MS CH 48 Nursing Care of Patients With Central Nervous System Disorders

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Questions and Answers

What is characterized by bruising of brain tissue possibly accompanied by hemorrhage?

Diffuse axonal injury

Cerebral contusion (correct)

Acute intraventricular hemorrhage

Subdural hematoma

What type of symptoms is associated with an acute subdural hematoma?

Gradual decline in cognitive function

Immediate loss of consciousness

Symptoms appearing within 24 hours following injury (correct)

Symptoms appearing more than 72 hours after injury

Which symptoms can indicate a brainstem contusion?

Diminished motor skills

Severe headaches

Altered level of consciousness (correct)

Persistent nausea

What can be a consequence of severe contusions that affects the overall brain function?

Diffuse axonal injury Signup and view all the answers

What can be affected by edema or hypothalamic injury in patients with cerebral contusions?

Autonomic nervous system Signup and view all the answers

What is the recommended head elevation to help reduce intracranial pressure (ICP)?

30 degrees Signup and view all the answers

Why is hip flexion to be avoided in patients with increased ICP?

It can increase intra-abdominal and thoracic pressure. Signup and view all the answers

Which of the following actions is recommended to prevent increased ICP?

Minimize unnecessary noise Signup and view all the answers

What is a recommended measure to manage coughing and vomiting in a patient at risk for increased ICP?

Administering antiemetics Signup and view all the answers

Which position should the head and neck be maintained to avoid obstructing venous outflow?

Neutral position Signup and view all the answers

What is one of the types of headaches mentioned in the content?

Secondary headaches Signup and view all the answers

What should be minimized to help prevent increased intracranial pressure?

Suctioning procedures Signup and view all the answers

What is the role of describing the brain to significant others?

To help understand symptoms of neurological disorders Signup and view all the answers

What is an aura in the context of seizure activity?

A warning sensation that indicates a seizure may occur. Signup and view all the answers

What are automatisms in relation to partial seizures?

Repetitive, purposeless behaviors exhibited during partial seizures. Signup and view all the answers

Which of the following techniques may help reduce tension headaches?

Biofeedback and stress reduction techniques. Signup and view all the answers

What is the duration typically associated with simple partial seizures?

Less than 1 minute. Signup and view all the answers

What is the main goal of recognizing seizure triggers for a patient?

To lessen the frequency and intensity of seizures. Signup and view all the answers

What should patients be educated about concerning their medications?

How to administer medications for effective control. Signup and view all the answers

What is a recommended measure for managing a migraine headache?

Ensure the patient rests in a dark room. Signup and view all the answers

Why might patients exhibiting automatisms during seizures be misinterpreted?

Their behaviors could resemble those of intoxication. Signup and view all the answers

What is indicated by a positive Brudzinski's sign?

Flexion of the neck causes the hips and knees to flex Signup and view all the answers

What is a common cause of nausea and vomiting in patients with meningitis?

Direct irritation of brain tissue and increased ICP Signup and view all the answers

Which type of meningitis generally has no lasting effects after resolution?

Viral meningitis Signup and view all the answers

What therapeutic measure can be taken to control fever in meningitis patients?

Using antipyretics such as acetaminophen Signup and view all the answers

What cognitive changes are typically seen in patients with meningitis?

Disorientation and difficulty following commands Signup and view all the answers

What is a potential complication of bacterial meningitis?

Cranial nerve damage leading to blindness or deafness Signup and view all the answers

What should be monitored closely when using cooling blankets for fever management?

Risk of shivering that could increase metabolic demands Signup and view all the answers

When should a patient with meningococcal meningitis be isolated?

For at least 24 hours after medication administration Signup and view all the answers

What are common bacteria associated with bacterial meningitis?

Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type b Signup and view all the answers

What is a common presentation of meningococcal meningitis?

Petechiae on the skin Signup and view all the answers

Which sign is characterized by pain and stiffness when the neck is moved?

Nuchal rigidity Signup and view all the answers

What is the correct method to elicit Kernig's sign?

Flex the patient's knee and then try to extend the leg Signup and view all the answers

Which cranial nerves are commonly affected by meningitis?

III, IV, VI Signup and view all the answers

What symptom often accompanies photophobia in meningitis patients?

