Exam 65: Management of Patients With Neurologic Dysfunction

A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school?

A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply?

During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed and dilated. What is the most plausible clinical significance of the nurses finding?

The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient?

The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority?

A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate?

The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?

The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?

A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol?

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?

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?

A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?

A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?

A nurse is collaborating with the interdisciplinary team to help manage a patients recurrent headaches. What aspect of the patients health history should the nurse identify as a potential contributor to the patients headaches?

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?

A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding?

The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What Diagnostic procedures might be included in this patients admission orders? Select all that apply.

The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.