Deck 11: Intracranial Regulation

Question 1

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?

A) Altered level of consciousness
B) Developing a seizure disorder
C) Brain stem impairment
D) Corticospinal tract impairment

Answer 1

Brain stem impairment

Question 2

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?

A) Teach the family the importance of using seat belts.
B) Encourage the family to express feelings.
C) Refer the family to support services in the community.
D) Explain rules for visiting in the Intensive Care Unit.

Answer 2

Encourage the family to express feelings.

Question 3

A school-age client loses consciousness after being hit in the head with a bat at baseball practice.The child was not wearing a helmet.The last set of vital signs showed heart rate 48,blood pressure 148/74 mmHG,and respiratory rate 28 and irregular.Based on this data,which conclusion by the nurse is the most appropriate?

A) Typical for a sleeping child at this age
B) A sign of increased intracranial pressure
C) Normal for this child
D) A sign that this child has a spinal cord injury

Answer 3

A sign of increased intracranial pressure

Question 4

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?

A) Passive range-of-motion exercises
B) Elevating the head of the bed to 30°
C) Vital signs and neuro checks every hour
D) Administering oxygen at 2 L nasal cannula to keep saturation above 95%

Question 5

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) "If our child has a bulging soft spot, we will call the doctor."
B) "If our child develops an altered level of consciousness, we will notify the doctor."
C) "If we notice our child's head is expanding, we will notify the doctor."
D) "If our child develops sunset eyes, it will be important to call the doctor."

Question 6

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?

A) Ensuring adequate oxygenation
B) Maintaining a calm environment
C) Monitoring for nausea and vomiting
D) Controlling pain

Question 7

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.

A) Limit the client's visitors.
B) Teach family to speak softly and minimize touching.
C) Elevate the head of the bed.
D) Provide all care quickly at one time to provide periods of rest.
E) Keep the room dark and quiet.

Question 8

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.

A) Turn the client to a lateral position, if possible.
B) Stay with the client.
C) Insert a tongue blade into the client's mouth.
D) Call for help.
E) Restrain the client.

Question 9

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.

A) The client is not driving.
B) The client has not had a seizure for 1 month.
C) The client is participating in the school basketball team.
D) The client has bruises on both arms from seizure activity.
E) The client has several episodes of constipation each week.

Question 10

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) Loop diuretics
B) Antibiotics
C) Anticonvulsants
D) Histamine H₂ antagonists
E) Antipyretics

Question 11

The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP).Which assessment data indicates that the nurse is successful? Select all that apply.

A) Body temperature elevated 1 degree in 4 hours
B) Absent gag reflex
C) Pupils equal and reactive to light
D) Oxygen saturation 93% via pulse oximetry
E) Sluggish response to verbal stimuli

Question 12

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.

A) The head of the bed should be elevated to 30 degrees.
B) The client should remain in a supine position.
C) The family should use slow, gentle movements when repositioning the client.
D) The client should be repositioned as needed.
E) Patients with ICP should remain in a stationary position.

Question 13

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.

A) Anxiety, illness, and pain can alter the ability to learn.
B) Reflexes are less intense in an older client.
C) Impulse transmission and reactions to stimuli are slower.
D) The plantar and Achilles reflexes are hyperactive in this age group.
E) Impairment in vision and hearing should be taken into consideration.

Question 14

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?

A) Assess airway, breathing, and circulation.
B) Assess patency of the Foley catheter.
C) Treat the client's pain.
D) Get a complete history from the client.

Question 15

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) "There is nothing that can be done."
B) "Increasing brain pressure decreases the amount of blood flow to the brain itself."
C) "The pressure in the brain is increasing because the brain is shrinking."
D) "Because there is more pressure in the brain, the blood flow is also increasing."

Question 16

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?

A) It is a routine part of the physical assessment.
B) The client's symptoms indicated meningitis
C) The nurse was assessing range of motion of the neck.
D) The nurse was assessing optic nerve functioning.

Question 17

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.

A) Bronchoscopy results
B) MRI result
C) Head CT scan with and without contrast
D) Electroencephalogram
E) Complete blood count of the cerebrospinal fluid

Question 18

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?

A) Brush teeth less frequently.
B) Take the medication with milk.
C) Increase fluid intake.
D) Increase vitamin D intake.

Question 19

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

A) "Pulled arms in toward the body and flexed hands over the chest. This lasted 2 minutes."
B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes."
C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes."
D) "Sat very still and was unresponsive with a blank stare for 2 minutes."

Question 20

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?

A) Bowel obstruction
B) Renal calculi
C) Urinary tract infection
D) Appendicitis

Question 21

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?

A) Intramuscular injection of diazepam
B) 5% dextrose solution IV
C) Intravenous diazepam slowly over several minutes
D) Intravenous bolus of 10% dextrose

Question 22

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) Place a tongue blade between the child's jaws.
B) Restrain the child to prevent injury.
C) Prepare the suction equipment.
D) Stay with the child to observe for complications.