Chapter 66 Management of Patients with Neurologic Dysfunction NCLEX
Chapter 66: Management of Patients with Neurologic Dysfunction NCLEX
Study online at https://quizlet.com/_9pg6v2
1. C A patient is being admitted to the neurologic ICU
following an acute head injury that has resulted
(Feedback: The osmotic diuretic man- in cerebral edema. When planning this patient's
nitol is given to dehydrate the brain care, the nurse would expect to administer what
tissue and reduce cerebral edema. This priority medication?
drug acts by reducing the volume of
brain and extracellular fluid. Spirolac- A) Hydrochlorothiazide (HydroDIURIL)
tone, furosemide, and hydrochloroth- B) Furosemide (Lasix)
iazide are diuretics that are not typical- C) Mannitol (Osmitrol)
ly used in the treatment of increased D) Spirolactone (Aldactone)
ICP resulting from cerebral edema.)
2. B The nurse is providing care for a patient who
is unconscious. What nursing intervention takes
(Feedback: Maintaining a patent air- highest priority?
way always takes top priority, even
though each of the other listed actions A) Maintaining accurate records of intake and out-
is necessary and appropriate.) put
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control
3. C The nurse is caring for a patient in the ICU who has
a brain stem herniation and who is exhibiting an
(Feedback: The cerebral perfusion altered level of consciousness. Monitoring reveals
pressure (CPP) is 55 mm Hg, which is that the patient's mean arterial pressure (MAP)
considered low. The normal CPP is 70 is 60 mm Hg with an intracranial pressure (ICP)
to 100 mm Hg. Patients with a CPP reading of 5 mm Hg. What is the nurse's most
of less than 50 mm Hg experience appropriate action?
irreversible neurologic damage. As a
result, interventions are necessary. A A) Position the patient in the high Fowler's posi-
craniotomy is not directly indicated. Di- tion as tolerated.
actualstudy 1
, Chapter 66 Management of Patients with Neurologic Dysfunction NCLEX
Chapter 66: Management of Patients with Neurologic Dysfunction NCLEX
Study online at https://quizlet.com/_9pg6v2
uretics and increased height of bed B) Administer osmotic diuretics as ordered.
would exacerbate the patient's condi- C) Participate in interventions to increase cerebral
tion.) perfusion pressure.
D) Prepare the patient for craniotomy.
4. B The nurse is caring for a patient who is postop-
erative following a craniotomy. When writing the
(Feedback: The postoperative fluid reg- plan of care, the nurse identifies a diagnosis of
imen depends on the type of neuro- "deficient fluid volume related to fluid restriction
surgical procedure and is determined and osmotic diuretic use." What would be an ap-
on an individual basis. The volume propriate intervention for this diagnosis?
and composition of fluids are adjusted
based on daily serum electrolyte val- A) Change the patient's position as indicated.
ues, along with fluid intake and output. B) Monitor serum electrolytes.
Fluids may have to be restricted in pa- C) Maintain NPO status.
tients with cerebral edema. Changing D) Monitor arterial blood gas (ABG) values.
the patient's position, maintaining an
NPO status, and monitoring ABG val-
ues do not relate to the nursing diag-
nosis of deficient fluid volume.)
5. D A patient with a documented history of seizure
disorder experiences a generalized seizure. What
(Feedback: An appropriate nursing in- nursing action is most appropriate?
tervention would include loosening
any restrictive clothing on the patient. A) Restrain the patient to prevent injury.
No attempt should be made to restrain B) Open the patient's jaws to insert an oral airway.
the patient during the seizure because C) Place patient in high Fowler's position.
muscular contractions are strong and D) Loosen the patient's restrictive clothing.
restraint can produce injury. Do not
attempt to pry open jaws that are
clenched in a spasm to insert anything.
actualstudy 2
, Chapter 66 Management of Patients with Neurologic Dysfunction NCLEX
Chapter 66: Management of Patients with Neurologic Dysfunction NCLEX
Study online at https://quizlet.com/_9pg6v2
Broken teeth and injury to the lips and
tongue may result from such an action.
If possible, place the patient on one
side with head flexed forward, which
allows the tongue to fall forward and
facilitates drainage of saliva and mu-
cus.)
6. C A patient who has been on long-term phenytoin
(Dilantin) therapy is admitted to the unit. In light
(Feedback: Gingival hyperplasia of the adverse of effects of this medication, the
(swollen and tender gums) can be asso- nurse should prioritize which of the following in
ciated with long-term phenytoin (Dilan- the patient's plan of care?
tin) use. Thorough oral hygiene should
be provided consistently and encour- A) Monitoring of pulse oximetry
aged after discharge. Fluid and pro- B) Administration of a low-protein diet
tein restriction are contraindicated and C) Administration of thorough oral hygiene
there is no particular need for constant D) Fluid restriction as ordered
oxygen saturation monitoring.)
7. C A nurse is admitting a patient with a severe mi-
graine headache and a history of acute coronary
(Feedback: Triptans can cause chest syndrome. What migraine medication would the
pain and are contraindicated in pa- nurse question for this patient?
tients with ischemic heart disease.
