational: Short and simple explanations should be given to patients and
family members. The other explanations are either too complicated to be
easily understood or may increase the family member's anxiety.
A patient with a head injury has admission vital signs of blood pressure
128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1
hour after admission, will be of most concern to the nurse? - answer-Blood
pressure 156/60, pulse 55, respirations 12
rational: Systolic hypertension with widening pulse pressure, bradycardia,
and respiratory changes represent Cushing's triad and indicate that the
intracranial pressure (ICP) has increased, and brain herniation may be
imminent unless immediate action is taken to reduce ICP. The other vital
signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
When the nurse applies a painful stimulus to the nail beds of an unconscious
patient, the patient responds with internal rotation, adduction, and flexion of
the arms. The nurse documents this as _____________ - answer-decorticate
posturing.
rational: Internal rotation, adduction, and flexion of the arms in an
unconscious patient is documented as decorticate posturing. Extension of
the arms and legs is decerebrate posturing. Because the flexion is
generalized, it does not indicate localization of pain or flexion withdrawal.
[Type here]
, 1
1
Which parameter is best for the nurse to monitor to determine whether the
prescribed IV mannitol (Osmitrol) has been effective for an unconscious
patient? - answer-Intracranial pressure
rational: Mannitol is an osmotic diuretic and will reduce cerebral edema and
intracranial pressure. It may initially reduce hematocrit and increase blood
pressure, but these are not the best parameters for evaluation of the
effectiveness of the drug. Oxygen saturation will not directly improve as a
result of mannitol administration.
A patient with a head injury opens the eyes to verbal stimulation, curses
when stimulated, and does not respond to a verbal command to move but
attempts to remove a painful stimulus. The nurse records the patient's
Glasgow Coma Scale score as _______ - answer-11
rational: The patient has a score of 3 for eye opening, 3 for best verbal
response, and 5 for best motor response.
Following a head injury, an unconscious 32-year-old patient is admitted to
the emergency department (ED). The patient's spouse and children stay at
the patient's side and constantly ask about the treatment being given. What
action is best for the nurse to take? - answer-Allow the family to stay with the
patient and briefly explain all procedures to them.
rational: The need for information about the diagnosis and care is very high
in family members of acutely ill patients, and the nurse should allow the
family to observe care and explain the procedures. A pastor or counseling
service can offer some support, but research supports information as being
more effective. Asking the family to stay in the waiting room will increase
their anxiety.
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will
be included in the plan of care? - answer-Keep the head of the bed elevated
to 30 degrees.
rational: The patient with increased intracranial pressure (ICP) should be
maintained in the head-up position to help reduce ICP. Flexion of the hips
and knees increases abdominal pressure, which increases ICP. Because the
stimulation associated with nursing interventions increases ICP, clustering
interventions will progressively elevate ICP. Coughing increases intrathoracic
pressure and ICP.
[Type here]