Severe headache Signup and view all the answers

Which route of entry can lead to a meningitis infection through the bloodstream?

Insect bite and otitis media Signup and view all the answers

What does Brudzinski's sign indicate when observed in a patient?

Meningitis Signup and view all the answers

What is the medical term for light sensitivity experienced by some meningitis patients?

Photophobia Signup and view all the answers

Which bacterium is associated with pneumococcal meningitis?

Streptococcus pneumoniae Signup and view all the answers

What is the primary recommended schedule for meningococcal vaccination in adolescents?

Two doses at ages 11 or 12 and 16 Signup and view all the answers

Which of the following can increase a patient's vulnerability to infections such as meningitis?

Chemotherapy and steroid administration Signup and view all the answers

What is a common cause of bacterial meningitis?

Airborne transmission from respiratory discharge Signup and view all the answers

What is the most common symptom of meningitis?

Severe headache Signup and view all the answers

Which of the following is considered viral meningitis?

Aseptic meningitis Signup and view all the answers

Which group is not specifically recommended for meningococcal vaccination?

Individuals over 65 years old Signup and view all the answers

What type of antimicrobial agents are recommended for chemoprophylaxis in meningitis exposure?

Rifampin, quinolones, or sulfonamides Signup and view all the answers

How long does it typically take for patients recovering from viral meningitis?

1 to 2 weeks Signup and view all the answers

What condition is indicated by weakness in all four limbs due to spinal cord injury?

Quadriplegia Signup and view all the answers

Which of the following is a common risk factor for neurodegenerative disorders?

Genetic predisposition Signup and view all the answers

What is a significant complication associated with bacterial meningitis?

Cognitive impairment Signup and view all the answers

Which of the following diseases is not classified as a neurodegenerative disorder?

Multiple sclerosis Signup and view all the answers

What is a primary nursing intervention for a patient with increased intracranial pressure (ICP)?

Maintaining the head of the bed elevated Signup and view all the answers

Which symptom is commonly associated with central nervous system disorders?

Transient paralysis Signup and view all the answers

What can be a consequence of untreated meningitis?

Hearing loss Signup and view all the answers

Which vaccine is recommended for individuals over age 65 to help prevent meningitis?

Pneumococcal Signup and view all the answers

What is the primary advantage of using a subarachnoid bolt?

Provides ease of placement Signup and view all the answers

Which of the following is a disadvantage of external ventricular drainage?

Clotting of the catheter Signup and view all the answers

What is a potential complication associated with an intraparenchymal monitor?

Occlusion by brain tissue Signup and view all the answers

In what setting are patients with ICP monitors typically cared for?

Intensive care unit (ICU) Signup and view all the answers

What is one of the challenges faced during the placement of a catheter for external ventricular drainage?

Difficulty in locating the ventricle Signup and view all the answers

Which condition can lead to increased intracranial pressure (ICP)?

Excess cerebrospinal fluid production Signup and view all the answers

Which of the following statements about a subarachnoid bolt is true?

It may become occluded by brain tissue. Signup and view all the answers

Which monitoring method is believed to most accurately reflect the situation within the skull?

Intraparenchymal monitor Signup and view all the answers

What symptom indicates increasing intracranial pressure in patients?

Dilated pupil on affected side Signup and view all the answers

Which intervention is essential for a patient diagnosed with hyperthermia related to an infectious process?

Assess temperature every 4 hours Signup and view all the answers

Which of these outcomes is expected for a patient with hyperthermia?

Control body temperature Signup and view all the answers

How should patient education be tailored based on their condition?

Include significant others when the patient is unable to participate Signup and view all the answers

What type of posturing may indicate severe neurological impairment?

Decorticate then decerebrate posturing Signup and view all the answers

What is the rationale for assessing temperature regularly in patients with hyperthermia?

To evaluate risk for seizures Signup and view all the answers

What physical sign is often observed in patients with decreased levels of consciousness?

Decorticate posturing Signup and view all the answers

What physiological change may occur alongside rising systolic blood pressure in patients with increased intracranial pressure?

Increased then decreasing pulse rate Signup and view all the answers

What is a significant risk factor during the weaning process off anticonvulsant therapy?

Increased seizure frequency Signup and view all the answers

What immediate action is recommended when a seizure occurs?

