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After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes
level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this
assessment - (answer)Motor function is part of a neurologic assessment and provides information about
cerebral function. Blood pressure and temperature are not direct measures of neurologic status. Head
circumference provides information as to skeletal development and brain growth, not neurologic data. A
change in head circumference as a result of increased intracranial pressure is not expected in a 4-year-
old whose cranial bones are fused.
A 12-year-old child is admitted to the hospital for observation after sustaining a head injury. Twelve
hours after the injury the child has none of the signs or symptoms of a head injury. What is the nurse's
priority intervention at this time - (answer)Assessing the level of consciousness every hour. Evidence of a
subdural hemorrhage may take hours or days to develop; a diminishing level of consciousness is an early
indication of neurological damage.
What interventions should the nurse implement when caring for a client with syndrome of inappropriate
antidiuretic hormone - (answer)Providing frequent oral care
Instituting fall risk precautions
Monitoring for and reporting neurologic changes
The excess production of antidiuretic hormone associated with SIADH leads to increased water
reabsorption by the kidneys. Increased water reabsorption results in decreased urinary output,
increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. Because
treatment includes restricting fluids, frequent oral care is provided to increase client comfort. Fall risk
precautions are instituted to protect the client from injury that might occur as a result of neurologic
changes associated with declining serum sodium. The nurse monitors for and reports changes in
neurologic status resulting from cerebral edema and hyponatremia. Immediate treatment goals are to
restore normal fluid balance and normal serum osmolality. Fluids are restricted to no more than 1000 mL
and to no more than 500 mL for the client with severe hyponatremia. Treatment of SIADH includes
placing the bed flat or elevating the head of the bed no more than 10 degrees. This position promotes
venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular
filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that
antidiuretic hormone release should be decreased.
A nurse is assessing sudden changes in the neurologic status of different clients after an earthquake.
Which client should require endotracheal intubation and mechanical ventilation? - (answer)The Glasgow
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Coma Scale (GCS) assigns a numeric score for each of the areas of the client's neurologic status. The
lower the score of the GCS, the lower the client's neurologic function. Client 3 is opening the eyes on
pain, so the score is 2. The client shows abnormal flexion motor response, which has a score of 3, and
the verbal response is incomprehensible, scoring 2. Therefore, the total score is 2+3+2=7. A score equal
to or below 8 indicates a need for endotracheal intubation and mechanical ventilation. Client 1 will have
a GCS score of 12. Client 2 will have a GCS score of 13. Client 4 will have a GCS score of 9.
A nurse is assessing the level of consciousness of four different clients. Which client would have the
lowest neurologic function? - (answer)GCS again
The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes
associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? -
(answer)"Clients with decreased sensory perception of touch should be carefully monitored for
infection."
Decreased sensory perception is a neurological change associated with aging. Clients with this change
should be instructed to reduce the risks associated with falling. Therefore, the nurse should intervene to
correct this misconception. All the other statements are correct and require no follow up. Clients with an
increased risk for infections due to structural deterioration of microglia should be monitored for
infections. Clients with recent memory loss should be taught by repetition and by using memory aids
that provide recurrent alerts to facilitate retention of information. This would help the client to learn
new information and recall it when needed. Clients with slower processing time should be provided with
sufficient time to respond to questions or directions. Allowing adequate time for processing helps
differentiate normal findings from neurologic deterioration. Clients with decreased coordination should
be instructed to hold handrails when ambulating to provide support and prevent falls.
For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol
withdrawal? - (answer)Irritability
Tachycardia
Increasing anxiety
Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's
neurologic adaptation to the withdrawal of alcohol. Tachycardia is one of the early sign of withdrawal; it
results from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they
,(NURS 401) NURSING 401 CRIT CARE EXAM STUDY SET WITH 100%
VERIFIED SOLUTIONS!!!! ALREADY GRADED A+ LATEST UPDATE!!!
usually do not occur before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of
withdrawal that may be seen during alcohol withdrawal delirium; they result from autonomic
overactivity.
The nurse is conducting a neurologic assessment on a client brought to the emergency room after a
motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward
and inward. The nurse recognizes that this response represents an injury to what part of the brain? -
(answer)Midbrain
Decorticate posturing[1][2][3] is a sign of significant deterioration in a client's neurologic status and is
manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to
the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation,
judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and
brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion,
alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses
in the above listed areas.
A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The
nurse concludes that these neurologic deficits are caused primarily by which response? -
(answer)Vascular spasms
In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to
the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to
significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged
ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure
diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause
generalized weakness; however, hemiparesis and aphasia are not the result of electrolyte loss.
To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central
venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing
action? - (answer)Auscultate the lungs to evaluate breath sounds.
