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Neuro ICP, LOC, meningitis1) A client admitted to the hospital with a subarachnoid hemorrhagehas complaints of severe headache, nuchal rigidity, and projectilevomiting. The nurse knows lumbar puncture (!) would becontraindicated in this client in which of the following circumstances"

1 #omiting continues$ %ntracranial pressure (%&!) is increased' The client needs mechanical ventilation lood is anticipated in the cerebralspinal *uid (&+)

$) A client with a subdural hematoma becomes restless andconfused, with dilation of the ipsilateral pupil. The physician ordersmannitol for which of the following reasons"

1 To reduce intraocular pressure$ To prevent acute tubular necrosis' To promote osmotic diuresis to decrease %&! To draw water into the vascular system to increase blood

pressure') A client with subdural hematoma was given mannitol to decreaseintracranial pressure (%&!). -hich of the following results would bestshow the mannitol was eective"

1 /rine output increases$ !upils are 0 mm and nonreactive' +ystolic blood pressure remains at 12 mm 3g /4 and creatinine levels return to normal

) -hich of the following values is considered normal for %&!"1 2 to 1 mm 3g$ $ mm 3g

' ' to mm 3g 1$2502 mm 3g

) -hich of the following symptoms may occur with a phenytoinlevel of '$ mg5dl"

1 Ata6ia and confusion$ +odium depletion' Tonic7clonic sei8ure /rinary incontinence

9) -hich of the following signs and symptoms of increased %&! afterhead trauma would appear :rst"

1 radycardia

$ arge amounts of very dilute urine' ;estlessness and confusion -idened pulse pressure

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Temporal0) -hile cooking, your client couldn>t feel the temperature of a hotoven. -hich lobe could be dysfunctional"

1 rontal$ =ccipital

' !arietal Temporal?) The nurse is assessing the motor function of an unconsciousclient. The nurse would plan to use which of the following to test theclient>s peripheral response to pain"

1 +ternal rub$ !ressure on the orbital rim' +@uee8ing the sternocleidomastoid muscle 4ail bed pressure

12) The client is having a lumbar puncture performed. The nursewould plan to place the client in which position for the procedure"

1 +ide7lying, with legs pulled up and head bent down onto thechest

$ +ide7lying, with a pillow under the hip' !rone, in a slight Trendelenburg>s position !rone, with a pillow under the abdomen.

11) A nurse is assisting with caloric testing of the oculovestibularre*e6 of an unconscious client. &old water is injected into the leftauditory canal. The client e6hibits eye conjugate movements towardthe left followed by a rapid nystagmus toward the right. The nurseunderstands that this indicates the client has

1 A cerebral lesion

$ A temporal lesion' An intact brainstem rain death

1$) The nurse is caring for the client with increased intracranialpressure. The nurse would note which of the following trends in vitalsigns if the %&! is rising"

1 %ncreasing temperature, increasing pulse, increasing respirations,decreasing blood pressure.

$ %ncreasing temperature, decreasing pulse, decreasingrespirations, increasing blood pressure.

' Becreasing temperature, decreasing pulse, increasing

respirations, decreasing blood pressure. Becreasing temperature, increasing pulse, decreasing

respirations, increasing blood pressure.1') The nurse is evaluating the status of a client who had acraniotomy ' days ago. The nurse would suspect the client isdeveloping meningitis as a complication of surgery if the cliente6hibits

1 A positive rud8inski>s sign

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$ A negative Cernig>s sign' Absence of nuchal rigidity A Dlascow &oma +cale score of 1

1) A client is arousing from a coma and keeps saying, EFust stop thepain.G The nurse responds based on the knowledge that the human

body typically and automatically responds to pain :rst with attemptsto1 Tolerate the pain$ Becrease the perception of pain' Hscape the source of pain Bivert attention from the source of pain.

1) Buring the acute stage of meningitis, a '7year7old child is restlessand irritable. -hich of the following would be most appropriate toinstitute"

1 imiting conversation with the child$ Ceeping e6traneous noise to a minimum

' Allowing the child to play in the bathtub !erforming treatments @uickly

19) -hich of the following would lead the nurse to suspect that a childwith meningitis has developed disseminated intravascular coagulation"

1 3emorrhagic skin rash$ Hdema' &yanosis Byspnea on e6ertion

1

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' &lear &+, elevated protein, and decreased glucose &lear &+, decreased pressure, and elevated protein

$2) A nurse is planning care for a child with acute bacterial meningitis.ased on the mode of transmission of this infection, which of thefollowing would be included in the plan of care"

1 4o precautions are re@uired as long as antibiotics have beenstarted$ Iaintain enteric precautions' Iaintain respiratory isolation precautions for at least $ hours

after the initiation of antibiotics Iaintain neutropenic precautions

$1) A nurse is reviewing the record of a child with increased %&! andnotes that the child has e6hibited signs of decerebrate posturing. =nassessment of the child, the nurse would e6pect to note which of thefollowing if this type of posturing was present"