Assist in airway maintenance Signup and view all the answers

Which of the following medications is typically used to stop active seizures?

Lorazepam Signup and view all the answers

What potential complication arises if cerebral metabolic needs are not met during seizures?

Irreversible neuronal damage Signup and view all the answers

During the preoperative assessment for epilepsy surgery, what is a primary goal?

Identify seizure foci Signup and view all the answers

What should be done to adequately assist a patient experiencing status epilepticus?

Ensure proper positioning and airway management Signup and view all the answers

What is a key aspect of care during a seizure to prevent injury?

Padding side rails and removing nearby furniture Signup and view all the answers

Why is intubation and mechanical ventilation sometimes necessary during status epilepticus?

To ensure adequate oxygenation Signup and view all the answers

What may occur if there is an increase in one component of the skull without a decrease in others?

Increased intracranial pressure Signup and view all the answers

Which symptom is NOT typically associated with increased intracranial pressure?

Loss of appetite Signup and view all the answers

Which condition can lead to lasting cognitive disabilities after its occurrence?

Herpes encephalitis Signup and view all the answers

What is the potential mortality rate if a patient becomes comatose from cerebral edema before treatment begins?

70% to 80% Signup and view all the answers

Increased intracranial pressure can often be detected within what critical time frame after cerebral edema occurs?

72 hours Signup and view all the answers

Which condition can cause a sudden and sharp increase in intracranial pressure?

Subarachnoid hemorrhage Signup and view all the answers

Which of the following is a common immediate symptom of increased intracranial pressure?

Photophobia Signup and view all the answers

What is the consequence of significant cerebral edema in herpes encephalitis?

Increased intracranial pressure and potential herniation Signup and view all the answers

What should you do to help a patient during a seizure?

Use padding and talk calmly to the patient. Signup and view all the answers

What might individuals with poorly controlled seizures experience regarding their job opportunities?

Limited opportunities due to transport dependency. Signup and view all the answers

Why should patients with uncontrolled seizures avoid operating motor vehicles?

It can be a legal requirement in some places. Signup and view all the answers

What is recommended for a patient after a seizure has ended?

Let them come out of the seizure naturally. Signup and view all the answers

How can seizures affect a patient's self-esteem?

Patients may experience embarrassment and fear. Signup and view all the answers

What is the significance of a state identification card for patients with seizure disorders?

It serves as a replacement for a driver's license. Signup and view all the answers

Which of the following actions is NOT advised during a seizure?

Sitting on or holding down the patient. Signup and view all the answers

What role can role-playing serve for patients dealing with seizures?

It helps in understanding potential concerns when confiding in others. Signup and view all the answers

What happens to cerebral blood vessels during hyperventilation?

They constrict, reducing blood flow. Signup and view all the answers

Which symptom is typically the earliest indication of increased intracranial pressure (ICP)?

Restlessness and irritability. Signup and view all the answers

The compression of which nerve is associated with fixed and dilated pupils as ICP increases?

Oculomotor nerve. Signup and view all the answers

What role does hyperventilation play in the body's response to increasing ICP?

It decreases the amount of blood within the cranial vault. Signup and view all the answers

Which factor might worsen the symptoms of cluster headaches?

Alcohol consumption Signup and view all the answers

Which of the following is a late indication of increasing ICP?

Vital sign changes. Signup and view all the answers

What is a common description used by patients to characterize tension headaches?

Dull and aching Signup and view all the answers

What is particularly important to monitor in a patient with signs of increased ICP?

Pupil response and level of consciousness. Signup and view all the answers

Which symptom is typically associated with a headache that may indicate a need for caution in diagnosis?

Nausea and vomiting Signup and view all the answers

What effect does increased ICP have on the oculomotor nerve over time?

It can lead to compression resulting in fixed and dilated pupils. Signup and view all the answers

What is a potential alleviating factor for tension headaches?

Resting in a dark room Signup and view all the answers

What is essential for effective data collection regarding a patient with possible ICP increases?

Obtaining a complete history from the patient and significant others. Signup and view all the answers

What should be thoroughly ruled out before attributing headaches to psychosocial origins?

Physical causes Signup and view all the answers

What is the primary purpose of administering acetaminophen or aspirin to patients with brain lesions or injuries?