The most significant and life-threatening complication of insertion of a subclavian catheter is a
pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the
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VERIFIED SOLUTIONS!!!! ALREADY GRADED A+ LATEST UPDATE!!!
lung; a client's respiratory status always is the priority. Although a chest x-ray may be done before TPN is
begun, it is not the priority immediately after insertion of the catheter. A baseline blood glucose level
should be obtained before insertion of the catheter. After TPN is started, routine monitoring of blood
glucose levels is important. Although assessing for a neurologic deficit should be done eventually, it is
not the priority at this time.
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? -
(answer)Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
Because one-half NS is a hypotonic solution, it is contraindicated. It would actually compound the issue
instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake
and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of
hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the
brain, resulting in altered mental status. Therefore it is important for the nurse to assess for neurologic
changes.
A group of clients is admitted with neurologic injury after hiking at high altitude. The nurse is assessing
using the "AVPU" mnemonic. Which type of emergency assessment is the nurse performing? -
(answer)Disability assessment is a part of the primary survey that is done to assess the level of
consciousness that may occur due to a neurologic injury. In the mnemonic " AVPU," A indicates alert, V
indicates response to voice, P stands for response to pain, and U indicates unresponsive. Exposure
assessment is one of the priorities of a primary survey, which involves removing clothing for a complete
assessment and preventing hypothermia using heat devices. Breathing assessment involves checking
breath sounds and respiratory effort. Circulation assessment is performed in a primary survey to monitor
blood pressure and pulse.
A client has undergone hypophysectomy. Which action would the nurse consider to be most appropriate
during postoperative care to prevent a cerebrospinal fluid (CSF) leak? - (answer)Prohibiting coughing or
sneezing
Hypophysectomy is the surgical removal of the pituitary gland and tumor for the treatment of
hyperpituitarism. Coughing and sneezing should be avoided because this may lead to increased pressure
in the incision area and CSF leak. Performing deep-breathing exercises would help in preventing
pulmonary problems. Nasal drainage should be assessed to determine the leakage of CSF. Neurologic
status of the client should be monitored to determine intracranial pressure.
VERIFIED SOLUTIONS!!!! ALREADY GRADED A+ LATEST UPDATE!!!
After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes
level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this
assessment - (answer)Motor function is part of a neurologic assessment and provides information about
cerebral function. Blood pressure and temperature are not direct measures of neurologic status. Head
circumference provides information as to skeletal development and brain growth, not neurologic data. A
change in head circumference as a result of increased intracranial pressure is not expected in a 4-year-
old whose cranial bones are fused.
A 12-year-old child is admitted to the hospital for observation after sustaining a head injury. Twelve
hours after the injury the child has none of the signs or symptoms of a head injury. What is the nurse's
priority intervention at this time - (answer)Assessing the level of consciousness every hour. Evidence of a
subdural hemorrhage may take hours or days to develop; a diminishing level of consciousness is an early
indication of neurological damage.
What interventions should the nurse implement when caring for a client with syndrome of inappropriate
antidiuretic hormone - (answer)Providing frequent oral care
Instituting fall risk precautions
Monitoring for and reporting neurologic changes
The excess production of antidiuretic hormone associated with SIADH leads to increased water
reabsorption by the kidneys. Increased water reabsorption results in decreased urinary output,
increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. Because
treatment includes restricting fluids, frequent oral care is provided to increase client comfort. Fall risk
precautions are instituted to protect the client from injury that might occur as a result of neurologic
changes associated with declining serum sodium. The nurse monitors for and reports changes in
neurologic status resulting from cerebral edema and hyponatremia. Immediate treatment goals are to
restore normal fluid balance and normal serum osmolality. Fluids are restricted to no more than 1000 mL
and to no more than 500 mL for the client with severe hyponatremia. Treatment of SIADH includes
placing the bed flat or elevating the head of the bed no more than 10 degrees. This position promotes
venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular
filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that
antidiuretic hormone release should be decreased.
A nurse is assessing sudden changes in the neurologic status of different clients after an earthquake.
Which client should require endotracheal intubation and mechanical ventilation? - (answer)The Glasgow
,(NURS 401) NURSING 401 CRIT CARE EXAM STUDY SET WITH 100%
VERIFIED SOLUTIONS!!!! ALREADY GRADED A+ LATEST UPDATE!!!
Coma Scale (GCS) assigns a numeric score for each of the areas of the client's neurologic status. The
lower the score of the GCS, the lower the client's neurologic function. Client 3 is opening the eyes on
pain, so the score is 2. The client shows abnormal flexion motor response, which has a score of 3, and
the verbal response is incomprehensible, scoring 2. Therefore, the total score is 2+3+2=7. A score equal
to or below 8 indicates a need for endotracheal intubation and mechanical ventilation. Client 1 will have
a GCS score of 12. Client 2 will have a GCS score of 13. Client 4 will have a GCS score of 9.
