Chapter 42 - Care of Patients with Problems of the Central Nervous System: The Brain
A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?
- Assessing neurologic status at least every 2–4 hours
- Decreasing environmental stimuli
- Managing pain through drug and nondrug methods
- Strict monitoring of hourly intake and output
A. Assessing neurologic status at least every 2–4 hours
Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis?
- Cloudy, turbid CSF
- Decreased white blood cells
- Decreased protein
- Increased glucose
A. Cloudy, turbid CSF
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.
- Increased blood glucose
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?
- Documents the length and time of the seizure.
- Forces a tongue blade in the mouth.
- Positions the client on the side.
- Restrains the client.
C. Positions the client on the side.
A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply.
- Bite block at the bedside
- Intravenous access (IV)
- Continuous sedation
- Suction equipment at the bedside
- Siderails raised
B. Intravenous access (IV)
D. Suction equipment at the bedside
E. Siderails raised
Which is the most effective way for a college student to minimize the risk for bacterial meningitis?
- Avoid large crowds.
- Get the meningococcal vaccine.
- Take a high dose vitamin C daily.
- Take prophylactic antibiotics.
B. Get the meningococcal vaccine.
The nurse has received report on a group of clients. Which client requires the nurse’s attention first?
- Adult who is lethargic after a generalized tonic–clonic seizure
- Young adult who has experienced four tonic–clonic seizures within the past 30 minutes
- Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions
- 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
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?
- Apple juice
- Grape juice
- Grapefruit juice
- Prune juice
C. Grapefruit juice
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?
- Administer phenytoin (Dilantin).
- Draw the client’s blood.
- Establish an airway.
- Start an intravenous (IV) line.
C. Establish an airway.
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.
- Oropharyngeal airway
- Nasogastric tube
- Suction setup
- Padded tongue blade