ATI Detailed Answer Key SS.N4581 Stroke and Intracranial Problems

1. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to read following a stroke would have involvement of the left hemisphere. B. Inability to recognize his family members Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere. C. Right hemiparesis Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the body reflects damage to the upper motor neurons on the opposite side of the brain. A client who has right hemiparesis would have involvement of the left hemisphere. D. Aphasia Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to speak or understand language following a stroke would have involvement of the left hemisphere. 2. A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? A. History of smoking Rationale: Smoking is a modifiable risk factor, because the client has an ability to change via cessation. B. Obesity Rationale: Obesity is a modifiable risk factor, because the client should have the ability to change via diet. C. History of hypertension Rationale: Hypertension is a modifiable risk factor, because the client should have the ability to change via medication, exercise, and diet. D. Race Rationale: Race is a nonmodifiable risk factor, which the client is unable to control. 3. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? A. Poor impulse control Rationale: A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment. B. Unable to discriminate words and letters Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have deficits that involve language, mathematical skills, and thinking. The nurse should expect the client who had a stroke involving the right cerebral hemisphere to have deficits that include loss of sense of humor, inability to recognize faces, and disorientation to time, place and person. C. Deficits in the right visual field Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have deficits in the right visual field. The nurse should expect the client who had a stroke involving the right cerebral hemisphere to have deficits that include neglect of the left visual field and loss of depth perception. D. Motor retardation Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have motor retardation, cautiousness and possibly depression. The nurse should expect the client who had a stroke involving the right cerebral hemisphere to have deficits that include euphoria, overestimation of abilities and lack of awareness of neurologic deficits. 4. A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? A. Impaired sense of humor Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have language deficits, which include difficult using or comprehending language and difficulty writing. The nurse should expect a client who had a stroke involving the right cerebral hemisphere to have an impaired sense of humor. B. Loss of depth perception Rationale: A client who had a stroke involving the left cerebral hemisphere is more likely to have visual deficits which include inability to discriminate words and letters, reading problems and deficits in the right visual field. The nurse should expect a client who had a stroke involving the right cerebral hemisphere to have loss of depth perception, visual spatial deficits and neglect of the left visual field. C. Poor judgment Rationale: A client who had a stroke involving the left cerebral hemisphere is more likely to have behavior changes that include cautiousness, depression and anxiety. The nurse should expect a client who had a stroke involving the right cerebral hemisphere to have personality changes which can include impulsiveness, confabulation and poor judgment. D. Intellectual impairment Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have deficits that involve language, mathematical skills, and thinking. 5. A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours Rationale: A client who has a thrombotic (ischemic) stroke will have a gradual onset of manifestations occurring over several minutes to hours. A client who has had a hemorrhagic stroke tends to have an acute onset. B. Manifestations preceded by a severe headache Rationale: A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke. C. Maintains consciousness Rationale: A client who has an ischemic stroke maintains a level of consciousness. A client who has a hemorrhagic stroke has a decreased level of consciousness, extending from stupor to coma. D. History of neurologic deficits lasting less than 1 hr Rationale: A client who has an ischemic stroke might have experienced transient ischemic attacks that caused neurologic deficits lasting for short periods of time before. These transient attacks are not present in a client who has had a hemorrhagic stroke. 6. A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? A. Transient ischemic attack (TIA) Rationale: A client who has a TIA develops a sudden loss of motor, sensory, or visual function usually lasting less than an hour. It is caused by temporary impairment of blood flow to the brain and is often a warning sign of an impending stroke. B. Hemorrhagic stroke Rationale: A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma. C. Thrombotic stroke Rationale: A thrombotic stroke develops gradually, over minutes to hours, and is the result of a clot (thrombus) which interrupts cerebral blood flow. Thrombotic strokes are commonly associated with atherosclerosis and manifests as numbness or loss of function of the face, arm, or leg usually on one side. The client does not lose consciousness or have seizures. D. Embolic stroke Rationale: An embolic stroke is caused by an emboli from another area of the body which travels to the brain and causes brain ischemia. They are commonly seen in clients who have atrial fibrillation, heart valve disease, or a recent myocardial infarction. Embolic strokes are characterized by sudden onset of neurological deficits which improve over time. The client does not have a loss of consciousness or seizures. 