1 Abnormal *e6ion of the upper e6tremities and e6tension of the

lower e6tremities$ ;igid e6tension and pronation of the arms and legs' ;igid pronation of all e6tremities laccid paralysis of all e6tremities

$$) -hich of the following assessment data indicated nuchal rigidity"1 !ositive Cernig>s sign$ 4egative rud8inski>s sign' !ositive homan>s sign 4egative Cernig>s sign

$') Ieningitis occurs as an e6tension of a variety of bacterialinfections due to which of the following conditions"

1 &ongenital anatomic abnormality of the meninges$ ack of ac@uired resistance to the various etiologic organisms' =cclusion or narrowing of the &+ pathway 4atural aJnity of the &4+ to certain pathogens

$) -hich of the following pathologic processes is often associatedwith aseptic meningitis"

1 %schemic infarction of cerebral tissue$ &hildhood diseases of viral causation such as mumps' rain abscesses caused by a variety of pyogenic organisms &erebral ventricular irritation from a traumatic brain injury

A4+-H;+

1 $. +udden removal of &+ results in pressures lower in thelumbar area than the brain and favors herniation of the brainKtherefore, ! is contraindicated with increased %&!. #omiting maybe caused by reasons other than increased %&!K therefore, !isn>t strictly contraindicated. An ! may be preformed on clientsneeding mechanical ventilation. lood in the &+ is diagnostic forsubarachnoid hemorrhage and was obtained before signs andsymptoms of %&!.

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$ '. Iannitol promotes osmotic diuresis by increasing the pressuregradient, drawing *uid from intracellular to intravascular spaces.Although mannitol is used for all the reasons described, thereduction of %&! in this client is a concern.

' 1. Iannitol promotes osmotic diuresis by increasing the pressure

gradient in the renal tubes. i6ed and dilated pupils aresymptoms of increased %&! or cranial nerve damage. 4oinformation is given about abnormal /4 and creatinine levels orthat mannitol is being given for renal dysfunction or bloodpressure maintenance.

1. 4ormal %&! is 271 mm 3g. 1. A therapeutic phenytoin level is 12 to $2 mg5dl. A level of '$

mg5dl indicates to6icity. +ymptoms of to6icity include confusionand ata6ia. !henytoin doesn>t cause hyponatremia, sei8ure, orurinary incontinence. %ncontinence may occur during or after asei8ure.

9 '. The earliest symptom of elevated %&! is a change in mentalstatus. radycardia, widened pulse pressure, and bradypneaoccur later. The client may void large amounts of very diluteurine if there>s damage to the posterior pituitary.

< . The temporal lobe functions to regulate memory and learningproblems because of the integration of the hippocampus. Thefrontal lobe primarily functions to regulate thinking, planning,and judgment. The occipital lobe functions regulate vision. Theparietal lobe primarily functions with sensory function.

0 '. The parietal lobe regulates sensory function, which wouldinclude the ability to sense hot or cold objects. The frontal lobe

regulates thinking, planning, and judgment, and the occipitallobe is primarily responsible for vision function. The temporallobe regulates memory.

? . Iotor testing on the unconscious client can be done only bytesting response to painful stimuli. 4ailbed pressure tests a basicperipheral response. &erebral responses to pain are testing usingsternal rub, placing upward pressure on the orbital rim, ors@uee8ing the clavicle or sternocleidomastoid muscle.

12. 1. The client undergoing lumbar puncture is positioned lying onthe side, with the legs pulled up to the abdomen, and with the headbent down onto the chest. This position helps to open the spaces

between the vertebrae.11. '. &aloric testing provides information about dierentiatingbetween cerebellar and brainstem lesions. After determining patencyof the ear canal, cold or warm water is injected in the auditory canal. Anormal response that indicates intact function of cranial nerves %%%, %#,and #%%% is conjugate eye movements toward the side being irrigated,followed by rapid nystagmus to the opposite side. Absent ordysconjugate eye movements indicate brainstem damage.

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1$. $. A change in vital signs may be a late sign of increasedintracranial pressure. Trends include increasing temperature and bloodpressure and decreasing pulse and respirations. ;espiratoryirregularities also may arise.1'. 1. +igns of meningeal irritation compatible with meningitis include

nuchal rigidity, positive rud8inski>s sign, and positive Cernig>s sign.4uchal rigidity is characteri8ed by a sti neck and soreness, which isespecially noticeable when the neck is :6ed. Cernig>s sign is positivewhen the client feels pain and spasm of the hamstring muscles whenthe knee and thigh are e6tended from a *e6ed7right angle position.rud8inski>s sign is positive when the client *e6es the hips and kneesin response to the nurse gently *e6ing the head and neck onto thechest. A Dlascow &oma +cale of 1 is a perfect score and indicates theclient is awake and alert with no neurological de:cits.1. '. The client>s innate responses to pain are directed initiallytoward escaping from the source of pain. #ariations in individuals>

