Neurocritical Care and Head Injury Management: Key Concepts and Interventions

The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion from a head injury. Which information about the primary action of the medication would be included in the client's education?

A. It will prevent hypertension.

B. It will prevent hyperthermia.

C. It decreases cerebrospinal fluid production.

D. It maintains adequate blood pressure for cerebral perfusion.

D. It maintains adequate blood pressure for cerebral perfusion.

Rationale:

Acetazolamide is a carbonic anhydrase inhibitor and a diuretic. It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production. The remaining options are not actions of this medication.

The nurse is planning care for a client who displays confusion secondary to a brain attack (stroke). Which approaches by the nurse would be helpful in assisting this client? Select all that apply.

A. Providing sensory cues

B. Giving simple, clear directions

C. Providing a stable environment

D. Keeping family pictures at the bedside

E. Encouraging family members to visit at the same time

A. Providing sensory cues

B. Giving simple, clear directions

C. Providing a stable environment

D. Keeping family pictures at the bedside

Rationale:

Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition would the nurse document?

A. The intracranial pressure reading is normal.

B. The intracranial pressure reading is elevated.

C. The intracranial pressure reading is borderline.

D. An intracranial pressure reading of 8 mm Hg is low.

A. The intracranial pressure reading is normal.

Rationale:

The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse would place the client in which position postoperatively?

A. Head of bed flat, head and neck midline

B. Head of bed flat, head turned to the nonoperative side

C. Head of bed elevated 30 to 45 degrees, head and neck midline

D. Head of bed elevated 30 to 45 degrees, head turned to the operative side

C. Head of bed elevated 30 to 45 degrees, head and neck midline

Rationale:

After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck would not be angled either anteriorly or laterally but rather would be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

Which indicates worsening TBI?

A. GCS ↑

B. Pupils equal

C. Decerebrate posturing

D. Alert

Answer: C

Rationale:

Decerebrate = brainstem damage → severe

Clear drainage from nose after head injury — priority?

A. Insert NG tube

B. Apply nasal packing

C. Test drainage for glucose

D. Encourage coughing

Answer: C

Rationale:

Clear drainage = possible CSF leak

CSF contains glucose → test confirms leak

A patient with increased ICP has PaCO₂ of 55 mmHg. What is the effect?

A. Vasoconstriction

B. Decreased ICP

C. Vasodilation

D. Increased oxygenation

Answer: C

CO₂ ↑ → vasodilation → ↑ ICP

Rationale:

A PaCO₂ of 55 mmHg is above normal and indicates hypercapnia.

Normal Range:35 - 45 mmHg

A patient with increased ICP is being monitored. Which actions are appropriate?

(Select all that apply)

A. Elevate HOB 30°

B. Keep head midline

C. Suction frequently

D. Maintain normocapnia

E. Cluster care to reduce stimulation

Answers: A, B, D, E

A. Elevating the head of the bed to about 30 degrees helps improve venous return from the brain. This decreases cerebral blood volume and can help lower ICP.

B the head and neck in a neutral midline position prevents compression or kinking of the jugular veins. If venous drainage is blocked, blood backs up in the brain and ICP rises.

D. Normocapnia means keeping PaCO₂ in the normal range (35-45 mmHg).

This is important because:

high PaCO₂ causes cerebral vasodilation → increased cerebral blood volume → increased ICP.

E.Reducing excessive stimulation helps prevent spikes in ICP. Grouping care can help reduce repeated stimulation.

The nurse is monitoring a pt receiving a rt-PA who develops a sudden headache. Which are the priority actions in evaluating this change in assessment? (SATA)

a. Decrease rate of the rt-PA infusion.

b. Administer Tylenol for pain

c. Stop the rt-PA infusion

d. Notify the provider of the change

e. Performa neurologic assessment

Answer: C, D, E

Rationale: Development of a sudden headache is concerning for occurrence of an intracranial hemorrhage. Discontinuing the infusion, notifying the provider and performing a neuro assessment in rapid succession represent the expected nursing action.