7. A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Perform passive range of motion on each extremity. Rationale: The nurse should perform passive range of motion for the client who is unconscious, to help prevent complications of impaired physical mobility; however, this is not the highest priority intervention according to the safety and risk reduction priority setting framework. B. Monitor the client’s electrolyte levels. Rationale: The nurse should monitor the electrolyte levels for the client who is unconscious, to help identify complications of increased intracranial pressure and to limit the risk of cardiac dysrhythmia; however, this is not the highest priority intervention according to the safety and risk reduction priority setting framework. C. Suction saliva from the client’s mouth. Rationale: The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client’s airway, breathing, and circulation is the highest priority. D. Record the client’s intake and output. Rationale: The nurse should record the intake and output for the client who is unconscious, to help identify complications of altered neurological status and increased intracranial pressure; however, this is not the highest priority intervention according to the safety and risk reduction priority setting framework. 8. A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take? A. Provide the client with water to test the gag reflex. Rationale: The nurse should not give the client anything to eat or drink in case the client's gag reflex is impaired, as this could cause aspiration. Assessment of swallowing ability can be performed when the client is stable and equipment to suction the client's airway is available. B. Perform carotid massage. Rationale: The nurse should understand carotid massage is used to correct atrioventricular tachycardia. The technique will not improve the client's condition and could cause harm if the client has carotid stenosis. C. Notify emergency management services. Rationale: The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering appropriate treatment; therefore, the nurse should call the emergency management services. D. Drive the client to the nearest medical facility. Rationale: The nurse should not attempt to drive the client away from the scene. The nurse should position the client to maintain an open airway. 9. A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? A. Hypotension Rationale: The nurse should identify hypertension as a manifestation of increased intracranial pressure. B. Tachycardia Rationale: The nurse should identify bradycardia as a manifestation of increased intracranial pressure. C. Irritability Rationale: The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure. D. Tinnitus Rationale: The nurse should identify changes in pupillary response as a manifestation of increased intracranial pressure. 10. A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? A. Speak to the client about one idea at a time. Rationale: The nurse should speak using sentences that contain one clear thought or idea for better communication and understanding. B. Ask the client to multi-task. Rationale: The nurse use simple one-step directions, rather than ask the client to multi-task. C. Limit questions to yes and no answers. Rationale: The nurse should avoid asking questions that stimulate "yes" and "no" responses because the client might give automatic responses that are not correct. D. Focus on a single form of communication. Rationale: The nurse should include a variety of aids to assist with communication. 11.A A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse’s priority? A. The client's ECG tracing shows irregular heart rate without P waves. Rationale: A client who has atrial fibrillation will have an irregularly irregular heart rate, absent P waves, and a variable ventricular rate; therefore, this is not the nurse’s priority finding. B. The client has an aPTT of 80 seconds. Rationale: A client who has atrial fibrillation may receive heparin to extend the clotting time and prevent the formation of clots. APTT result of 80 seconds is double the control value and indicates effectiveness of the heparin therapy; therefore, this is not the nurse's priority finding. C. The client experiences sudden weakness of one arm and leg. Rationale: Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse's priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache. D. The client's urine output is cloudy and odorous. Rationale: Cloudy, odorous urine output can indicate the client has a urinary tract infection; however, there is another finding that is the nurse's priority. 12.A A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? A. Obtain the telephone number of the client's provider. Rationale: This action could delay treatment and result in further injury and disability. B. Find a location for the client to sit. Rationale: The nurse should support the client where she is and try to make her comfortable while ensuring airway patency. But she should not attempt to move her. C. Call emergency services. Rationale: The client might have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke center. D. Drive the client to the nearest emergency department. Rationale: The nurse should support the client where she is and try to make her comfortable while ensuring airway patency. But she should not attempt to move her, as doing so could cause additional injury and disability. 13. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration. B. Check the client's motor strength. Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment following the seizure; however, there is another action the nurse should take first. C. Loosen the clothing around the client's waist. Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury; however, there is another action the nurse should take first. D. Document the time the seizure began. Rationale: The nurse should document the time the seizure began and ended to provide information to the provider about the severity of the seizure; however, there is another action the nurse should take first. 