tolerance and perception of pain are apparent only in conscious clients,and only conscious clients are able to employ distraction to helprelieve pain.1. $. A child in the acute stage of meningitis is irritable andhypersensitive to loud noise and light. Therefore, e6traneous noiseshould be minimi8ed and bright lights avoided as much as possible.There is no need to limit conversations with the child. 3owever, thenurse should speak in a calm, gentle, reassuring voice. The child needsgentle and calm bathing. ecause of the acuteness of the infection,sponge baths would be more appropriate than tub baths. Althoughtreatments need to be completed as @uickly as possible to prevent

overstressing the child, any treatments should be performed carefullyand at a pace that avoids sudden movements to prevent startling thechild and subse@uently increasing intracranial pressure.19. 1. B%& is characteri8ed by skin petechiae and a purpuric skin rashcaused by spontaneous bleeding into the tissues. An abnormalcoagulation phenomenon causes the condition.1

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) -hen evaluating an AD from a client with a subduralhematoma, the nurse notes the !a&=$ is '2 mm 3g. -hich of thefollowing responses best describes this result"

AppropriateK lowering carbon dio6ide (&=$) reduces intracranialpressure (%&!).

9 HmergentK the client is poorly o6ygenated.< 4ormal0 +igni:cantK the client has alveolar hypoventilation.

) A client who had a transsphenoidal hypophysectomy should bewatched carefully for hemorrhage, which may be shown by which ofthe following signs"

loody drainage from the ears9 re@uent swallowing< Duaiac7positive stools0 3ematuria

9) After a hypophysectomy, vasopressin is given %I for which of the

following reasons" To treat growth failure9 To prevent syndrome of inappropriate antidiuretic hormone

(+%AB3)< To reduce cerebral edema and lower intracranial pressure0 To replace antidiuretic hormone (AB3) normally secreted by the

pituitary.salert and oriented. -hich of the following nursing interventions shouldbe done :rst"

Assess full ;=I to determine e6tent of injuries

9 &all for an immediate chest 67ray< %mmobili8e the client>s head and neck0 =pen the airway with the head7tilt chin7lift maneuver

0) A client with a &9 spinal injury would most likely have which ofthe following symptoms"

Aphasia9 3emiparesis< !araplegia0 Tetraplegia

?) A '27year7old was admitted to the progressive care unit with a &fracture from a motorcycle accident. -hich of the following

assessments would take priority" ladder distension9 4eurological de:cit< !ulse o6 readings0 The client>s feelings about the injury

12) -hile in the H;, a client with &0 tetraplegia develops a bloodpressure of 0252, pulse 0, and ;; of 10. The nurse suspects which ofthe following conditions"

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Autonomic dysre*e6ia9 3emorrhagic shock< 4eurogenic shock0 !ulmonary embolism

11) A client is admitted with a spinal cord injury at the level of T1$. 3e

has limited movement of his upper e6tremities. -hich of the followingmedications would be used to control edema of the spinal cord" Aceta8olamide (Biamo6)9 urosemide (asi6)< Iethylprednisolone (+olu7Iedrol)0 +odium bicarbonate

1$) A $$7year7old client with @uadriplegia is apprehensive and *ushed,with a blood pressure of $125122 and a heart rate of 2 bpm. -hich ofthe following nursing interventions should be done :rst"

!lace the client *at in bed9 Assess patency of the indwelling urinary catheter

< Dive one + nitroglycerin tablet0 ;aise the head of the bed immediately to ?2 degrees

1') A client with a cervical spine injury has Dardner7-ells tongsinserted for which of the following reasons"

To hasten wound healing9 To immobili8e the surgical spine< To prevent autonomic dysre*e6ia0 To hold bony fragments of the skull together

1) -hich of the following interventions describes an appropriatebladder program for a client in rehabilitation for spinal cord injury"

%nsert an indwelling urinary catheter to straight drainage

9 +chedule intermittent catheri8ation every $ to hours< !erform a straight catheri8ation every 0 hours while awake0 !erform &rede>s maneuver to the lower abdomen before the

client voids.1) A client is admitted to the H; for head trauma is diagnosed withan epidural hematoma. The underlying cause of epidural hematoma isusually related to which of the following conditions"

aceration of the middle meningeal artery9 ;upture of the carotid artery< Thromboembolism from a carotid artery0 #enous bleeding from the arachnoid space

19) A $'7year7old client has been hit on the head with a baseball bat.The nurse notes clear *uid draining from his ears and nose. -hich ofthe following nursing interventions should be done :rst"

!osition the client *at in bed9 &heck the *uid for de6trose with a dipstick< +uction the nose to maintain airway patency0 %nsert nasal and ear packing with sterile gau8e

