Deck 11: Intracranial Regulation

Question 1

The nurse selects the diagnosis of Risk of Infection for a child who sustained a brain injury during an automobile accident.Which nursing intervention would be appropriate to include in this client's plan of care related to this diagnosis?

A)Teach the family the importance of using seat belts.
B)Change the client's dressings on a prescribed basis.
C)Refer the family to support services in the community.
D)Explain rules for visiting in the Intensive Care Unit.

Answer 1

Change the client's dressings on a prescribed basis.

Question 2

A newly admitted adult client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS)score of 6.Which of the following assessment findings is most likely in this client?

A)Extension to painful stimuli
B)Spontaneous eye opening
C)Oriented to time,place,and person
D)Withdraws to touch

Answer 2

Extension to painful stimuli

Question 3

The statement "A decrease in level of consciousness may lead to a decrease in respiration" best describes the relationship between intracranial regulation and which of the following?

A)Acid-base balance
B)Cognition
C)Mobility
D)Oxygenation

Answer 3

Oxygenation

Question 4

The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP).Which assessment data indicates that the nurse is successful?

A)Body temperature elevated 1 degree in 4 hours
B)Absent gag reflex
C)Pupils equal and reactive to light
D)Sluggish response to verbal stimuli

Question 5

Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent alterations to intracranial regulation related to what?

A)Prescription drug side effects
B)Congenital hydrocephalus
C)Stroke
D)Trauma

Question 6

The nurse is caring for a pregnant client with a history of idiopathic intracranial hypertension (IIH)and optic neuritis.What should the nurse least assume regarding this client?

A)The client will deliver her baby via cesarean birth.
B)Pregnancy-related weight gain should be kept to no more than 9 kg.
C)The client has been prescribed a medication to treat the IIH.
D)The second stage of labor should not be prolonged.

Question 7

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure.Which actions should the nurse take to support this client's care need? Select all that apply.

A)Limit the client's visitors.
B)Teach family to speak softly and minimize touching.
C)Elevate the head of the bed.
D)Raise pads and bedrails.
E)Keep the room dark and quiet.

Question 8

The nurse notices that a client who sustained a head injury from a motor vehicle crash begins to demonstrate an abnormal posture.(See image. )What does this posture suggest to the nurse about the client's brain functioning?

A)Improved level of consciousness
B)Developing a seizure disorder
C)Brainstem impairment
D)Corticospinal tract impairment

Question 9

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP).Which classifications of medications should the nurse anticipate administering to this client? Select all that apply.

A)Loop diuretics
B)Antibiotics
C)Antiseizure drugs
D)Histamine H₂ antagonists
E)Antipyretics

Question 10

The nurse is planning care for an older adult client with a head injury secondary to a motor vehicle crash.Which information should the nurse keep in mind when planning this client's care? Select all that apply.

A)Anxiety,illness,and pain can alter the ability to learn.
B)Baseline reflexes may be slower or diminished.
C)Impulse transmission and reactions to stimuli are slower.
D)Neurologic assessment should be completed in a single session.
E)Impairment in vision and hearing should be taken into consideration.

Question 11

A school-age client is experiencing photophobia,a sore neck,chills,and fever.During a physical assessment,the nurse uses the technique in the Exhibit.Why did the nurse use this technique when assessing the client?

A)It is a routine part of the physical assessment.
B)Flexion of the hips or knees would be consistent with meningitis.
C)The nurse was assessing range of motion of the neck.
D)This technique assesses optic nerve functioning.

Question 12

Which lobe of the brain stores memory and interprets auditory stimuli?

A)Frontal
B)Occipital
C)Parietal
D)Temporal

Question 13

What part of the body controls reflexes and regulates activities such as vomiting,hiccupping,coughing,and sneezing?

A)Brainstem
B)Hypothalamus
C)Spinal cord
D)Thalamus

Question 14

A nurse is performing a neurologic assessment on a 9-year-old child who has displayed unexplained changes in behavior.Which assessment finding is consistent with a neurologic deficit?

A)Child has a negative Babinski reflex.
B)Child recalls names of well-known cartoon characters.
C)Child is able to walk backward heel to toe.
D)Child is incapable of balancing on one foot.

Question 15

The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP)in preparation for an evaluation to be done by the healthcare provider during morning rounds.Which diagnostic test results should the nurse make available to the healthcare provider for review? Select all that apply.

A)Bronchoscopy results
B)MRI result
C)Head CT scan with and without contrast
D)Electroencephalogram
E)Cerebrospinal fluid differential cell count

Question 16

The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP)shunt as treatment for increased intracranial pressure (IICP).The nurse has taught the parents to monitor the child for shunt malfunction.Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met?