14.A A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? A. Insert a tongue blade in the client's mouth. Rationale: The nurse should never force anything into the mouth of a client who is having a seizure. Doing so can obstruct the client's airway or chip the client's teeth. B. Place the client on his side. Rationale: The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed. C. Hold the client's arms and legs from moving. Rationale: The nurse should not try to restrain the client from moving because this could injure the client. D. Place the client back in bed. Rationale: The nurse should remove all furniture out of the way from the client during the seizure and place the client‘s head on a pillow or lap. However, the nurse should avoid moving the client back into bed until the seizure is completed. 15. A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? A. Obtain IV access. Rationale: The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure. B. Keep the lights on when the client is sleeping. Rationale: An important part of seizure precautions and management is to allow the client to rest. Illumination may interfere with the client’s ability to rest and sleep. C. Place the client's bed in the high position. Rationale: Placing the client's bed in the lowest position will protect the client from injuries if he falls out of bed during a seizure. Placing a mattress on the floor can also project the client from injury during a seizure. D. Keep a padded tongue blade available at the client's bedside. Rationale: The nurse should not use padded tongue blades or force anything into the client's mouth during a seizure. This can chip the client's teeth and place the client at risk for aspirating tooth fragments. This also can block the client's airway. 16. A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) A. Provide a suction setup at the bedside. B. Elevate the side rails near the head when the client is in bed. C. Place the bed in the lowest position. D. Keep an oxygen setup at the bedside. E. Furnish restraints at the bedside. Rationale: Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed. Furnish restraints at the bedside is incorrect. The nurse should not plan to restrain a client during a seizure, as this can cause harm to the client's muscles and limbs. 17.A A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? A. "Insert a padded tongue blade into the client's mouth." Rationale: The nurse should instruct the family not to insert anything into the client's mouth during a seizure to prevent causing injuring to the client. B. "Restrain the client." Rationale: The nurse should instruct the family not to restrain the client to reduce the risk of causing injury to the client. C. "Place the client on his back." Rationale: The nurse should instruct the family to place the client on his side to decrease the risk for aspiration. D. "Move objects away from the client." Rationale: The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client. 18.A A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A. Delay in disease progression Rationale: Diphenhydramine may be helpful in controlling symptoms in the early stage of the disease; however, it will not delay disease progression. B. Improved bladder function Rationale: Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may cause urinary retention. C. Relief of depression Rationale: Relief of depression is not associated with the use of antihistamines or anticholinergics. D. Decreased tremors Rationale: Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease. 19. A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Provide client supervision. Rationale: Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment. B. Limit client physical activity. Rationale: The nurse should recommend an exercise program, alternated with periods of rest, to improve the client's mobility. C. Speak loudly to the client. Rationale: The speech patterns of clients who have Parkinson's disease are often affected with slurring or hesitation, but not their hearing. D. Leave the television on continuously. Rationale: The nurse should recommend decreasing excess environmental stimuli to increase the client's ability to concentrate on listening. 20.A A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus Rationale: The nurse should expect to find oily skin, which results from autonomic dysfunction, rather than pruritus, which results from dry skin. B. Hypertension Rationale: The nurse should expect to find orthostatic hypotension, which results from autonomic dysfunction. C. Bradykinesia Rationale: The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease. D. Xerostomia Rationale: The nurse should expect to find uncontrolled drooling, especially at night, instead of xerostomia or dry mouth in a client who has Parkinson's disease. 21.A A nurse is teaching a client who taking benztropine to treat Parkinson’s disease. The nurse should instruct the client to report which of the following adverse effects? A. Excess salivation Rationale: Dry mouth is an adverse effect of benztropine, due to the anticholinergic response of the medication. B. Difficulty voiding Rationale: The nurse should instruct the client to report difficulty voiding, which may indicate urinary C. Diarrhea retention, as an adverse effect of benztropine. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson’s disease. Rationale: Constipation is an adverse effect of benztropine, which is due to the anticholinergic response of the medication that slows peristalsis. D. Slow pulse Rationale: Tachycardia is an adverse effect of benztropine, which is due to the anticholinergic response of the medication. 22.A A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? A. Confusion Rationale: Myasthenia gravis does not affect cognition, level of consciousness, or orientation. B. Weakness Rationale: Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections. C. Increased intracranial pressure Rationale: Myasthenia gravis does not affect pressure within the brain. D. Increased urinary output Rationale: Myasthenia gravis does not cause increased urine output. 