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1

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' Hpidural hematoma &ontusion

'2) After falling $2>, a '97year7old man sustains a &9 fracture withspinal cord transaction. -hich other :ndings should the nurse e6pect"

1 Luadriplegia with gross arm movement and diaphragmic

breathing$ Luadriplegia and loss of respiratory function' !araplegia with intercostal muscle loss oss of bowel and bladder control

'1) A $27year7old client who fell appro6imately '2> is unresponsive andbreathless. A cervical spine injury is suspected. 3ow should the :rst7responder open the client>s airway for rescue breathing"

1 y inserting a nasopharyngeal airway$ y inserting a oropharyngeal airway' y performing a jaw7thrust maneuver y performing the head7tilt, chin7lift maneuver

'$) The nurse is caring for a client with a T complete spinal cordinjury. /pon assessment, the nurse notes *ushed skin, diaphoresisabove the T, and a blood pressure of 19$5?9. The client reports asevere, pounding headache. -hich of the following nursinginterventions would be appropriate for this client" +elect all that apply.

1 Hlevate the 3= to ?2 degrees$ oosen constrictive clothing' /se a fan to reduce diaphoresis Assess for bladder distention and bowel impaction Administer antihypertensive medication9 !lace the client in a supine position with legs elevated

'') The client with a head injury has been urinating copious amountsof dilute urine through the oley catheter. The client>s urine output forthe previous shift was '222 ml. The nurse implements a new physicianorder to administer

1 Besmopressin (BBA#!, stimate)$ Be6amethasone (Becadron)' Hthacrynic acid (Hdecrin) Iannitol (=smitrol)

') The nurse is caring for the client in the H; following a head injury.The client momentarily lost consciousness at the time of the injury andthen regained it. The client now has lost consciousness again. The

nurse takes @uick action, knowing this is compatible with1 +kull fracture$ &oncussion' +ubdural hematoma Hpidural hematoma

') The nurse is caring for a client who suered a spinal cord injury 0hours ago. The nurse monitors for D% complications by assessing for

1 A *attened abdomen

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$ 3ematest positive nasogastric tube drainage' 3yperactive bowel sounds A history of diarrhea

'9) A client with a spinal cord injury is prone to e6periencingautonomic dysre*e6ia. The nurse would avoid which of the following

measures to minimi8e the risk of recurrence"1 +trict adherence to a bowel retraining program$ imiting bladder catheri8ation to once every 1$ hours' Ceeping the linen wrinkle7free under the client !reventing unnecessary pressure on the lower limbs

'

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$) -hich of the following respiratory patterns indicate increasing %&!in the brain stem"

1 +low, irregular respirations$ ;apid, shallow respirations' Asymmetric chest e6pansion

4asal *aring') -hich of the following nursing interventions is appropriate for aclient with an %&! of $2 mm 3g"

1 Dive the client a warming blanket$ Administer low7dose barbiturate' Hncourage the client to hyperventilate ;estrict *uids

) A client has signs of increased %&!. -hich of the following is anearlyindicator of deterioration in the client>s condition"

1 -idening pulse pressure$ Becrease in the pulse rate

' Bilated, :6ed pupil Becrease in =&

) A client who is regaining consciousness after a craniotomybecomes restless and attempts to pull out her %# line. -hich nursingintervention protects the client without increasing her %&!"

1 !lace her in a jacket restraint$ -rap her hands in soft EmittenG restraints' Tuck her arms and hands under the draw sheet Apply a wrist restraint to each arm

9) -hich of the following describes decerebrate posturing"1 %nternal rotation and adduction of arms with *e6ion of elbows,

wrists, and :ngers$ ack hunched over, rigid *e6ion of all four e6tremities with

supination of arms and plantar *e6ion of the feet' +upination of arms, dorsi*e6ion of feet ack archedK rigid e6tension of all four e6tremities.

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$ Hlevating the head of the bed to '2 degrees' og rolling or turning as a unit when turning Ceeping the head in neutral position

?) A client has been pronounced brain dead. -hich :ndings wouldthe nurse assess" &heck all that apply.

1 Becerebrate posturing$ Bilated non reactive pupils' Beep tendon re*e6es Absent corneal re*e6

A4+-H;+1 1. The nurse should :rst attempt nursing interventions, such as

repositioning the client to avoid neck *e6ion, which increasesvenous return and lowers %&!. %f nursing measures proveineective, notify the physician, who may prescribe mannitol,pentobarbital, or hyperventilation therapy.

$ $. Bilantin %# shouldn>t be given at a rate e6ceeding 2

mg5minute. ;apid administration can depress the myocardium,causing arrhythmias. Therapeutic drug levels range from 12 to$2 mg5ml. Bilantin shouldn>t be mi6ed in solution foradministration. 3owever, because it>s compatible with normalsaline solution, it can be injected through an %# line containingnormal saline. -hen given through an %# catheter hand, dilantinmay cause purple glove syndrome.

