Lewis Chapter 61: Intracranial Problems

1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which statement by the nurse would be the best initial response for this situation?

a. "This is a complex type of monitoring system, and it is managed by skilled staff."

b. "The system measures pressures to determine whether blood flow to the brain is

adequate."

c. "The ventriculostomy monitoring system helps check for changes in cerebral

perfusion pressure."

d. "This monitoring system has many benefits, including the ability to drain

cerebrospinal fluid."

b. "The system measures pressures to determine whether blood flow to the brain is adequate."

2. Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min

c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min

d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

3. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,

and flexion of the arms, how would the nurse report the response?

a. Flexion withdrawal

b. Localization of pain

c. Decorticate posturing

d. Decerebrate posturing

c. Decorticate posturing

4. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter would the nurse monitor to determine the medication's effectiveness?

a. Blood pressure

b. Oxygen saturation

c. Intracranial pressure

d. Hemoglobin and hematocrit

c. Intracranial pressure

5. A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus.How would the nurse record the patient's Glasgow Coma Scale score?

a. 9

b. 11

c. 13

d. 15

b. 11

6. An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. Which action is best for the nurse to take?

a. Call the family's pastor or spiritual advisor to take them to the chapel.

b. Ask the family to stay in the waiting room until the assessment is completed.

c. Allow the family to stay with the patient and briefly explain all procedures to

them.

d. Refer the family members to the hospital counseling service to deal with their

anxiety.

c. Allow the family to stay with the patient and briefly explain all procedures to them.

7. A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?

a. Encourage coughing and deep breathing.

b. Position the patient with knees and hips flexed.

c. Keep the head of the bed elevated to 30 degrees.

d. Cluster nursing interventions to provide rest periods.

c. Keep the head of the bed elevated to 30 degrees.

8. A 20-yr-old is admitted with a head injury after a collision while playing sports. After noting that the patient has developed clear nasal drainage, which action would the nurse take?

a. Have the patient gently blow the nose.

b. Check the drainage for glucose content.

c. Teach the patient that rhinorrhea is expected after a head injury.

d. Obtain a specimen of the fluid to send for culture and sensitivity.

b. Check the drainage for glucose content.

9. Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

a. Coordinate the transfer of the patient to the operating room.

b. Provide discharge instructions about monitoring neurologic status.

c. Arrange to admit the patient to the neurologic unit for observation.

d. Transport the patient to radiology for magnetic resonance imaging (MRI).

b. Provide discharge instructions about monitoring neurologic status.

10. A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

a. Administer IV furosemide (Lasix).

b. Prepare the patient for craniotomy.

c. Initiate high-dose barbiturate therapy.

d. Type and crossmatch for blood transfusion.

b. Prepare the patient for craniotomy.

11. The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order would the nurse question?

a. Keep the head of bed elevated.

b. Insert nasogastric tube to low suction.

c. Turn patient side to side every 2 hours.

d. Apply cold packs intermittently to face.

b. Insert nasogastric tube to low suction.

12. An athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing post concussion syndrome?

a. Short-term memory

b. Muscle coordination

c. Glasgow Coma Scale

d. Pupil reaction to light

a. Short-term memory

13. When assessing a patient who has a right frontal lobe tumor, which finding would the nurse expect?

a. Expressive aphasia

b. Impaired judgment

c. Right-sided weakness

d. Difficulty swallowin

b. Impaired judgment

14. Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

a. "I will return if I feel dizzy or nauseated."

b. "I am going to drive home and go right to bed."

c. "I do not even remember being in an accident today."

d. "I can take acetaminophen (Tylenol) for my headache."

b. "I am going to drive home and go right to bed."

15. After having a craniectomy and left anterior fossae incision, a patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

a. Cluster nursing activities to allow longer rest periods.

b. Turn and reposition the patient side to side every 2 hours.

c. Position the bed flat and log roll to reposition the patient.

d. Perform range-of-motion (ROM) exercises every 4 hours.

d. Perform range-of-motion (ROM) exercises every 4 hours.

16. A patient who has bacterial meningitis is disoriented and anxious. Which action will the nurse include in the plan of care?

a. Encourage family members to remain at the bedside.

b. Apply soft restraints to protect the patient from injury.

c. Keep the room well-lighted to improve patient orientation.

d. Minimize contact with the patient to decrease sensory input.

a. Encourage family members to remain at the bedside.

17. The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

a. Emphasize the importance of hand washing before meals.

b. Encourage immunization for adolescents and college freshmen.

c. Tell adolescents and young adults to avoid crowds in the winter.

d. Support serving healthy nutritional options in the college cafeteria.

b. Encourage immunization for adolescents and college freshmen.

18. A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

a. The patient received a regular diet tray.

b. Staff turned off the lights in the patient's room.

c. The bedrails on both sides of the bed are elevated.

d. Staff have entered the patient's room without a mask.

d. Staff have entered the patient's room without a mask.

19. When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

a. The patient exhibits nuchal rigidity.

b. The patient has a positive Kernig's sign.

c. The patient's temperature is 101F (38.3C).

d. The patient's blood pressure is 88/42 mm Hg

d. The patient's blood pressure is 88/42 mm Hg

20. A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action would the nurse take first?

a. Document the BP and ICP in the patient's record.

b. Report the BP and ICP to the health care provider.

c. Elevate the head of the patient's bed to 60 degrees.

d. Continue to monitor the patient's vital signs and ICP.

b. Report the BP and ICP to the health care provider.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action would the nurse take first?

a. Document the increase in intracranial pressure.

b. Ensure that the patient's neck is in neutral position.

c. Notify the health care provider about the change in pressure.

d. Increase the rate of the prescribed propofol (Diprivan) infusion.

b. Ensure that the patient's neck is in neutral position.

22. Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

b. A 35-yr-old patient with intracranial pressure monitoring after a head injury

c. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day

d. A 55-yr-old patient who is receiving hyperventilation therapy for increased ICP

a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

23. A patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). The patient is now reporting a headache. Which prescribed intervention would the nurse implement first?

a. Administer IV hypertonic saline.

b. Draw blood for arterial blood gases (ABGs).

c. Send patient for computed tomography (CT).

d. Administer acetaminophen (Tylenol) 650 mg.

a. Administer IV hypertonic saline.

24. After the emergency department nurse has received a status report on the following patients with head injuries, which patient would the nurse assess first?

a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture

b. A 30-yr-old patient who lost consciousness for 10 seconds after a fall

c. A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13

d. A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

d. A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

25. The nurse is caring for a patient who was admitted the previous day with a basilar skull

fracture after a motor vehicle crash. Which assessment finding indicates a possible

complication that should be reported to the health care provider?

a. Report of severe headache

b. Large contusion behind left ear

c. Bilateral periorbital ecchymosis

d. Temperature of 101.4F (38.6C)

d. Temperature of 101.4F (38.6C)

26. After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being

monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

a. Pulse of 102 beats/min

b. Temperature of 101.6F

c. Intracranial pressure of 15 mm Hg

d. Mean arterial pressure of 90 mm Hg

b. Temperature of 101.6F

27. The charge nurse observes a new staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the new nurse requires the charge nurse to intervene?

a. The staff nurse assesses neurologic status every hour.

b. The staff nurse elevates the head of the bed to 30 degrees.

c. The staff nurse suctions the patient routinely every 2 hours.

d. The staff nurse administers an analgesic before turning the patient.

c. The staff nurse suctions the patient routinely every 2 hours.

28. A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor. Which action will the nurse take first?

a. Check oxygen saturation.

b. Palpate the head for injuries.

c. Assess pupil reaction to light.

d. Verify Glasgow Coma Scale (GCS) score.

a. Check oxygen saturation.

29. A patient with increased intracranial pressure after a head injury has a ventriculostomy in

place. Which action can the nurse delegate to the assistive personnel (AP) who regularly

works in the intensive care unit?

a. Document intracranial pressure every hour.

b. Turn and reposition the patient every 2 hours.

c. Check capillary blood glucose level every 6 hours.

d. Monitor cerebrospinal fluid color and volume hourly.

c. Check capillary blood glucose level every 6 hours.

30. Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

a. Intracranial pressure of 15 mm Hg

b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr

c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

d. Cardiac monitor shows sinus tachycardia at 120 beats/min

c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

31. The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires the most rapid action by the nurse?

a. The patient reports a headache.

b. The apical pulse is slightly irregular.

c. The patient is more difficult to arouse.

d. The blood pressure increases to 140/62 mm Hg.

c. The patient is more difficult to arouse.

32. The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, would the nurse expect will result in new prescribed interventions?

a. Pale yellow urine output of 1200 mL over the past 2 hours.

b. Ventriculostomy drained 40 mL of fluid in the past 2 hours.

c. Brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

d. Intracranial pressure spikes to 16 mm Hg when patient is turned.

a. Pale yellow urine output of 1200 mL over the past 2 hours.

33. While admitting a patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

a. The patient reports a severe dull headache.

b. The patient takes warfarin (Coumadin) daily.

c. The patient's blood pressure is 162/94 mm Hg.

d. The patient is unable to remember the accident

b. The patient takes warfarin (Coumadin) daily.

34. A patient being admitted with bacterial meningitis has a temperature of 102.5F (39.2C) and a severe headache. Which prescribed intervention would the nurse implement first?

a. Administer ceftizoxime (Cefizox) 1 g IV.

b. Give acetaminophen (Tylenol) 650 mg PO.

c. Use a cooling blanket to lower temperature.

d. Swab the nasopharyngeal mucosa for cultures.

d. Swab the nasopharyngeal mucosa for cultures.

35. A patient with possible meningitis is admitted to the nursing unit after a lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider would the nurse question?

a. Restrict oral fluids to 1000 mL/day.

b. Elevate the head of the bed 20 degrees.

c. Administer ceftriaxone 1 g IV every 12 hours.

d. Give ibuprofen 400 mg every 6 hours as needed for headache

a. Restrict oral fluids to 1000 mL/day.

36. Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

a. Teach about prophylactic antibiotics after exposure to encephalitis.

b. Encourage the use of effective insect repellent during mosquito season.

c. Remind patients that most cases of viral encephalitis can be cared for at home.

d. Arrange to screen school-age children for West Nile virus during the school year.

b. Encourage the use of effective insect repellent during mosquito season.

37. Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits?

a. "Do you have any difficulty in hearing?"

b. "Are you experiencing vision problems?"

c. "Are you having any trouble with your balance?"

d. "Have you developed any weakness on one side?"

b. "Are you experiencing vision problems?"

38. During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

a. 1

b. 2

c. 3

d. 4

a. 1

39. The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). What new finding indicates that the nurse needs to notify the health care provider immediately?

a. O2 saturation of 93%

b. Respirations of 20 breaths/min

c. Green nasogastric tube drainage

d. Increased jugular venous distention

d. Increased jugular venous distention

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