Deck 57: Nursing Management: Acute Intracranial Problems

Question 1

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?

A) Oral temperature 101.6° F
B) Intracranial pressure 15 mm Hg
C) Mean arterial pressure 70 mm Hg
D) Apical pulse 106 beats/min

Answer 1

Oral temperature 101.6° F

Question 2

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

A) Blood pressure 130/72, pulse 90, respirations 32
B) Blood pressure 148/78, pulse 112, respirations 28
C) Blood pressure 156/60, pulse 60, respirations 14
D) Blood pressure 110/70, pulse 120, respirations 30

Answer 2

Blood pressure 156/60, pulse 60, respirations 14

Question 3

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to

A) maintain the patient in a head-up position.
B) position the patient with the knees and hips flexed.
C) cluster nursing interventions to provide uninterrupted periods of rest.
D) encourage coughing and deep-breathing to improve oxygenation.

Answer 3

maintain the patient in a head-up position.

Question 4

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

A) high blood flow to the brain.
B) normal intracranial pressure (ICP).
C) impaired brain blood flow.
D) adequate cerebral perfusion.

Question 5

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

A) The staff nurse has the patient deep-breathe and cough.
B) The staff nurse assesses neurologic status every hour.
C) The staff nurse elevates the head of the bed to 30 degrees.
D) The staff nurse administers an analgesic before turning the patient.

Question 6

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of

A) apneustic breathing.
B) crackles on inspiration.
C) Glasgow Coma Scale score of 7.
D) cerebral perfusion pressure of 56 mm Hg.

Question 7

When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

A) corneal reflexes are absent.
B) patient develops nystagmus.
C) right pupil does not react to light.
D) left pupil is 10 mm in size.

Question 8

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

A) The blood pressure increases from 120/54 to 136/62.
B) The patient is more difficult to arouse.
C) The patient complains of a headache at pain level 5 of a 10-point scale.
D) The patient's apical pulse is slightly irregular.

Question 9

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

A) Document and continue to monitor the parameters.
B) Elevate the head of the patient's bed.
C) Notify the health care provider about the assessments.
D) Check the patient's pupillary response to light.

Question 10

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should

A) monitor oxygen saturation.
B) check arterial blood gases (ABGs).
C) monitor intracranial pressure (ICP).
D) assess patient breath sounds.

Question 11

The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the medication is effective if

A) seizure behavior is reduced.
B) intracranial pressure (ICP) is lower.
C) abnormal electroencephalographic (EEG) activity decreases.
D) Glasgow Coma score (GCS) is lower.

Question 12

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

A) decorticate posturing.
B) decerebrate posturing.
C) localization of pain.
D) flexion withdrawal.

Question 13

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess

A) medication history.
B) oxygen saturation.
C) Glasgow Coma Scale (GCS).
D) pupil reaction to light.

Question 14

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?

A) A 23-year-old patient who had a skull fracture and craniotomy the previous day
B) A 30-year-old patient who has an ICP monitor in place after a head injury a week ago
C) A 44-year-old patient receiving IV antibiotics for meningococcal meningitis
D) A 61-year-old patient who has increased ICP and is receiving hyperventilation therapy

Question 15

Family members are optimistic about a comatose patient's recovery because the patient's eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?

A) "The behavior is only a reflex and does not indicate improvement in the comatose condition."
B) "Sleep-wake cycles are indicators of recovery and a sign that the brain function is improving."
C) "When patients begin to recover from a coma, the first behaviors seen are those of wakefulness and opening the eyes."
D) "The part of the brain responsible for arousal is not injured, but the wakefulness does not indicate improvement in higher brain centers."

Question 16

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

A) Administer acetaminophen (Tylenol) 650 mg orally.
B) Administer 5% hypertonic saline intravenously.
C) Draw blood for arterial blood gases (ABGs).
D) Send patient to radiology for computed tomography (CT) of the head.

Question 17

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 ml/hr for 3 days. The nurse will anticipate the need to

A) continue the D₅W to provide the needed glucose for brain function.
B) decrease the rate of IV infusion to avoid increasing cerebral edema.
C) insert an enteral feeding tube to provide nutritional replacement.
D) administer IV 5% albumin to increase serum protein levels.

Question 18

A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock while hiking. The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. The nurse's best approach to the patient's family is to

A) call the family's pastor or spiritual advisor to support them while initial care is given.
B) refer the family members to the hospital counseling service to deal with their anxiety.
C) allow the family to stay with the patient and explain all procedures thoroughly to them.
D) ask the family to stay in the waiting room while the initial assessment and care are done.

Question 19

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

A) vomiting.
B) headache.
C) change in level of consciousness (LOC).
D) sluggish pupil response to light.

Question 20

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

A) 9.
B) 11.
C) 13.
D) 15.

Question 21

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?

A) The nursing assistant goes into the patient's room without a mask.
B) The bedrails at the head and foot of the bed are both elevated.
C) The lights in the patient's room are turned off and the blinds are shut.
D) The patient receives a regular diet from the dietary department.