To lower fever and achieve comfort. Signup and view all the answers

Which intervention can be employed to enhance patient comfort during cooling therapy?

Gradually cool the patient and wrap extremities in bath blankets. Signup and view all the answers

What pattern does the occurrence of cluster headaches typically follow?

In clusters during a specific time span Signup and view all the answers

What assessment tool is recommended for evaluating level of consciousness in patients with suspected increased intracranial pressure?

Glasgow Coma Scale or FOUR Score. Signup and view all the answers

Which psychosocial stressors are commonly associated with tension headaches?

Anxiety and emotional distress Signup and view all the answers

What is an important consideration when asking about headache severity?

Its consistency from headache to headache Signup and view all the answers

Why should nursing interventions include monitoring the patient's ability to follow simple commands?

To assess reflexes independently from purposeful movement. Signup and view all the answers

How should a patient's orientation be assessed to ensure safety and effective care planning?

Determining if the patient can identify their identity, location, and time. Signup and view all the answers

What is a common risk observed in patients as they engage in increased activities following a brain injury?

Dizziness, imbalance, and confusion. Signup and view all the answers

Which safety measure should be implemented if a patient cannot be reoriented?

Assess for safety and implement necessary safety measures. Signup and view all the answers

Which evaluation question assesses the effectiveness of using antipyretics in patients?

Are antipyretics effective in normalizing the patient’s body temperature? Signup and view all the answers

What can result from severe cerebral contusions affecting brain function?

Diffuse axonal injury Signup and view all the answers

How are acute subdural hematomas characterized?

Symptoms appear within 24 hours post-injury Signup and view all the answers

Which of the following autonomic responses can occur due to hypothalamic injury?

Rapid heart rate Signup and view all the answers

What effect can brainstem contusions have on a patient?

Transitory level of consciousness Signup and view all the answers

What type of bleeding is typically associated with acute subdural hematoma?

Venous bleeding Signup and view all the answers

What type of behaviors are characterized as automatisms during partial seizures?

Repetitive, purposeless behaviors Signup and view all the answers

What is a common characteristic of an aura experienced before a seizure?

An unusual sound or visual distortion Signup and view all the answers

Which strategy can assist patients in controlling headache symptoms?

Practicing biofeedback and stress reduction Signup and view all the answers

What is the expected duration of a simple partial seizure?

Less than 1 minute Signup and view all the answers

What might patients who experience automatism during a seizure be incorrectly labeled as?

Mentally ill Signup and view all the answers

What is an important technique for patients to mitigate risks when they sense an impending seizure?

Sitting or lying down Signup and view all the answers

How should patients manage medication administration for seizure control?

Following appropriate dosages and understanding potential side effects Signup and view all the answers

What environmental adjustment can help reduce migraine headaches?

Providing a dark room for rest Signup and view all the answers

What condition is most likely to occur weeks to months after a seemingly minor head injury?

Chronic subdural hematoma Signup and view all the answers

What kind of injury occurs when a stationary head is struck by a moving object?

Acceleration-deceleration injury Signup and view all the answers

Which group is particularly vulnerable to chronic subdural hematomas due to brain atrophy?

Older adults and individuals with alcoholism Signup and view all the answers

What symptom might indicate an increase in intracranial pressure (ICP) after a head injury?

Deterioration of consciousness Signup and view all the answers

When managing a patient with seizures, which action is essential to ensure the safety of the patient?

Moving nearby objects to protect from injury Signup and view all the answers

Which of the following suggests that the care of a patient with epilepsy has been successful?

Decrease in seizure frequency to the lowest possible level Signup and view all the answers

What type of injury is characterized as having the potential to cause lacerations and contusions due to shearing forces?

Rotational injury Signup and view all the answers

Which factor is crucial to monitor in a patient who has experienced a head injury?

Vital signs Signup and view all the answers

What phase is characterized by visual disturbances and numbness before a migraine headache occurs?

Prodromal phase Signup and view all the answers

Which of the following triggers is least likely to contribute to the onset of a migraine headache?

Low humidity Signup and view all the answers

Which option correctly describes the typical symptom associated with cluster headaches?

Unilateral pain affecting the eye Signup and view all the answers

Which description of migraine pain is not commonly used by patients?

