Nokea
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
- A. Sleep pattern
- B. Mood and affect
- C. Appetite
- D. Muscle spasms
Correct Answer: D
Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.
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The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?
- A. Additional inflammation occurs in the brain.
- B. Blood vessels dilate circulating blood.
- C. Herniation occurs through the foramen magnum.
- D. Venous congestion occurs causing peripheral edema.
Correct Answer: C
Rationale: Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate downward through the foramen magnum. Inflammation occurs from damage to the brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial pressure. Peripheral edema is not a concern.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
- A. Insert an airway or bite block.
- B. Manually restrain the extremities.
- C. Turn client to side-lying position.
- D. Monitor vital signs.
Correct Answer: C
Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is most important for the nurse to do with this client?
- A. Optimizing nutrition
- B. Managing muscle weakness
- C. Explaining hospice care and services
- D. Offering family support groups
Correct Answer: C
Rationale: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
- A. Blood pressure 100/60 mm Hg
- B. Lethargy
- C. Nausea
- D. Periorbital edema
Correct Answer: B
Rationale: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
- A. Damage to the nerves that facilitate vision and hearing
- B. Damage to the vagal nerve
- C. Damage to the olfactory nerve
- D. Damage to the facial nerve
Correct Answer: A
Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.