Chapter 42 - Care of Patients with Problems of the Central Nervous System: The Brain

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Chapter 42 - Care of Patients with Problems of the Central Nervous System: The Brain
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1

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?

  1. Assessing neurologic status at least every 2–4 hours
  2. Decreasing environmental stimuli
  3. Managing pain through drug and nondrug methods
  4. Strict monitoring of hourly intake and output

A. Assessing neurologic status at least every 2–4 hours

2

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis?

  1. Cloudy, turbid CSF
  2. Decreased white blood cells
  3. Decreased protein
  4. Increased glucose

A. Cloudy, turbid CSF

3

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply.

  1. Alopecia
  2. Headaches
  3. Dizziness
  4. Diplopia
  5. Increased blood glucose

B. Headaches

C. Dizziness

D. Diplopia

4

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next?

  1. Documents the length and time of the seizure.
  2. Forces a tongue blade in the mouth.
  3. Positions the client on the side.
  4. Restrains the client.

C. Positions the client on the side.

5

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply.

  1. Bite block at the bedside
  2. Intravenous access (IV)
  3. Continuous sedation
  4. Suction equipment at the bedside
  5. Siderails raised

B. Intravenous access (IV)

D. Suction equipment at the bedside

E. Siderails raised

6

Which is the most effective way for a college student to minimize the risk for bacterial meningitis?

  1. Avoid large crowds.
  2. Get the meningococcal vaccine.
  3. Take a high dose vitamin C daily.
  4. Take prophylactic antibiotics.

B. Get the meningococcal vaccine.

7

The nurse has received report on a group of clients. Which client requires the nurse’s attention first?

  1. Adult who is lethargic after a generalized tonic–clonic seizure
  2. Young adult who has experienced four tonic–clonic seizures within the past 30 minutes
  3. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions
  4. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B. Young adult who has experienced four tonic–clonic seizures within the past 30 minutes

8

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage?

  1. Apple juice
  2. Grape juice
  3. Grapefruit juice
  4. Prune juice

C. Grapefruit juice

9

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first?

  1. Administer phenytoin (Dilantin).
  2. Draw the client’s blood.
  3. Establish an airway.
  4. Start an intravenous (IV) line.

C. Establish an airway.

10

A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply.

  1. Oropharyngeal airway
  2. Oxygen
  3. Nasogastric tube
  4. Suction setup
  5. Padded tongue blade

A.

B.

D.