Recognize Cues
Which early sign suggests increasing ICP?
Change in level of consciousness
A patient's pupils change from brisk to sluggish. What does this change indicate?
Worsening ICP or neurological decline
Which condition is the highest priority in a client with a history of headaches?
Sudden severe headache with neurological deficits
Which position best reduces ICP?
HOB at 30 degrees
The nurse is preparing an instructional discharge plan for a client with damage to cranial nerve II. Which item will be included in the discharge instruction?
A. Make sure the environment is clutter free and clear of obstacles B. Make sure all family and caretakers speak loudly C. Have the client open their mouth for inspection of the tongue daily D. Have the client drink only thickened liquids
A. Make sure the environment is clutter free and clear of obstacles
A patient reports "the worst headache of my life." What condition does this cue suggest?
Possible brain bleed
VS: BP high, HR low, RR irregular
What clinical meaning does this cluster indicate?
Cushing's Triad
(late sign of inc ICP)
The nurse is caring for a client with increased intracranial pressure (ICP). Which assessment finding would have the most priority?
A. Tachycardia B. Hypothermia C. Unequal pupil size D. Dec BP
C. Unequal pupil size
A client is admitted for observation following a motor vehicle accident that occurred on the way to the client’s daughter’s wedding. The next morning, instead of asking about the wedding, the client tells the nurse “I have to leave now since the wedding is in a few minutes.” The client then becomes agitated when the nurse re-orients and states the actual date (which is the day following the wedding). What should the nurse do next?
A. Change the date on the hospital room whiteboard to yesterday B. Perform neurological assessment and assess pupil response C. Administer Valium 40 mg IV since a seizure is imminent D. Call the family to see if the wedding can be repeated
B. Perform neurological assessment and assess pupil response
A client is being discharged with a new prescription of phenytoin sodium (dilantin). Which instruction by the nurse is most important to include?
If stopped suddenly, status epilepticus may occur.
Which assessment cue is most concerning in a patient with a seizure disorder?
A. Aura
B. Postictal drowsiness
C. New unilateral weakness
D. Headache
C. New unilateral weakness
(possible stroke or ICP shift)
A patient with neck stiffness, fever, and photophobia may be experiencing what?
Meningitis
A client with Parkinson’s disease is prescribed carbidopa-levodopa (Sinemet). What is a priority complication to monitor when adjusting the initial phase of medication?
A. jaundice B. orthostatic hypotension C. glucose D. monitor for weight gain
B. Orthostatic hypotension
The nurse and rehabilitation disciplines are collaborating on the care for a client with Parkinson’s disease. Which collaborative goal is the most appropriate for the client with Parkinson’s disease?
A. stop progression of the disease B. establish palliative care C. maintain optimal body function D. cure the disease
C. maintain optimal body function
The nurse is teaching a client on toxicity while taking phenytoin sodium. The nurse determines the teaching is successful after the client describes which of the following should be reported to the health care provider (HCP)? (select all that apply)
A. excessive alertness B. diplopia C. bruising D. slurred speech
B. diplopia and D. slurred speech
You walk into the room and see the patient looking upward with eyes deviated to one side, hands jerking rhythmically. What is the first cue you should note?
Duration of the seizure
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes will signal increased intracranial pressure?
Slow, irregular respirations
During the ictal phase, which of the following is important in the assessment of the client?
A. VS B. Movement of eyes, head, and muscle rigidity C. Determining what type of aura occurred D. Determining what the client was doing just before the seizure
B. Movement of eyes, head, and muscle rigidity
Which medication is the first-line for an active tonic-clonic seizure?
IV lorazepam (Ativan)
The nurse caring for a client with brain injury administered mannitol (Osmitrol) for intracranial pressure. Which is the most important for the nurse to monitor following administration of mannitol (Osmitrol)?
A. I&O B. Pupil response C. Changes in pulse pressure D. Respiratory rate
A. I&O
A patient with Alzheimer's suddenly becomes agitated, pulls at lines, and is disoriented to place. What cue should the nurse recognize?
Possible delirium
A CT scan indicates a midline shift. What does this mean for the patient?
Significant brain swelling -> high ICP -> risk for herniation
A nurse is caring for a client with increased intracranial pressure (ICP) following a diagnosis of traumatic brain injury. The client is on a ventilator and requires suctioning. Which of the following is a priority when suctioning a client with increased intracranial pressure?
A. suction as needed since the client requires airway clearance B. limit suction to every 30 minutes, every hour C. limit suction to reduce increases in ICP D. limit suction because bradycardia may occur
C. limit suction to reduce increases in ICP
A client is having a grand mal seizure. Which of the following interventions by the nurse will ensure safety during the seizure.
A. protect the client from injury B. place a tongue blade between the teeth C. lay the client supine immediately D. give oxygen by facemask
A. protect the client from injury
A client with Parkinson's starts levodopa-carbidopa. What evaluation shows medication effectiveness?