Nursing Care of Patients With Central Nervous System Disorders

The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. For what early signs of increased intracranial pressure (ICP) should the nurse be alert? a. Bradycardia b. Hypothermia c. Pinpoint pupils d. Decreased level of consciousness ____ 2. The vital signs for a client with a possible head injury were on admission: blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Which vital sign assessment conducted four hours later most likely indicates the presence of increased intracranial pressure (ICP)? a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min b. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min c. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min d. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min ____ 3. A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. Which action should the nurse make a priority at this time? a. Find out how the accident happened. b. Ensure the patient is bathed before surgery. c. Have the patient’s next of kin sign a consent form. d. Send the patient’s belongings home with a family member. ____ 4. A patient with a severe headache due to viral meningitis requests an opioid analgesic. What explanation about opioids should the nurse provide? a. “Opioid analgesics increase intracranial pressure.” b. “Opioid analgesics are used as a last resort for headaches.” c. “Opioid analgesics are contraindicated in patients with meningitis.” d. “Acetaminophen (Tylenol) is more effective in treating meningitis-related headaches.” ____ 5. The nurse concludes that a patient’s meningitis is improving. What activity did the patient perform for the nurse to come to this conclusion? a. Dorsiflex both feet. b. Sit up and drink water. c. Touch the chin to the chest. d. Maintain a side-lying position in bed. ____ 6. The nurse is assisting with teaching a patient about tension headaches. Which explanation of tension headaches should the nurse provide? a. “Tension headaches result from release of pain mediators in the periphery.” b. “Tension headaches are caused by stress, which causes cerebral vessel constriction.” c. “Tension headaches are a result of stress and sustained muscle contraction of the head and neck.” d. “Tension headaches are caused by blood sugar fluctuations that result from excessive stress.” ____ 7. The nurse is determining care for a patient with acute migraine headaches. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches? a. Keep a headache diary. b. Avoid sugar and caffeine. c. Avoid bright light and noise. d. Avoid taking analgesics until the cause has been determined. ____ 8. The nurse administers an analgesic to a patient with a headache. How should the nurse assess the patient’s response to the medication? a. Observe the patient’s behavior. b. Ask the patient to describe the pain. c. Monitor the patient’s blood pressure and pulse. d. Have the patient rate the pain on a scale of 0 to 10. ____ 9. A student under a great deal of stress develops a severe tension headache and goes to the school clinic. What strategy should the nurse teach the student for dealing with the onset of headaches in the future? a. Aerobic exercise b. Relaxation exercises c. Use of vitamin C and zinc d. Use of distraction techniques