Pulsating Signup and view all the answers

In addition to the headache, which symptom is often accompanied by migraines?

Nausea Signup and view all the answers

During which phase of a migraine might a patient experience difficulty speaking?

Aura phase Signup and view all the answers

Which of the following treatments is considered a prophylactic measure for migraines?

Tricyclic antidepressants Signup and view all the answers

What is a common characteristic of migraine headaches in terms of their location?

Unilateral and localized Signup and view all the answers

What is the primary concern when administering phenytoin to patients receiving tube feedings?

Tube feedings should be held 1 hour before and 2 hours after the dose. Signup and view all the answers

What indicates a need to discontinue lamotrigine therapy?

Development of a rash. Signup and view all the answers

Which therapeutic drug requires monitoring of vital signs during administration?

Phenobarbital Signup and view all the answers

What is the typical therapeutic level range for valproic acid when treating seizures?

15–40 mcg/mL Signup and view all the answers

Which emergency agent is administered to stop a seizure that has not resolved within 5 minutes?

Lorazepam Signup and view all the answers

Which condition is characterized by at least 30 minutes of repetitive seizure activity?

Status epilepticus Signup and view all the answers

What is a critical step in managing status epilepticus effectively?

Identify and address the epileptic focus. Signup and view all the answers

Which laboratory tests should be assessed for patients on levetiracetam?

WBC, RBC, and liver function tests Signup and view all the answers

What should patients with generalized seizures be instructed to do when they recognize an aura?

Get to safety by lying down away from furniture. Signup and view all the answers

Which of the following is NOT an expected information patients should verbalize about their medications?

Alternative therapies that are ineffective. Signup and view all the answers

What is a primary risk factor for traumatic brain injury in adults?

Motor vehicle accidents. Signup and view all the answers

Which of the following best describes the expected outcome for a patient with a risk for injury related to seizure activity?

The patient will remain free from injury. Signup and view all the answers

What can therapeutic drug levels help evaluate in patients taking anticonvulsants?

Adherence to the medication regimen. Signup and view all the answers

What complications can arise from traumatic brain injury besides the primary insult?

Cerebral edema and hydrocephalus. Signup and view all the answers

Which of the following might indicate that a patient has resources to purchase prescribed anticonvulsant medications?

The patient has a steady income. Signup and view all the answers

What does the phenomenon of traumatic brain injury potentially range from?

No detectable effect to a persistent vegetative state. Signup and view all the answers

What is indicated by a positive Kernig's sign during an examination?

Stiffness in the neck Signup and view all the answers

What is typically revealed in the CSF analysis of a patient with encephalitis?

Increased WBC count and normal glucose levels Signup and view all the answers

Which therapeutic intervention is essential for patients at risk of seizures related to encephalitis?

Implementing seizure precautions Signup and view all the answers

Which factor must be realistically assessed when determining discharge plans for patients with encephalitis?

Patient's behavioral control Signup and view all the answers

What might indicate the need for custodial care upon the patient's discharge?

Severe functional impairment Signup and view all the answers

Which diagnostic test is commonly used to confirm viral encephalitis?

CT scan Signup and view all the answers

Which symptom is unlikely to be present in a patient with encephalitis?

Nasal congestion Signup and view all the answers

What is an important consideration for outpatient therapy in discharged patients?

Consistency of therapy sessions Signup and view all the answers

What is the likely consequence if a chronic subdural hematoma persists or increases in size?

Development of hemiparesis and pupillary changes Signup and view all the answers

Which characteristic is typical of a patient with an epidural hematoma following a severe brain injury?

Regaining consciousness then decreasing responsiveness Signup and view all the answers

What immediate impact does a concussion have on an individual?

Loss of consciousness for 5 minutes or less Signup and view all the answers

What common symptom might a patient with a chronic subdural hematoma exhibit?

Irritability and forgetfulness Signup and view all the answers

During a motor vehicle accident, which of the following mechanisms could lead to damage to the reticular activating system?

Twisting of the brainstem caused by lateral force Signup and view all the answers

What is a distinguishing feature of cerebral concussion compared to other types of brain injuries?

No documented abnormalities on imaging tests Signup and view all the answers

What primary reason can cause individuals to delay seeking medical care after a brain injury?

