Quiz Chapter 53 Care of the Patient with a Neurologic Disorder Questions with Correct Answers

Quiz Chapter 53 Care of the Patient with a Neurologic Disorder Questions with Correct Answers What is the earliest sign of increased intracranial pressure? - Correct Answer Change in level of consciousness (LOC) A change in LOC is the earliest sign of increased intracranial pressure. This change in LOC may include disorientation, restlessness, or lethargy. Widening pulse pressure occurs because of an increased systolic blood pressure (resulting from excitation of vasoconstrictor fibers from ischemia of the vasomotor center) coupled with a stable diastolic blood pressure. This occurs later in the process of increased intracranial pressure, when herniation is imminent. Ipsilateral pupil dilation will occur as a result of compression of cranial nerve III (oculomotor) when the lesion is in one hemisphere. This occurs later in the process of increased intracranial pressure, when herniation is imminent. An ataxic breathing pattern is an irregular and unpredictable breathing pattern with random, shallow, and deep breaths and occasional pauses. This will occur very late in the process of increased intracranial pressure. When taking the history of a patient with a migraine headache, what features of a migraine headache is the patient likely to report? Select all that apply. - Correct Answer The headache is usually unilateral. The headache is preceded by an aura. The headache is usually triggered by foods, such as chocolate. Migraine headaches are usually unilateral and are usually preceded by an aura, which can be a visual, sensory, or motor phenomenon. The headache can be triggered by certain foods, including chocolate, cheese, tomatoes, onions, and oranges. Migraine headaches may last from 4 hours to 72 hours. The nature of the headache is not sharp and stabbing but rather steady and throbbing. A nurse is assessing a patient using the Full Outline of UnResponsiveness (FOUR) score coma scale. Which categories will the nurse use to evaluate the patient's status? Select all that apply. - Correct Answer Respiration Eye response Motor response Brainstem reflexes The FOUR score coma scale uses respiration, eye response, motor response, and brainstem reflexes to measure the patient's level of consciousness and coma status. Verbal response is a part of the Glasgow Coma Scale