23.A A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? A. Have the client empty his bladder. Rationale: There is no need for a client who has myasthenia gravis, an autoimmune disorder, to empty his bladder prior to receiving oral medication. B. Put up the side rails on the client's bed. Rationale: There is no need for the nurse to raise the side rails for a client who has myasthenia gravis, an autoimmune disorder, prior to administering oral medication. C. Ask the client to take a few sips of water. Rationale: Clients who have myasthenia gravis, an autoimmune disorder, have weakness of the muscles of the face and throat, which increases the risk for aspiration. The nurse should check the client's ability to swallow before administering oral medication. D. Place the client in low Fowler's position. Rationale: It is unsafe for the nurse to position a client who has myasthenia gravis, an autoimmune disorder, in low Fowler's position prior to administering oral medication. 24. A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Prepare the client for mechanical ventilation. Rationale: The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation. B. Administer an anticholinesterase medication. Rationale: The client who is experiencing a myasthenic crisis should not receive anticholinesterase medications during a myasthenic crisis. These medications are often ineffective during a crisis and may increase respiratory secretions. C. Instruct the client to perform the pursed lip breathing. Rationale: Myasthenia gravis is an autoimmune illness that results in progressive muscular weakness. A client who is experiencing myasthenic crisis is at risk for respiratory failure and will not benefit from pursed lip breathing. D. Prepare to administer a vasoconstrictor. Rationale: A client who is experiencing myasthenic crisis will be hypertensive rather than hypotensive. 25. A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis? A. Developing a respiratory infection Rationale: The most common triggers of myasthenic crises are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures. B. Taking too much prescribed medication Rationale: Not taking, or taking too little, of the prescribed medication is more likely to trigger a myasthenic crisis. Taking an excess amount of medication can cause a cholinergic crisis. C. Diet high in protein Rationale: A diet high in protein should be avoided in the client who has renal failure; however, there is no correlation between dietary intake and the development of myasthenic crisis. D. Not exercising enough Rationale: Vigorous physical activity, such as exercising excessively, can trigger a myasthenic crisis. 26.A A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia (termed Cushing’s triad) are signs of increased ICP. B. Amnesia Rationale: The client who has a traumatic brain injury may experience a loss of consciousness along with a lack of memory of events prior to or following the injury, but does not indicate an increase in ICP. C. Hypotension Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia (termed Cushing’s triad) are signs of increased ICP. D. Restlessness Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern. 27.A A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? A. Nuchal rigidity Rationale: Neck stiffness or nuchal rigidity, along with myalgia and altered reflexes, is a manifestation of meningeal inflammation. B. Pupils reactive to light Rationale: Cranial nerve III is responsible for pupil constriction, so changes in pupillary reaction is a definite cause for concern, but reactivity does not indicate increased ICP. C. Widened pulse pressure Rationale: A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness. D. Elevated temperature Rationale: Fever, sometimes accompanied by chills, is a manifestation of bacterial infection. 28. A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) A. Headache B. Neck pain and stiffness C. Slurred speech D. Pupillary changes E. Disorientation Rationale: Headache is correct. A client who has increasing ICP might manifest a headache.Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP.Slurred speech is correct. A client who has increasing ICP might manifest slurred speech.Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes.Disorientation is correct. A client who has increasing ICP might display disorientation or confusion. 29.A A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) A. Confusion B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred speech Rationale: Confusion is incorrect. A change in the level of consciousness is an early sign of neurologic status. This is often manifested as restlessness, irritability, and confusion. Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia. Hypotension is incorrect. Severe hypertension is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have hypotension. Nonreactive dilated pupils is correct. Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils. Slurred speech is incorrect. Slowed speech can be an early sign of increased intracranial pressure. Late manifestations include stupor, progressing to coma, and abnormal motor responses, including decorticate and decerebrate posturing. 30.A A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. Rationale: A client who has increased ICP is at risk for brain herniation, a potentially life-threatening condition. Actions, such as deep breathing, coughing, and blowing the nose, can increase ICP. The nurse should take measures to maintain or reduce the client's ICP. B. Place the client in a supine position. Rationale: An important intervention for ICP is positioning the client in a neutral position with the head of the bed elevated to 30&deg to 45&deg. This placement allows the cerebral spinal fluid to flow freely through the brain and spinal cord, minimizes pressure within the central nervous system, and prevents aspiration. C. Place a warming blanket on the client. Rationale: A client who has increased ICP can develop a fever in response to systemic trauma, the presence of blood in the cranium, infection, or as a generalized inflammatory response to the brain injury. Therapeutic cooling is often initiated, even in the absence of fever, in order to slow the brain's metabolism and prevent secondary brain injury. D. Use log rolling to reposition the client. Rationale: Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.