Failing to associate symptoms with a prior incident Signup and view all the answers

What is the typical nature of bleeding associated with an epidural hematoma?

Arterial bleeding causing rapid accumulation Signup and view all the answers

What is the primary reason for using padding during a seizure?

To protect the patient from injury. Signup and view all the answers

Which of the following actions should be avoided when a patient is having a seizure?

Holding down the patient to prevent movement. Signup and view all the answers

What emotional impact can a seizure have on a patient regarding social interactions?

Limited interpersonal relationships due to fear. Signup and view all the answers

After a seizure ends, which action is recommended for the patient?

Allowing them to rest and recover. Signup and view all the answers

What potential issue may patients with poorly controlled seizures face in everyday life?

Mobility limitations due to fear of seizure onset. Signup and view all the answers

Which identification document is recommended for patients who cannot drive?

State identification card. Signup and view all the answers

Which experience might contribute to a patient's fear surrounding seizures?

Witnessing another person having an unprotected seizure. Signup and view all the answers

What is the impact of seizures on a patient's self-esteem?

Lowered self-esteem due to inability to drive. Signup and view all the answers

Study Notes

Nursing Care of Patients With Central Nervous System Disorders

This chapter covers nursing care for various CNS disorders, including infections, headaches, seizures, increased intracranial pressure, injuries to the brain and spinal cord, neurodegenerative disorders, and dementia.
CNS Infections: Meningitis and encephalitis are discussed, including their causes, risk factors, pathophysiology, nursing interventions, and preventative measures (vaccines and chemoprophylaxis). Routes of entry for CNS infections are detailed in a table. Bacterial meningitis is a serious infection spread by direct contact with discharge from the respiratory tract. Viral meningitis is also discussed, with a shorter duration and less severe course. Specific bacterial causes (Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae type b) are mentioned, with decreasing incidence of Hib due to immunization efforts. The role of meningococcal vaccines in prevention is highlighted. Chemoprophylaxis is also discussed as a preventative measure.
Headaches: Different types of headaches are differentiated, along with teaching strategies and interventions for patients. Causes and types of seizures are also listed, along with management strategies, including seizure precautions.
Increased Intracranial Pressure (ICP): Recognizing and preventing increased ICP, with focus on causes and nursing interventions. A table outlines ways that ICP can be increased. Manifestations of increased intracranial pressure (including headache, nuchal rigidity, positive Kernig's and Brudzinski's signs, and changes in vital signs) and related interventions are specifically included. The importance of prompt recognition of ICP increases for effective intervention is emphasized. The effects of ICP on the brain, blood, and CSF components are described.
Brain and Spinal Cord Injuries: Causes, risk factors, pathophysiology, and nursing interventions (including airway management and preventing complications) are discussed. Closed head injuries and open/penetrating injuries are addressed. The importance of preventing complications like aspiration pneumonia is emphasized.
Neurodegenerative Disorders: Parkinson's, Huntington's, and Alzheimer's are discussed, along with their causes, risk factors, pathophysiology, and nursing care, including specific nursing interventions. Specific symptoms, like tremors (resting tremor, pill-rolling tremor), rigidity, bradykinesia, and bradycardia, for Parkinson's are noted, along with methods of management such as deep brain stimulation, pallidotomy, and medication adjustments (including drug holidays). The variability of the disease process is covered. The complexities of diabetes insipidus and the psychosocial impact of these diseases on finances, employment and family relationships are addressed.
Dementia: Specific nursing interventions, including strategies for maintaining safety, are detailed for patients with dementia. Information about educating the patient and family about the disease process and treatment is included, as well as the necessity to determine patient's wishes while they are still capable. Different stages of dementia (early, middle, and late) are addressed with specific symptoms associated with each stage. Delirium is distinguished from dementia as a separate distinct condition. Detailed nursing interventions for the patient receiving care at home or in an inpatient facility related to the management of safety, behavior, and physical care are addressed, and the caregiver's role is highlighted.

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Description

This quiz explores key concepts related to cerebral contusions, including their symptoms, potential complications, and management strategies to prevent increased intracranial pressure (ICP). Test your knowledge on the impact of head position and recommended interventions for patients at risk for ICP. Perfect for students and professionals in neurological health.