' 1. /rine output of '22 ml5hr may indicate diabetes insipidus,which is a failure of the pituitary to produce anti7diuretichormone. This may occur with increased intracranial pressureand head traumaK the nurse evaluates for low urine speci:c

gravity, increased serum osmolarity, and dehydration. There>s noevidence that the client is e6periencing renal failure. !rovidingemollients to prevent skin breakdown is important, but doesn>tneed to be performed immediately. +lowing the rate of %# *uidwould contribute to dehydration when polyuria is present.

1. A normal !a&=$ value is ' to mm 3g. &=$ hasvasodilating propertiesK therefore, lowering !a&=$ throughhyperventilation will lower %&! caused by dilated cerebralvessels. =6ygenation is evaluated through !a=$ and o6ygensaturation. Alveolar hypoventilation would be re*ected in anincreased !a&=$.

$. re@uent swallowing after brain surgery may indicate *uid orblood leaking from the sinuses into the oropharyn6. lood or *uiddraining from the ear may indicate a basilar skull fracture.

9 . After hypophysectomy, or removal of the pituitary gland, thebody can>t synthesi8e AB3. +omatropin or growth hormone, notvasopressin is used to treat growth failure. +%AB3 results frome6cessive AB3 secretion. Iannitol or corticosteroids are used todecrease cerebral edema.

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< '. All clients with a head injury are treated as if a cervical spineinjury is present until 67rays con:rm their absence. ;=I wouldbe contraindicated at this time. There is no indication that theclient needs a chest 67ray. The airway doesn>t need to be openedsince the client appears alert and not in respiratory distress. %n

addition, the head7tilt chin7lift maneuver wouldn>t be used untilthe cervical spine injury is ruled out.0 . Tetraplegia occurs as a result of cervical spine injuries.

!araplegia occurs as a result of injury to the thoracic cord andbelow.

? '. After a spinal cord injury, ascending cord edema may cause ahigher level of injury. The diaphragm is innervated at the level of&, so assessment of ade@uate o6ygenation and ventilation isnecessary. Although the other options would be necessary at alater time, observation for respiratory failure is the priority.

12. '. +ymptoms of neurogenic shock include hypotension,

bradycardia, and warm, dry skin due to the loss of adrenergicstimulation below the level of the lesion. 3ypertension, bradycardia,*ushing, and sweating of the skin are seen with autonomic dysre*e6ia.3emorrhagic shock presents with an6iety, tachycardia, andhypotensionK this wouldn>t be suspected without an injury. !ulmonaryembolism presents with chest pain, hypotension, hypo6emia,tachycardia, and hemoptysisK this may be a later complication of spinalcord injury due to immobility.11. '. 3igh doses of +olu7Iedrol are used within $ hours of spinalinjury to reduce cord swelling and limit neurological de:cit. The otherdrugs aren>t indicated in this circumstance.

1$. . An6iety, *ushing above the level of the lesion, piloerection,hypertension, and bradycardia are symptoms of autonomic dysre*e6ia,typically caused by such no6ious stimuli such as a full bladder, fecalimpaction, or decubitus ulcer. !utting the client *at will cause the bloodpressure to increase even more. The indwelling urinary catheter shouldbe assessed immediately after the 3= is raised. 4itroglycerin is givento reduce chest pain and reduce preloadK it isn>t used for hypertensionor dysre*e6ia.1'. $. Dardner7-ells, #inke, and &rutch:eld tongs immobili8e the spineuntil surgical stabili8ation is accomplished.1. $. %ntermittent catheri8ation should begin every $ to hours early

in the treatment. -hen residual volume is less than 22 ml, theschedule may advance to every to 9 hours. %ndwelling catheters maypredispose the client to infection and are removed as soon as possible.&rede>s maneuver is not used on people with spinal cord injury.1. 1. Hpidural hematoma or e6tradural hematoma is usually causedby laceration of the middle meningeal artery. An embolic stroke is athromboembolism from a carotid artery that ruptures. #enous bleedingfrom the arachnoid space is usually observed with subdural hematoma.

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19. $. &lear *uid from the nose or ear can be determined to becerebral spinal *uid or mucous by the presence of de6trose. !lacing theclient *at in bed may increase %&! and promote pulmonary aspiration.The nose wouldn>t be suctioned because of the risk for suctioning braintissue through the sinuses. 4othing is inserted into the ears or nose of

a client with a skull fracture because of the risk of infection.1t prone to dysre*e6ia.1?. '. +pasticity, the return of re*e6es, is a sign of resolving shock.+pinal or neurogenic shock is characteri8ed by hypotension,