A)"If our child has a bulging soft spot,we will call the doctor."
B)"If our child develops an altered level of consciousness,we will notify the doctor."
C)"If we notice our child's head is expanding,we will notify the doctor."
D)"If our child vomits,we will call the doctor."

Question 17

While caring for a client with increased intracranial pressure (IICP),a family member asks to assist.Which interventions are appropriate for the nurse to teach the family member regarding this client's care? Select all that apply.

A)Maintain head of the bed elevated to 30 degrees.
B)Position client in a supine position.
C)Decrease stimuli.
D)Keep bedrails raised.
E)Keep the client in a stationary position.

Question 18

A school-age client loses consciousness after being hit in the head with a bat at baseball practice.The child was not wearing a helmet.The last set of vital signs showed heart rate 48,blood pressure 132/58 mmHg,and respiratory rate 28 and irregular.Based on this data,which conclusion by the nurse is the most appropriate?

A)These vital signs indicate respiratory distress.
B)These vital signs indicate increased intracranial pressure.
C)These vital signs indicate cardiovascular disease.
D)These vital signs indicate that this child has a spinal cord injury.

Question 19

The nurse is caring for a client in the neurologic intensive care unit (ICU)with head trauma.The client is being monitored for increased intracranial pressure (IICP).Using the Monro-Kellie hypothesis as a basis for explanation,which comment by the nurse to the client's family would be most appropriate?

A)"It is normal for brain pressure to increase in times of stress."
B)"Increasing brain pressure decreases the amount of blood flow to the brain itself."
C)"The pressure in the brain is increasing because the brain is shrinking."
D)"Because there is more pressure in the brain,the blood flow is also increasing."

Question 20

The nurse is planning care for a client who is experiencing increased intracranial pressure (IICP)secondary to a head injury sustained during a motor vehicle crash.Which intervention is a priority for this client?

A)Ensuring adequate oxygenation
B)Maintaining a calm environment
C)Monitoring for nausea and vomiting
D)Controlling pain

Question 21

Which of the following is characteristic of triggers for seizures?

A)They are externalized.
B)They are generalized.
C)They are internalized.
D)They are variable.

Question 22

Traumatic brain injury occurs when which of the following causes some degree of impairment to brain structure or function?

A)Congenital disorder
B)External force
C)Infection
D)Stress reaction

Question 23

Which events are associated with the loss of autoregulation?

A)Both intracranial pressure and cerebral perfusion decrease.
B)Both intracranial pressure and cerebral perfusion increase.
C)Intracranial pressure decreases and cerebral perfusion increases.
D)Intracranial pressure increases and cerebral perfusion decreases.

Question 24

What type of seizure does not affect memory or awareness and occurs when abnormal electrical activity is contained to a limited area of the brain?

A)Absence
B)Complex focal
C)Generalized
D)Simple focal

Question 25

The nurse identifies the diagnosis Risk for Injury as appropriate for a client with a seizure disorder.Based on this diagnosis,which nursing interventions are appropriate when this client experiences a seizure? Select all that apply.

A)Turn the client to a lateral position,if possible.
B)Stay with the client.
C)Insert a tongue blade into the client's mouth.
D)Call for help.
E)Restrain the client.

Question 26

When a nurse provides a client with the guidance to wear seat belts and avoid mobile device use while driving,this measure is intended to lower the risk of which of the following?

A)Cerebral edema
B)Head trauma
C)Hydrocephalus
D)Intracranial tumors

Question 27

Which of the following statements best describes the state of dynamic equilibrium of the Monro-Kellie hypothesis?

A)An imbalance in the volumes of the brain,blood,and cerebrospinal fluid (CSF)will trigger a compensatory response.
B)Normal intracranial pressure requires that the volumes of the brain,blood,and CSF are low.
C)The brain can compress dynamically to compensate for an increase in blood or CSF volume.
D)The volume of the blood must remain constant regardless of the volume of the brain and CSF.

Question 28

An older adult client is experiencing a tonic-clonic (grand mal)seizure exceeding 10 minutes in length.Which medication should the nurse prepare to administer to this client?

A)Intramuscular injection of diazepam
B)Intramuscular injection of phenytoin
C)Intravenous diazepam slowly over several minutes
D)Oral administration of gabapentin

Question 29

Hydrocephalus results from an imbalance between production and absorption of which of the following?

A)Blood
B)Cerebrospinal fluid
C)Oxygen
D)Water

Question 30

Which of the following statements best describes a seizure threshold?

