Increased Intracranial Pressure and Headaches

The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. For what early signs of increased intracranial pressure (ICP) should the nurse be alert?

The vital signs for a client with a possible head injury were on admission: blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 16 breaths/min. Which vital sign assessment conducted four hours later most likely indicates the presence of increased intracranial pressure (ICP)?

A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. Which action should the nurse make a priority at this time?

A patient with a severe headache due to viral meningitis requests an opioid analgesic. What explanation about opioids should the nurse provide?

The nurse concludes that a patient's meningitis is improving. What activity did the patient perform for the nurse to come to this conclusion?

The nurse is assisting with teaching a patient about tension headaches. Which explanation of tension headaches should the nurse provide?

The nurse is determining care for a patient with acute migraine headaches. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches?

The nurse administers an analgesic to a patient with a headache. How should the nurse assess the patient's response to the medication?

A student under a great deal of stress develops a severe tension headache and goes to the school clinic. What strategy should the nurse teach the student for dealing with the onset of headaches in the future?

While walking to the bathroom a patient begins having a generalized tonic-clonic seizure. What should the nurse do first?

A patient recovering from surgery to remove a brain tumor is found jerking rhythmically in the bed and unresponsive to verbal stimuli. What should the nurse do first?

A patient is incontinent during a seizure and sleeps for several hours afterward. What type of seizure did the patient most likely experience?

A patient in the post-ictal period after a seizure remembers smelling something like dead fish prior to the seizure. Which response by the nurse is best?

A patient with a newly diagnosed seizure disorder is being prepared for discharge. What medication should the nurse anticipate will be prescribed for the patient to prevent recurrent seizures?

A patient who has had a seizure is crying, saying life is over, and that working and driving will no longer be possible. Which response by the nurse is most appropriate?

The nurse is assessing a patient recovering from a tonic-clonic seizure. Which finding indicates a need for immediate nursing intervention?

A 17-year-old patient with a new onset of seizures is diagnosed with epilepsy. What should the nurse include in the patient teaching?

A patient arriving in the emergency department with a bullet wound to the left frontal lobe is comatose. What should the nurse make a priority for this patient?

The nurse is caring for a patient admitted to the emergency department with massive trauma to the right frontal lobe of the brain. Which data should the nurse collect related to the location of the injury?

A patient with a cerebral injury is experiencing increased intracranial pressure (ICP). Which intervention should the nurse use to help prevent further increasing intracranial pressure?

The nurse is caring for a patient with a traumatic brain injury. Which assessment finding alerts the nurse to possible diabetes insipidus?

The physician prescribes intravenous mannitol for a patient who has a head injury and increased intracranial pressure (ICP). Which assessment finding indicates to the nurse that the patient is having a therapeutic response to the mannitol?

A teen is experiencing a headache and dizziness after falling of a bicycle and hitting the head. The physician diagnoses a concussion. What explanation should the nurse provide to the patient's mother?

A patient is recovering from an epidural bleed. In which part of the brain should the nurse explain to the family that this bleed occurred?

The nurse is assisting with teaching family members about a patient's epidural bleed. Which information about an epidural bleed should guide the nurse's teaching?

The nurse is preparing to assess a patient with a head injury. Which data should the nurse include in this routine neurological nursing assessment?

The nurse notes that a patient with a head injury has a widening pulse pressure. Which action should the nurse take at this time?

A patient with a newly diagnosed brain tumor receives dexamethasone (Decadron) IV, which completely relieves the patient's symptoms. What should the nurse explain to the family about the patient's response to the medication?

The nurse suspects a patient with a spinal cord injury is experiencing spinal shock. What did the nurse assess to come to this conclusion?

A patient with quadriplegia from a C5 injury is wearing a Halo vest and begins to experience a throbbing headache and nausea. What should the nurse do first?

A patient with suspected spinal cord and head injuries has a Glasgow Coma Scale score of 15; blood pressure 130/82 mm Hg, pulse 102 beats/min, respirations 20 breaths/min, and temperature 98°F (36.6°C). What is the most important nursing intervention during the initial care of the patient?

The spouse of a patient with a C7 spinal cord injury provides all care for the patient in addition to caring for three children. Which outcome criteria should the nurse identify as relevant for a nursing diagnosis of Caregiver Role Strain for this patient's plan of care?

An adolescent sustains an injury while swimming in a river. Friends bring the adolescent to the riverbank and note that the adolescent is conscious and breathing but not moving any extremities. What should the friends do next?

A patient with a spinal cord injury is unable to move the extremities. In which area should the nurse suspect that this client's injury occurred?

A patient is unable to move the extremities after experiencing a spinal cord injury. What term should the nurse use to document paralysis of all four extremities?

The nurse is caring for a patient who has had Parkinson's disease for 15 years. What symptoms should the nurse anticipate when assisting with a routine assessment?

A patient newly diagnosed with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which patient statement indicates teaching about the medication has been effective?

A patient with Parkinson's disease has difficulty tying shoes. What nursing intervention would be the most helpful?

The nurse is caring for residents on an Alzheimer's unit. Which assessment finding indicates that a patient is in early stages of the disease?

The nurse is planning care for a patient with advancing Alzheimer's disease. Which nursing diagnosis should be the priority for this patient?

A nursing home resident with Alzheimer's disease appears extremely distressed after breakfast. On which understanding should the nurse base interventions for this patient?

The nurse caring for patients with dementia. Which intervention would be least helpful when coordinating care for patients who are experiencing confusion?

A patient is prescribed phenytoin (Dilantin) for seizure activity. What should the nurse include when teaching the patient about this medication?

The nurse is notes that a patient recovering from a craniotomy has a pink spot with a yellow ring around it on the pillow. What should the nurse do?

A patient is diagnosed with increased intracranial pressure. What pressure measurement should the nurse expect to be associated with this diagnosis?

The nurse is observing a patient to determine if seizure activity is status epilepticus. For what length of time should seizure activity occur for this diagnosis to be appropriate for the patient?

A patient recovering from a brain injury is having difficulty completing activities of daily living. What should the nurse suggest to help this patient recover independence with self-care?

The nurse is caring for an individual who has a tension headache. Which interventions should be included in the patient's plan of care? (Select all that apply.)

The nurse is planning care for a patient with a migraine headache. Which actions should the nurse include in this plan of care? (Select all that apply.)

The nurse is caring for a patient with an acute brain injury. Which interventions should the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.)

A patient is experiencing a new onset of a seizure. What should the nurse include in this patient's plan of care? (Select all that apply.)

The nurse suspects that a patient is experiencing increasing intracranial pressure. What observations did the nurse make to come to this conclusion? (Select all that apply.)

A patient is diagnosed with a benign familial tremor. Which characteristics of this tremor should the nurse expect to observe? (Select all that apply.)

A patient has been prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson's disease. Which are important for the nurse to include when teaching about this medication? (Select all that apply.)

A patient with a spinal cord injury at T3-T4 experiences a sudden increase in blood pressure (BP) and has cool, pale, gooseflesh skin on the lower extremities. What should the nurse do while awaiting physician orders? (Select all that apply.)

The nurse is caring for a patient diagnosed with bacterial meningitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.)

A patient with bacterial meningitis has an elevated temperature. Which actions should the nurse take to reduce this patient's temperature? (Select all that apply.)

A patient with a brain injury is not able to respond appropriately to sensory stimulation. What should the nurse do to ensure that this patient does not develop skin breakdown? (Select all that apply.)

After collecting data the nurse determines that a patient is experiencing cluster headaches. What information did the nurse use to come to this conclusion? (Select all that apply.)