bradycardia, dry skin, *accid paralysis, or the absence of re*e6esbelow the level of injury. The absence of pain sensation in the chestdoesn>t apply to spinal shock. +pinal shock descends from the injury,and respiratory diJculties occur at & and above.$2. . 4o6ious stimuli, such as a full bladder, fecal impaction, or adecub ulcer, may cause autonomic dysre*e6ia. A headache is asymptom of autonomic dysre*e6ia, not a cause. Autonomic dysre*e6iais most commonly seen with injuries at T12 or above. 4eurogenicshock isn>t a cause of dysre*e6ia.$1. . !utting the client in the high7owler>s position will decreasecerebral blood *ow, decreasing hypertension. Hlevating the client>s

legs, putting the client *at in bed, or putting the bed in theTrendelenburg>s position places the client in positions that improvecerebral blood *ow, worsening hypertension.$$. '. oss of sympathetic control and unopposed vagal stimulationbelow the level of injury typically cause hypotension, bradycardia,pallor, *accid paralysis, and warm, dry skin in the client in neurogenicshock. 3ypervolemia is indicated by rapid and bounding pulse andedema. Autonomic dysre*e6ia occurs after neurogenic shock abates.+igns of sepsis would include elevated temperature, increased heartrate, and increased respiratory rate.$'. . The diaphragm is stimulated by nerves at the level of &.

%nitially, this client may need mechanical ventilation due to cordedema. This may resolve in time. Absent corneal re*e6es, decerebateposturing, and hemiplegia occur with brain injuries, not spinal cordinjuries.$. $. 3ypertension, bradycardia, an6iety, blurred vision, and *ushingabove the lesion occur with autonomic dysre*e6ia due to uninhibitedsympathetic nervous system discharge. The other options areincorrect.

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$. . %ntermittent catheri8ation may be performed chronically withclean techni@ue, using soap and water to clean the urinary meatus.The meatus is always cleaned from front to back in a woman, or ine6panding circles working outward from the meatus in a man. %t isn>tnecessary to measure the urine. The catheter doesn>t need to be

rotated during removal.$9. '. &hanges in =& may indicate e6panding lesions such assubdural hematomaK orientation and =& are assessed fre@uently for$ hours. A keyhole pupil is found after iridectomy. !rofuse or projectilevomiting is a symptom of increased %&! and should be reportedimmediately. A slight headache may last for several days afterconcussionK severe or worsening headaches should be reported.$s such an important neurotransmitter inschi8ophrenia.

$0. '. An HHD measures the electrical activity of the brain. H6tent ofintracranial bleeding and location of the injury site would bedetermined by &T or I;%. !ercent of functional brain tissue would bedetermined by a series of tests.$?. '. An epidural hematoma occurs when blood collects between theskull and the dura mater. %n a subdural hematoma, venous bloodcollects between the dura mater and the arachnoid mater. %n asubarachnoid hemorrhage, blood collects between the pia mater andarachnoid membrane. A contusion is a bruise on the brain>s surface.'2. 1. A client with a spinal cord injury at levels & to &9 has@uadriplegia with gross arm movement and diaphragmic breathing.

%njury levels &1 to & leads to @uadriplegia with total loss of respiratoryfunction. !araplegia with intercostal muscle loss occurs with injuries atT1 to $. %njuries below $ cause paraplegia and loss of bowel andbladder control.'1. '. %f the client has a suspected cervical spine injury, a jaw7thrustmaneuver should be used to open the airway. %f the tongue or rela6edthroat muscles are obstructing the airway, a nasopharyngeal ororopharyngeal airway can be insertedK however, the client must havespontaneous respirations when the airway is open. The head7tilt, chin7lift maneuver re@uires neck hypere6tension, which can worsen thecervical spine injury.

'$. 1, $, , . The client has signs and symptoms of autonomicdysre*e6ia. The potentially life7threatening condition is caused by anuninhibited response from the sympathetic nervous system resultingfrom a lack of control over the autonomic nervous system. The nurseshould immediately elevate the 3= to ?2 degrees and placee6tremities dependently to decrease venous return to the heart andincrease venous return from the brain. ecause tactile stimuli cantrigger autonomic dysre*e6ia, any constrictive clothing should be

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loosened. The nurse should also assess for distended bladder andbowel impaction, which may trigger autonomic dysre*e6ia, and correctany problems. Hlevated blood pressure is the most life7threateningcomplication of autonomic dysre*e6ia because it can cause stroke, I%,or sei8ures. %f removing the triggering event doesn>t reduce the client>s

blood pressure, %# antihypertensives should be administered. A fanshouldn>t be used because cold drafts may trigger autonomicdysre*e6ia.''. 1. A complication of a head injury is diabetes insipidus, which canoccur with insult to the hypothalamus, the antidiuretic storage vesicles,or the posterior pituitary gland. /rine output that e6ceeds ? per daygenerally re@uires treatment with desmopressin. Be6amethasone, aglucocorticoid, is administered to treat cerebral edema. Thismedication may be ordered for the head injured patient. Hthacrynicacid and mannitol are diuretics, which would be contraindicated.'. . The changes in neurological signs from an epidural hematoma

begin with a loss of consciousness as arterial blood collects in theepidural space and e6erts pressure. The client regains consciousnessas the cerebral spinal *uid is reabsorbed rapidly to compensate for therising intracranial pressure. As the compensatory mechanisms fail,even small amounts of additional blood can cause the intracranialpressure to rise rapidly, and the client>s neurological statusdeteriorates @uickly.'. $. After spinal cord injury, the client can develop paralytic ileus,which is characteri8ed by the absence of bowel sounds and abdominaldistention. Bevelopment of a stress ulcer can be detected by hematestpositive 4D tube aspirate or stool. A history of diarrhea is irrelevant.

