Exam 11: Intracranial Regulation

The nurse is planning discharge teaching for a child with epilepsy who is prescribed phenytoin (Dilantin).Which information is important for the nurse to include in these instructions?

The nurse is caring for a child with decreased level of consciousness secondary to increased intracranial pressure (IICP)from a head trauma.Which prescription from the healthcare provider should the nurse question?

The nurse identifies the diagnosis of Interrupted Family Processes for a child who sustained a brain injury during an automobile accident.Which nursing intervention would support this diagnosis?

The nurse is caring for a client in the neurological intensive care unit (ICU)with head trauma.The client is being monitored for increased intracranial pressure (IICP).Using the Monroe-Kellie hypothesis as a basis for explanation,which comment by the nurse to the client's family would be most appropriate?

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP).Which classifications of medications should the nurse prepare to administer to this client? Select all that apply.

A preschool-age client with myoclonic seizures has been on a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided lower abdominal pain.Which complication of the ketogenic diet should the nurse suspect the client is experiencing?

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure.What actions should the nurse take to support this client's care need? Select all that apply.

The nurse is planning care for a client with a head injury and increased intracranial pressure (IICP)from a motor vehicle crash.Which intervention is a priority for this client?

The nurse is caring for a toddler-age client who starts to have a tonic-clonic (grand mal)seizure while in a crib in the hospital.The child's jaws are clamped shut.What is the most appropriate nursing action?

A school-age client is experiencing photophobia,a sore neck,chills,and fever.During a physical assessment,the nurse uses the technique in the Exhibit.Why did the nurse use this technique when assessing the client?

The nurse makes a visit to the home of an adolescent recently discharged from the hospital for a seizure disorder.Which observations indicate that outcomes for care have been achieved? Select all that apply.

The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP)in preparation for an evaluation to be done by the healthcare provider during morning rounds.Which diagnostic test results should the nurse make available to the healthcare provider for review? Select all that apply.

The nurse becomes concerned when a client who sustained a head injury from a motor vehicle crash begins to demonstrate an abnormal posture.(See image).What does this posture suggest to the nurse about the client's brain functioning?

The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP)shunt as treatment for increased intracranial pressure (IICP).The nurse has taught the parents to monitor the child for shunt malfunction.Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met?

A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS)score of 6.Which action by the nurse is the most appropriate?

The nurse observes a school-age client have an absence seizure.When documenting the seizure in the medical record,which is the most appropriate?

The nurse is planning care for an older adult client with a head injury sustained from a motor vehicle crash.Which information should the nurse keep in mind when planning this client's care? Select all that apply.

An older adult client is experiencing a tonic-clonic (grand mal)seizure exceeding 10 minutes in length.Which medication should the nurse prepare to administer to this client?

While caring for a client with increased intracranial pressure (IICP),a family member asks to assist.Which interventions are appropriate for the nurse to teach the family member regarding this client's care? Select all that apply.

The nurse identifies the diagnosis Risk for Trauma as appropriate for a client with a seizure disorder.Based on this diagnosis,which nursing interventions are appropriate when this client experiences a seizure? Select all that apply.