The nurse is caring for a pt who is being transported to the ED with clinical management of stroke. Which is the priority action upon arrival to the hospital?

a. Establish the time that the pt was last known to be without symptoms.

b. Draw blood for coagulation studies.

c. Perform an electrocardiogram

d. Perform an EEG

Answer: A

Rationale: Establishing the correct time of symptom onset is essential in guiding the response to this pt's s/s. Results from coagulation are important in the event that thrombolytic therapy is considered. A CT scan should be performed within 25 min. of pt arrival to the ED to rul out hemorrhage.

The nurse monitors for which clinical manifestation in the patient with neurogenic shock?

a. Tachycardia

b. Hypertension

c. Bradycardia

d. Rapid shallow respirations

Answer: Bradycardia

Rationale: Loss of sympathetic tone causes bradycardia instead of tachycardia

Which is the best position for the nurse to place a pt with increased ICP and decreased intercranial compliance?

a. flat

b. prone

c. side lying with neck flexed

d. semi fowlers with the neck in a neutral position

Answer: D

The nurse is caring for a patient with lung cancer who now reports back pain and weakness. What is the nurse's priority concern?

a. Muscle strain

b. Herniated disk

c. Spinal metasis

d. Multiple sclerosis

Answer: C

Rationale: Spinal tumors commonly metastasis from lung cancer and can cause spinal cord compression, leading to neuro deficits

The nurse is caring for a pt diagnosed with amyotrophic lateral sclerosis (ALS). Which assessment finding is most characteristic of this condition?

a. Loss of sensation in the lower extremities

b. Progressive muscle weakness with muscle atrophy and intact sensation

c. Sudden onset of unilateral paralysis

d. Hyperactive immune response causing nerve inflammation

Answer: B

Rationale: ALS is a progressive neurodegenerative disorder characterized by the degeneration of both upper and lower motor neurons. As motor neurons deteriorate, pt experiences progressive muscle weakness, atrophy, and fasciculations (muscle twitching). Despite the significant loss of motor function, sensory function stays intact.

the nurse is caring for a pt with a herniated nucleus pulposus. Which findings indicate possible severe nerve compression requiring immediate intervention?(SATA)

a. Loss of bowel and bladder control

b. Saddle anesthesia

c. Mild intermittent back pain

d. Progressive muscle weakness

e. Numbness and tingling in extremities

Answer: A, B, D

Rationale: Severe complication of a herniated nucleus pulposus occur when there is significant compression of spinal nerve root. Serious complications include loss of bowel and bladder control, saddle anesthesia, and weakness, all of which indicate worsening neuro impairment.

The nurse is caring for a pt with ALS who begins to show signs of respiratory decline. What is the nurse's priority action?

a. Encourage ambulation

b. Notify the provider

c. Administer pain medication

d. Increase oral intake

Answer: B

Rationale: Respiratory muscle involvement results in respiratory failure and may require the placement of an artificial airway and ventilatory support. Therefore, the onset of respiratory decline in a pt with ALS represent a life threatening complication that requires immediate intervention.

The nurse is assigned to care for an 8 year old child with a diagnosis of a basilar skull fracture. The nurse reviews the primary health care provider's prescriptions and would contact the PHCP to question which question?

a. Obtain daily weights

b. Provide clear liquid intake

c. Nasotracheal suction prn

d. Maintain a patent IV line

Answer: C

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

a. Meningitis

b. Spinal cord injury

c. Intracranial bleeding

d. Decreased cerebral blood flow

Answer: A

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse plans to respond by explaining that the limitations occur as a result of which pathophysiological process?

a. An infectious disease of the CNS

b. An inflammation of the brain as a result of a viral illness

c. A chronic disability characterized by impaired muscle movements and posture

d. A congenital condition that results in moderate sever intellectual disabilities.

Answer: C

Which nursing actions apply to the care of a child who is having a seizure? (SATA)

a. Time of seizure

b. Restrain the child

c. Stay with the child

d. Insert an oral airway

e. Loosen clothing around the child's neck

d. Place the child in a lateral side lying position

Answer: A, C, E, D