'9. $. The most fre@uent cause of autonomic dysre*e6ia is adistended bladder. +traight catheri8ation should be done every to 9hours, and oley catheters should be checked fre@uently to preventkinks in the tubing. &onstipation and fecal impaction are other causes,so maintaining bowel regularity is important. =ther causes includestimulation of the skin from tactile, thermal, or painful stimuli. Thenurse administers care to minimi8e risk in these areas.'

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maintaining alignment of the spine. %f a +tryker frame is not available,a :rm mattress with a bed board should be used.'?. '. ;esolution of spinal shock is occurring when there is a return ofre*e6es (especially *e6ors to no6ious cutaneous stimuli), a state ofhyperre*e6ia rather than *accidity, re*e6 emptying of the bladder, and

a positive abinski>s re*e6.2. ', 1, , $, . Autonomic dysre*e6ia is characteri8ed by severehypertension, bradycardia, severe headache, nasal stuJness, and*ushing. The cause is a no6ious stimulus, most often a distendedbladder or constipation. Autonomic dysre*e6ia is a neurologicalemergency and must be treated promptly to prevent a hypertensivestroke. %mmediate nursing actions are to sit the client up in bed in ahigh7owler>s position and remove the no6ious stimulus. The nurseshould loosen any tight clothing and then check for bladder distention.%f the client has a foley catheter, the nurse should check for kinks inthe tubing. The nurse also would check for a fecal impaction and

disimpact if necessary. The physician is contacted especially if theseactions do not relieve the signs and symptoms. Antihypertensivemedications may be prescribed by the physician to minimi8e cerebralhypertension.1. 1. %ncreasing %&! causes une@ual pupils as a result of pressure onthe third cranial nerve. %ncreasing %&! causes an increase in thesystolic pressure, which re*ects the additional pressure needed toperfuse the brain. %t increases the pressure on the vagus nerve, whichproduces bradycardia, and it causes an increase in body temperaturefrom hypothalamic damage.$. 1. 4eural control of respiration takes place in the brain stem.

Beterioration and pressure produce irregular respiratory patterns.;apid, shallow respirations, asymmetric chest movements, and nasal*aring are more characteristic of respiratory distress or hypo6ia.'. '. 4ormal %&! is 1 mm 3g or less. 3yperventilation causesvasoconstriction, which reduces &+ and blood volume, two importantfactors for reducing a sustained %&! of $2 mm 3g. A cooling blanket isused to control the elevation of temperature because a fever increasesthe metabolic rate, which in turn increases %&!. 3igh doses ofbarbiturates may be used to reduce the increased cellular metabolicdemands. luid volume and inotropic drugs are used to maintaincerebral perfusion by supporting the cardiac output and keeping the

cerebral perfusion pressure greater than 02 mm 3g.. . A decrease in the client>s =& is an early indicator ofdeterioration of the client>s neurological status. &hanges in =&, suchas restlessness and irritability, may be subtle. -idening of the pulsepressure, decrease in the pulse rate, and dilated, :6ed pupils occurlater if the increased %&! is not treated.. $. %t is best for the client to wear mitts which help prevent theclient from pulling on the %# without causing additional agitation. /sing

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a jacket or wrist restraint or tucking the client>s arms and hands underthe draw sheet restrict movement and add to feelings of beingcon:ned, all of which would increase her agitation and increase %&!.9. . Becerebrate posturing occurs in patients with damage to theupper brain stem, midbrain, or pons and is demonstrated clinically by

arching of the back, rigid e6tension of the e6tremities, pronation of thearms, and plantar *e6ion of the feet. %nternal rotation and adduction ofarms with *e6ion of the elbows, wrists, and :ngers describeddecorticate posturing, which indicates damage to corticospinal tractsand cerebral hemispheres.s mouth with a padded tongue blade. &leaning the client>s mouth and teeth with a toothbrush.

12 A

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1 !repare to administer recombinant tissue plasminogenactivator (rt7!A).

$ Biscuss the precipitating factors that caused the symptoms.' +chedule for A +TAT computer tomography (&T) scan of the

head.