A)The threshold is the length of time a seizure will last.
B)The threshold is the limit beyond which the occurrence of a seizure is possible.
C)Unless a seizure results in convulsions,it is considered to be below the threshold.
D)When the threshold is exceeded,a seizure is considered to be generalized.

Question 31

The nurse observes a school-age client have an absence seizure.Which statement will the nurse likely include when documenting this seizure?

A)"Reported experiencing tingling sensations but denied loss of consciousness."
B)"Became unconscious,and all four extremities were jerking uncontrollably for 2 minutes."
C)"Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes."
D)"Sat very still and was unresponsive with a blank stare for 30 seconds."

Question 32

A seizure that is not provoked by known stimuli is known as which of the following?

A)Acquired
B)Congenital
C)Febrile
D)Idiopathic

Question 33

The nurse provides teaching about phenytoin (Dilantin)to the mother of a school-age client with a seizure disorder.Which statement made by the mother indicates that teaching has been effective?

A)"I will give his medicine on an empty stomach so he will absorb it better."
B)"I will check his gums and increase visits to the dentist."
C)"I will use a carbonated beverage to dilute his medication."
D)"I will allow him to chew the tablet."

Question 34

The nurse is planning discharge teaching for a child with epilepsy who is prescribed phenytoin (Dilantin).The nurse should recommend a diet rich in which of the following to this client?

A)Carbohydrates
B)Fats
C)Protein
D)Vitamin D

Question 35

Which statement about cerebral edema or ischemia is true?

A)It often causes a skull fracture.
B)It is an example of a lacerating injury.
C)It is an example of a penetrating injury.
D)It is often secondary to a traumatic brain injury.

Question 36

A nurse is planning a teaching exercise on prevention of traumatic brain injury and identifying examples of people with a higher risk of TBI.Which of the following people is not in a higher-risk group for a TBI?

A)A 2-year-old child
B)A 13-year-old adolescent
C)A 44-year-old office worker
D)A 77-year-old retiree

Question 37

Which clinical manifestation is associated with a mild concussion?

A)Bleeding in the brain
B)Difficulty breathing
C)Acute headache
D)Prolonged unconsciousness

Question 38

The nurse makes a visit to the home of an adolescent recently discharged from the hospital following treatment for a tonic-clonic seizure disorder.Which observations indicate that outcomes for care have been achieved? Select all that apply.

A)The client is not driving.
B)The client has not had a seizure for 1 month.
C)The client is participating in the school basketball team.
D)The client has bruises on both arms.
E)The client is complaining of constipation.

Question 39

A preschool-age client with myoclonic seizures has been following a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided lower abdominal pain.Which complication of the ketogenic diet should the nurse suspect the client is experiencing?

A)Bowel obstruction
B)Kidney stone
C)Urinary tract infection
D)Appendicitis

Question 40

The nurse is caring for a toddler-age client who starts to have a tonic-clonic (grand mal)seizure while in a crib in the hospital.The child's jaws are clamped shut.What is the most appropriate nursing action?

A)Place a tongue blade between the child's jaws.
B)Restrain the child to prevent injury.
C)Prepare the suction equipment.
D)Stay with the child to observe for complications.

Question 41

A client is classified as Grade 4 for risk of cerebral vasospasm because of intracerebral clotting and absence of blood in the basal cisterns.Which diagnostic test is most useful to assess intracerebral hemorrhage and grade cerebral vasospasms?

A)Cerebrospinal fluid (CSF)analysis
B)CT scan
C)MRI
D)Transcranial Doppler

Question 42

The school nurse is teaching a group of adolescent athletes about reducing the risk for sustaining traumatic brain injuries (TBI).To provide client-centered education to this population,which information is most appropriate for the school nurse to include in the teaching session?

A)"A fall from even a low height can cause traumatic brain injury."
B)"A traumatic brain injury can occur to anyone from a wide range of causes."
C)"If you are injured in a game or practice,don't play through the pain."
D)"Wearing seat belts can protect against injuries in motor vehicle collisions."

Question 43

Which types of sports are most likely to cause concussion and traumatic brain injury?

A)Competitive
B)Energetic
C)High-impact
D)Team

Question 44

A client presents with a mild concussion following a fall.Which nursing diagnosis is least likely to be made for this client?

A)Acute Pain
B)Acute Confusion
C)Nausea
D)Risk for Post-Trauma Syndrome

Question 45

Which of the following infant clients presenting with traumatic brain injury (TBI)is least likely the victim of child abuse?

A)Infant with contusion sustained from fall from high chair
B)Infant with contusion,unknown cause
C)Infant with diffuse axonal injury following involvement as passenger in a vehicle collision
D)Infant with diffuse axonal injury,unknown cause