Maxalt, Amerge, and Zomig are trip- A) Rizatriptan (Maxalt)
tans used in routine clinical use for the B) Naratriptan (Amerge)
treatment of migraine headaches.) C) Sumatriptan succinate (Imitrex)
D) Zolmitriptan (Zomig)
8. D The nurse is caring for a patient with increased
intracranial pressure (ICP). The patient has a nurs-
(Feedback: An expected outcome of ing diagnosis of "ineffective cerebral tissue perfu-
actualstudy 3
Chapter 66: Management of Patients with Neurologic Dysfunction NCLEX
Study online at https://quizlet.com/_9pg6v2
1. C A patient is being admitted to the neurologic ICU
following an acute head injury that has resulted
(Feedback: The osmotic diuretic man- in cerebral edema. When planning this patient's
nitol is given to dehydrate the brain care, the nurse would expect to administer what
tissue and reduce cerebral edema. This priority medication?
drug acts by reducing the volume of
brain and extracellular fluid. Spirolac- A) Hydrochlorothiazide (HydroDIURIL)
tone, furosemide, and hydrochloroth- B) Furosemide (Lasix)
iazide are diuretics that are not typical- C) Mannitol (Osmitrol)
ly used in the treatment of increased D) Spirolactone (Aldactone)
ICP resulting from cerebral edema.)
2. B The nurse is providing care for a patient who
is unconscious. What nursing intervention takes
(Feedback: Maintaining a patent air- highest priority?
way always takes top priority, even
though each of the other listed actions A) Maintaining accurate records of intake and out-
is necessary and appropriate.) put
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control
3. C The nurse is caring for a patient in the ICU who has
a brain stem herniation and who is exhibiting an
(Feedback: The cerebral perfusion altered level of consciousness. Monitoring reveals
pressure (CPP) is 55 mm Hg, which is that the patient's mean arterial pressure (MAP)
considered low. The normal CPP is 70 is 60 mm Hg with an intracranial pressure (ICP)
to 100 mm Hg. Patients with a CPP reading of 5 mm Hg. What is the nurse's most
of less than 50 mm Hg experience appropriate action?
irreversible neurologic damage. As a
result, interventions are necessary. A A) Position the patient in the high Fowler's posi-
craniotomy is not directly indicated. Di- tion as tolerated.
actualstudy 1
, Chapter 66 Management of Patients with Neurologic Dysfunction NCLEX
Chapter 66: Management of Patients with Neurologic Dysfunction NCLEX
Study online at https://quizlet.com/_9pg6v2
uretics and increased height of bed B) Administer osmotic diuretics as ordered.
would exacerbate the patient's condi- C) Participate in interventions to increase cerebral
tion.) perfusion pressure.
D) Prepare the patient for craniotomy.
4. B The nurse is caring for a patient who is postop-
erative following a craniotomy. When writing the
(Feedback: The postoperative fluid reg- plan of care, the nurse identifies a diagnosis of
imen depends on the type of neuro- "deficient fluid volume related to fluid restriction
surgical procedure and is determined and osmotic diuretic use." What would be an ap-
on an individual basis. The volume propriate intervention for this diagnosis?
and composition of fluids are adjusted
based on daily serum electrolyte val- A) Change the patient's position as indicated.
ues, along with fluid intake and output. B) Monitor serum electrolytes.
Fluids may have to be restricted in pa- C) Maintain NPO status.
tients with cerebral edema. Changing D) Monitor arterial blood gas (ABG) values.
the patient's position, maintaining an
NPO status, and monitoring ABG val-
ues do not relate to the nursing diag-
nosis of deficient fluid volume.)
5. D A patient with a documented history of seizure
disorder experiences a generalized seizure. What
(Feedback: An appropriate nursing in- nursing action is most appropriate?
tervention would include loosening
any restrictive clothing on the patient. A) Restrain the patient to prevent injury.
No attempt should be made to restrain B) Open the patient's jaws to insert an oral airway.
the patient during the seizure because C) Place patient in high Fowler's position.
muscular contractions are strong and D) Loosen the patient's restrictive clothing.
restraint can produce injury. Do not
attempt to pry open jaws that are
clenched in a spasm to insert anything.
actualstudy 2
, Chapter 66 Management of Patients with Neurologic Dysfunction NCLEX
Chapter 66: Management of Patients with Neurologic Dysfunction NCLEX
Study online at https://quizlet.com/_9pg6v2
Broken teeth and injury to the lips and
tongue may result from such an action.
If possible, place the patient on one
side with head flexed forward, which
allows the tongue to fall forward and
facilitates drainage of saliva and mu-
cus.)
6. C A patient who has been on long-term phenytoin
(Dilantin) therapy is admitted to the unit. In light
(Feedback: Gingival hyperplasia of the adverse of effects of this medication, the
(swollen and tender gums) can be asso- nurse should prioritize which of the following in
ciated with long-term phenytoin (Dilan- the patient's plan of care?
tin) use. Thorough oral hygiene should
be provided consistently and encour- A) Monitoring of pulse oximetry
aged after discharge. Fluid and pro- B) Administration of a low-protein diet
tein restriction are contraindicated and C) Administration of thorough oral hygiene
there is no particular need for constant D) Fluid restriction as ordered
oxygen saturation monitoring.)
7. C A nurse is admitting a patient with a severe mi-
graine headache and a history of acute coronary
(Feedback: Triptans can cause chest syndrome. What migraine medication would the
pain and are contraindicated in pa- nurse question for this patient?
tients with ischemic heart disease.
Maxalt, Amerge, and Zomig are trip- A) Rizatriptan (Maxalt)
tans used in routine clinical use for the B) Naratriptan (Amerge)
treatment of migraine headaches.) C) Sumatriptan succinate (Imitrex)
D) Zolmitriptan (Zomig)
8. D The nurse is caring for a patient with increased
intracranial pressure (ICP). The patient has a nurs-
(Feedback: An expected outcome of ing diagnosis of "ineffective cerebral tissue perfu-
actualstudy 3