A nurse is assessing the level of consciousness of four different clients. Which client would have the
lowest neurologic function? - (answer)GCS again
The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes
associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? -
(answer)"Clients with decreased sensory perception of touch should be carefully monitored for
infection."
Decreased sensory perception is a neurological change associated with aging. Clients with this change
should be instructed to reduce the risks associated with falling. Therefore, the nurse should intervene to
correct this misconception. All the other statements are correct and require no follow up. Clients with an
increased risk for infections due to structural deterioration of microglia should be monitored for
infections. Clients with recent memory loss should be taught by repetition and by using memory aids
that provide recurrent alerts to facilitate retention of information. This would help the client to learn
new information and recall it when needed. Clients with slower processing time should be provided with
sufficient time to respond to questions or directions. Allowing adequate time for processing helps
differentiate normal findings from neurologic deterioration. Clients with decreased coordination should
be instructed to hold handrails when ambulating to provide support and prevent falls.
For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol
withdrawal? - (answer)Irritability
Tachycardia
Increasing anxiety
Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's
neurologic adaptation to the withdrawal of alcohol. Tachycardia is one of the early sign of withdrawal; it
results from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they
,(NURS 401) NURSING 401 CRIT CARE EXAM STUDY SET WITH 100%
VERIFIED SOLUTIONS!!!! ALREADY GRADED A+ LATEST UPDATE!!!
usually do not occur before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of
withdrawal that may be seen during alcohol withdrawal delirium; they result from autonomic
overactivity.
The nurse is conducting a neurologic assessment on a client brought to the emergency room after a
motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward
and inward. The nurse recognizes that this response represents an injury to what part of the brain? -
(answer)Midbrain
Decorticate posturing[1][2][3] is a sign of significant deterioration in a client's neurologic status and is
manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to
the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation,
judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and
brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion,
alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses
in the above listed areas.
A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The
nurse concludes that these neurologic deficits are caused primarily by which response? -
(answer)Vascular spasms
In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to
the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to
significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged
ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure
diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause
generalized weakness; however, hemiparesis and aphasia are not the result of electrolyte loss.
To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central
venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing
action? - (answer)Auscultate the lungs to evaluate breath sounds.
The most significant and life-threatening complication of insertion of a subclavian catheter is a
pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the
, (NURS 401) NURSING 401 CRIT CARE EXAM STUDY SET WITH 100%
VERIFIED SOLUTIONS!!!! ALREADY GRADED A+ LATEST UPDATE!!!
lung; a client's respiratory status always is the priority. Although a chest x-ray may be done before TPN is
begun, it is not the priority immediately after insertion of the catheter. A baseline blood glucose level
should be obtained before insertion of the catheter. After TPN is started, routine monitoring of blood
glucose levels is important. Although assessing for a neurologic deficit should be done eventually, it is
not the priority at this time.
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? -
(answer)Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
Because one-half NS is a hypotonic solution, it is contraindicated. It would actually compound the issue
instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake
and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of
hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the
brain, resulting in altered mental status. Therefore it is important for the nurse to assess for neurologic
changes.
A group of clients is admitted with neurologic injury after hiking at high altitude. The nurse is assessing
using the "AVPU" mnemonic. Which type of emergency assessment is the nurse performing? -
(answer)Disability assessment is a part of the primary survey that is done to assess the level of
consciousness that may occur due to a neurologic injury. In the mnemonic " AVPU," A indicates alert, V
indicates response to voice, P stands for response to pain, and U indicates unresponsive. Exposure
assessment is one of the priorities of a primary survey, which involves removing clothing for a complete
assessment and preventing hypothermia using heat devices. Breathing assessment involves checking
breath sounds and respiratory effort. Circulation assessment is performed in a primary survey to monitor
blood pressure and pulse.
A client has undergone hypophysectomy. Which action would the nurse consider to be most appropriate
during postoperative care to prevent a cerebrospinal fluid (CSF) leak? - (answer)Prohibiting coughing or
sneezing
Hypophysectomy is the surgical removal of the pituitary gland and tumor for the treatment of
hyperpituitarism. Coughing and sneezing should be avoided because this may lead to increased pressure
in the incision area and CSF leak. Performing deep-breathing exercises would help in preventing
pulmonary problems. Nasal drainage should be assessed to determine the leakage of CSF. Neurologic
status of the client should be monitored to determine intracranial pressure.