Question 22

A patient with increasing headaches who is having diagnostic testing for a brain tumor asks the nurse what type of treatment will be used if a tumor is discovered. Which response by the nurse is most appropriate?

A) "If the tumor is benign, treatment may not be necessary."
B) "Therapy to remove or reduce the tumor size will be recommended."
C) "Surgery will initially be used to reduce or remove the tumor."
D) "Chemotherapy is used to shrink the tumor, followed by craniotomy."

Question 23

A victim of an automobile accident was found unconscious at the scene of the accident but briefly regained consciousness during transport to the hospital. On admission, the Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse will anticipate the need to

A) prepare the patient for immediate craniotomy.
B) administer IV furosemide (Lasix).
C) type and crossmatch for blood transfusion.
D) initiate high-dose barbiturate therapy.

Question 24

Following a craniotomy with a craniectomy and left anterior fossae incision, the patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness (LOC) and weakness. An appropriate nursing intervention is to

A) position the bed flat and log roll the patient.
B) perform range-of-motion (ROM) exercises every 4 hours.
C) turn and reposition the patient side to side every 2 hours.
D) cluster nursing activities to allow longer rest periods.

Question 25

When assessing a patient with bacterial meningitis, the nurse obtains all of the following information. Which should be reported immediately to the health care provider?

A) The patient complains of having a stiff neck.
B) The patient has a positive Kernig's sign.
C) The patient's blood pressure is 86/42 mm Hg.
D) The patient's temperature is 102° F.

Question 26

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

A) expressive aphasia.
B) right-sided weakness.
C) judgment changes.
D) difficulty swallowing.

Question 27

A patient who has bacterial meningitis and is disoriented and anxious has a nursing diagnosis of disturbed sensory perception related to decreased level of consciousness. An appropriate nursing intervention is to

A) apply soft restraints to protect the patient from injury.
B) minimize contact with the patient to decrease sensory input.
C) encourage family members to remain at the bedside.
D) keep the room well-lighted to improve patient orientation.

Question 28

In planning discharge for the patient following brain trauma, the nurse includes teaching and support for the family, primarily because

A) the residual deficits of the brain damage are unlikely to improve in the months after discharge.
B) families become dysfunctional and unable to cope with the role reversals required during convalescence.
C) patients with severe head injuries often have changes in personality with loss of concentration and memory processing.
D) most patients experience seizure disorders in the weeks or even years following head injury.

Question 29

A patient is brought to the emergency department (ED) after being hit in the head with a baseball during a company picnic. On admission, the patient has a headache and cannot remember being hit but has no other signs of neurologic deficit. The nurse will plan to

A) send the patient for diagnostic testing with MRI.
B) admit the patient for observation for 24 hours.
C) discharge the patient with monitoring instructions.
D) observe the patient in the ED for several hours.

Question 30

A patient with a brain tumor is receiving radiation after having had a craniotomy. The nurse will explain that the purpose of the ordered methylprednisolone (Solu-Medrol) is to

A) eliminate the remaining tumor cells.
B) prevent an increase in intracranial pressure (ICP).
C) promote wound healing after the craniotomy.
D) decrease the risk of metastasis of the cancer.

Question 31

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?

A) Emphasize the importance of hand washing to prevent spread of infection.
B) Immunize adolescents and college freshman against Neisseria meningitides.
C) Vaccinate 11 and 12 year-old children against Haemophilus influenzae.
D) Encourage adolescents and young adults to avoid crowded areas in the winter.

Question 32

A patient admitted with bacterial meningitis and a temperature of 102° F has orders for all of these collaborative interventions. Which one should the nurse accomplish first?

A) IV ceftizoxime (Cefizox) 1 g now and every 6 hours
B) IV dexamethasone (Decadron) 4 mg now
C) Hypothermia blanket to keep temperature less than 101.6° F
D) Nasopharyngeal swab for culture and sensitivity

Question 33

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to

A) obtain a specimen of the fluid and send for culture and sensitivity.
B) take the patient's temperature to determine whether a fever is present.
C) check the nasal drainage for glucose with a Dextrostik or Testape.
D) have the patient to blow the nose and then check the nares for redness.

Question 34

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?

A) Insert nasogastric tube.
B) Turn patient every 2 hours.
C) Keep head of bed elevated.
D) Cold packs for facial bruising.

Question 35

Four days after a patient has undergone a craniotomy to remove an astrocytoma of the temporal lobe, the dressing is removed and the nurse finds the patient crying. The patient tells the nurse, "I look awful and feel even worse." The most appropriate nursing diagnosis for the patient is

A) grieving related to the patient's ongoing fear of dying.
B) disturbed body image related to postoperative change in appearance.
C) ineffective denial related to unrealistic expectations about surgery.
D) hopelessness related to emotional lability secondary to cerebral edema.