4otify the speech pathologist for an emergency consult.11 A client arrives in the emergency department with an ischemicstroke and receives tissue plasminogen activator (t7!A)administration. -hich is the priority nursing assessment"1 &urrent medications.$ &omplete physical and history.' Time of onset of current stroke. /pcoming surgical procedures.

1$ Buring the :rst $ hours after thrombolytic therapy for ischemicstroke, the primary goal is to control the client>s1 !ulse

$ ;espirations' lood pressure Temperature

1' -hat is a priority nursing assessment in the :rst $ hours afteradmission of the client with a thrombotic stroke"1 &holesterol level$ !upil si8e and papillary response' #owel sounds Hchocardiogram

1 -hat is the e6pected outcome of thrombolytic drug therapy"1 %ncreased vascular permeability.

$ #asoconstriction.' Bissolved emboli. !revention of hemorrhage

1 The client diagnosed with atrial :brillation has e6perienced atransient ischemic attack (T%A). -hich medication would thenurse anticipate being ordered for the client on discharge"1 An oral anticoagulant medication.$ A beta7blocker medication.' An anti7hyperuricemic medication. A thrombolytic medication.

19 -hich client would the nurse identify as being most at risk for

e6periencing a A"1 A 7year7old African American male.$ An 07year7old Fapanese female.' A 9

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$ A right7sided carotid bruit.' A blood pressure of $$251$2 mm 3g. The presence of bronchogenic carcinoma.

10 The nurse and unlicensed assistive personnel (/A!) are caringfor a client with right7sided paralysis. -hich action by the /A!

re@uires the nurse to intervene"1 The assistant places a gait belt around the client>s waist priorto ambulating.

$ The assistant places the client on the back with the client>shead to the side.

' The assistant places her hand under the client>s right a6illa tohelp him5her move up in bed.

The assistant praises the client for attempting to performAB>s independently.

? 1. A helpless client should be positioned on the side, not on the

back. This lateral position helps secretions escape from thethroat and mouth, minimi8ing the risk of aspiration. %t may benecessary to suction, so having suction e@uipment at thebedside is necessary. !added tongue blades are safe to use. Atoothbrush is appropriate to use.

12 '. A &T scan will determine if the client is having a stroke or hasa brain tumor or another neurological disorder. This would alsodetermine if it is a hemorrhagic or ischemic accident and guidethe treatment, because only an ischemic stroke can use rt7!A.This would make (1) not the priority since if a stroke wasdetermined to be hemorrhagic, rt7!A is contraindicated. Biscuss

the precipitating factors for teaching would not be a priority andslurred speech would as indicate interference for teaching.;eferring the client for speech therapy would be an interventionafter the A emergency treatment is administered according toprotocol.

11 '. The time of onset of a stroke to t7!A administration is critical.Administration within ' hours has better outcomes. A completehistory is not possible in emergency care. /pcoming surgicalprocedures will need to be delay if t7!A is administered. &urrentmedications are relevant, but onset of current stroke takespriority.

1$ '. &ontrolling the blood pressure is critical because anintracerebral hemorrhage is the major adverse eect ofthrombolytic therapy. lood pressure should be maintainedaccording to physician and is speci:c to the client>s ischemictissue needs and risks of bleeding from treatment. =ther vitalsigns are monitored, but the priority is blood pressure.

1' $. %t is crucial to monitor the pupil si8e and pupillary response toindicate changes around the cranial nerves. &holesterol level is

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an assessment to be addressed for long7term healthy lifestylerehabilitation. owel sounds need to be assessed because anileus or constipation can develop, but is not a priority in the :rst$ hours. An echocardiogram is not needed for the client with athrombotic stroke.

1 '. Thrombolytic therapy is use to dissolve emboli and reestablishcerebral perfusion.1 1. Thrombi form secondary to atrial :brillation, therefore, an

anticoagulant would be anticipated to prevent thrombi formationKand oral (warfarin M&oumadinN) at discharge verses intravenous.eta blockers slow the heart rate and lower the blood pressure.Anti7hyperuricemic medication is given to clients with gout.Thrombolytic medication might have been given at initialpresentation but would not be a drug prescribed at discharge.

19 1. Africana Americans have twice the rate of A>s as&aucasiansK males are more likely to have strokes than females

e6cept in advanced years. =riental>s have a lower risk, possiblydue to their high omega7' fatty acids. !regnancy is a minimalrisk factor for A.

1< '. /ncontrolled hypertension is a risk factor for hemorrhagicstroke, which is a rupture blood vessel in the cranium. A bruit inthe carotid artery would predispose a client to an embolic orischemic stroke. 3igh blood glucose levels could predispose apatient to ischemic stroke, but not hemorrhagic. &ancer is not aprecursor to stroke.

'. This action is inappropriate and would re@uire intervention by thenurse because pulling on a *accid shoulder joint could cause shoulder

dislocationK as always use a lift sheet for the client and nurse safety.All the other actions are appropriate.