Final Exam on Medical Surgical Nursing Management of Patients with Neurologic Dysfunction

Final Exam on Medical Surgical Nursing Management of Patients with Neurologic Dysfunction A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication? -Hydrochlorothiazide (HydroDIURIL) -Furosemide (Lasix) -Mannitol (Osmitrol) -Spirolactone (Aldactone) - Answer-Mannitol (Osmitrol) Feedback: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema. The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? -Maintaining accurate records of intake and output - Maintaining a patent airway - Inserting a nasogastric (NG) tube as ordered - Providing appropriate pain control - Answer-Maintaining a patent airway Feedback: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate. The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patient's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? -Position the patient in the high Fowler's position as tolerated. -Administer osmotic diuretics as ordered. -Participate in interventions to increase cerebral perfusion pressure. -Prepare the patient for craniotomy. - Answer-Participate in interventions to increase cerebral perfusion pressure. Feedback: The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the patient's condition. The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What would be an appropriate intervention for this diagnosis? - Change the patient's position as indicated. - Monitor serum electrolytes. -Maintain NPO status. -Monitor arterial blood gas (ABG) values. - Answer-Monitor serum electrolytes. Feedback: The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Changing the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume. A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? - Restrain the patient to prevent injury. -Open the patient's jaws to insert an oral airway. -Place patient in high Fowler's position. - Loosen the patient's restrictive clothing. - Answer-Loosen the patient's restrictive clothing. Feedback: An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. 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 mucus. 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? -MonroKellie hypothesis -Glasgow Coma Scale -Cranial nerve function -Mental status examination - Answer-Glasgow Coma Scale Feedback: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The MonroKellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC. While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? - Epileptic cry -Confusion - Urinary incontinence -Body rigidity - Answer-Confusion Feedback: In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure. A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? - Encephalitis - CSF leak - Meningitis -Catheter occlusion - Answer-Meningitis Feedback: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter. The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patient's treatment? -Computed tomography (CT) scan - Lumbar puncture - Magnetic resonance imaging (MRI) -Venous Doppler studies - Answer-Lumbar puncture Feedback: A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself. The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? -Intravenous phenobarbital (Luminal) - Intravenous diazepam (Valium) -Oral lorazepam (Ativan) -Oral phenytoin (Dilantin) - Answer-Intravenous diazepam (Valium) Feedback: Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given