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The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client’s plan of care?
- A. Tell the client to remain on bedrest.
- B. Maintain the intravenous rate at 150 mL/hour.
- C. Provide a soft, bland diet with three (3) snacks per day.
- D. Place the client on seizure precautions.
Correct Answer: D
Rationale: Brain tumors increase seizure risk, so seizure precautions (D) are essential. Bedrest (A) is unnecessary unless indicated, IV rate (B) depends on status, and diet (C) is not specific to intracranial regulation.
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Which signs and symptoms will the nurse detect with this disorder? Select all that apply.
- A. Speech by the client to consume a high-fiber diet
- B. Rapid heart rate
- C. Pounding headache
- D. Pale skin
- E. Blurred vision
- F. Nasal stuffiness
Correct Answer: C,E,F
Rationale: Autonomic dysreflexia presents with a pounding headache, blurred vision, and nasal stuffiness due to unopposed sympathetic activity.
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
- A. A computed tomography (CT).
- B. Blood cultures times two (2).
- C. Electromyogram (EMG).
- D. Lumbar puncture (LP).
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (D) confirms the diagnosis via CSF analysis. CT (A) may precede LP, blood cultures (B) are supportive, and EMG (C) is unrelated.
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
- A. Notify the health-care provider as soon as possible (ASAP).
- B. Calm the client down by talking therapeutically.
- C. Increase the IV rate by 50 mL/hour.
- D. Lower the head of the bed immediately.
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (D) restores cerebral perfusion. Notifying the provider (A) or increasing IV rate (C) follows, and talking therapeutically (B) does not address the urgent issue.
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- A. Push aside any furniture.
- B. Place the client on his side.
- C. Assess the client’s vital signs.
- D. Ease the client to the floor.
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (D) prevents injury from falling. Clearing furniture (A) follows, placing on the side (B) is done after the client is safe, and vital signs (C) are assessed post-seizure.