CH 56 EAQ Head Injury and Brain Tumors

The nurse observes the presence of cerebrospinal fluid (CSF) rhinorrhea. What is the priority action by the nurse? a. Insert a nasogastric tube. b. Elevate the head of the bed. c. Have the patient blow their nose. d. Pack the nasal cavity with 4x4' to stop the flow of CSF.

ANS: B CSF rhinorrhea is assessed by the presence of a halo or ring sign. Coalescence of blood in the center with an outer yellowish ring indicates the leakage of cerebrospinal fluid from the patient's nose. The first action by the nurse should be to elevate the head of the bed to decrease the CSF pressure so that the tear can heal. The patient should not be requested to blow their nose. No packing should be inserted, and a loose collection dressing may be placed under the nose to catch the drainage. A nasogastric tube should not be inserted, especially if a basilar skull fracture is suspected.

The nurse is assessing the waveforms for a patient receiving intracranial pressure (ICP) monitoring and observes a waveform representing venous pulsations. What type of waveform does the nurse document? a. Tidal wave b. Dicrotic wave c. Rebound wave d. Percussion wave

ANS: B The dicrotic wave follows the dicrotic notch and represents venous pulsations. Tidal wave and rebound waves represent relative brain volume. A percussion wave represents arterial pulsations.

A nurse in the neurologic intensive care unit is caring for a patient with intracranial pressure (ICP) monitoring through an intracranial device. Which aspect of the patient's care requires follow-up by the nurse? a. Using aseptic technique for intracranial device care b. Intracranial device monitoring for greater than 5 days c. Assessing the intracranial device insertion site routinely d. Monitoring the cerebrospinal fluid (CSF) for a change in color

ANS: B The intracranial device used for monitoring ICP should not be used for more than five days because it can lead to severe infection. Using aseptic technique, routinely assessing the insertion site, and monitoring the CSF for a change in drainage color prevents complications while monitoring ICP, and so are all appropriate aspects of patient care that do not require follow-up by the nurse.

The nurse notes watery sanguineous drainage from the nares of a patient who is being evaluated after falling from a roof. What is the best method for the nurse to validate suspicion of rhinorrhea? a. Gram stain b. The halo test c. Use a Dextrostix d. Slide smear for presence of leukocytes

ANS: B The patient may being experiencing rhinorrhea, or leakage of cerebral spinal fluid (CSF) from the nose, which is also sanguineous (bloody). In the presence of blood, the halo test will be the most accurate for determining presence of CSF. A Gram stain is used to identify bacterial presence. If blood is present, the Dextrostix will not be accurate because glucose is present in blood. CSF is sterile in the body and, under normal circumstances, does not contain white cells (leukocytes) or bacteria.

The nurse is performing an assessment for a patient that has been comatose for seven hours and then awakens. Which manifestations does the nurse anticipate finding while performing the assessment? Select all that apply. a. Decreased apathy b. Loss of concentration c. Loss of social restraint d. Increase in personal drive e. Euphoria and mood swings

ANS: B C E A patient with a head injury who has been comatose for more than six hours undergoes some personality changes. The patient may lose concentration, social restraint, and experience euphoria and mood swings. Apathy may increase, and personal drive may decrease.

The nurse is performing an assessment of a patient suspected of having a brain tumor. Which diagnostic procedure does the nurse anticipate preparing the patient for that will give an accurate diagnosis? Select all that apply. a. Lumbar puncture b. Electron microscopy c. Immunohistochemical stains d. Computed tomography (CT) scan e. Computer-guided stereotactic biopsy

ANS: B C E Electron microscopy, immunohistochemical stains, and computer-guided stereotactic biopsy can help in the correct diagnosis of a brain tumor. CT scan helps to detect seizures. Lumbar puncture does not detect the blood flow to tumor and involves additional risk.

A patient is reported to have a brain abscess in the occipital lobe. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. a. Visual field defects b. Headache and fever c. Nausea and vomiting d. Psychomotor seizures e. Visual impairment and hallucinations

ANS: B C E Headache, fever, and nausea and vomiting are common symptoms of a brain abscess, and visual impairment and hallucinations can be seen in occipital abscess. Visual field defects and psychomotor seizures are seen in abscesses of the temporal lobe.

The nurse is educating a patient about care after a head injury. Which symptoms should the nurse instruct the patient and caregiver to immediately notify a health care provider about? Select all that apply. a. Sneezing b. Seizures c. Stiff neck d. Constipation e. Increased drowsiness

ANS: B C E Seizures, a stiff neck, and increased drowsiness are the important symptoms that the patient and caregivers should immediately relay to the health care provider. Sneezing and constipation are not alarming and can also be due to other reasons.

The nurse is evaluating the use of surgical therapy in a patient with a brain tumor. Which important factors should the nurse consider? Select all that apply. a. Tumors of all types, sizes, and location can be completely removed. b. More invasive gliomas and medulloblastomas can be partially removed. c. More invasive gliomas and medulloblastomas can be completely removed. d. Meningiomas and oligodendrogliomas can usually be completely removed. e. The outcome of surgical therapy depends on the type, size, and location of tumor.

ANS: B D E The outcome of surgical therapy depends on the type, size, and location of the tumor. Meningiomas and oligodendrogliomas can usually be completely removed, and more invasive gliomas and medulloblastomas can be partially removed. Tumors of all types, sizes, and locations cannot be completely removed, and more invasive gliomas and medulloblastomas cannot be completely removed.

A patient with head trauma has a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which action should the nurse perform first? a. Evaluate the urine specific gravity. b. Prepare the patient for acute hemodialysis. c. Continue to monitor urine output over the next hour. d. Slow the IV rate and notify the primary health care provider.

ANS: A The patient is experiencing manifestations of diabetes insipidus related to a decrease in the pituitary gland production of ADH (antidiuretic hormone) as a result of a head injury. Without an adequate amount of ADH, the kidneys are unable to conserve water and therefore large fluid losses occur. The patient's problem is not related to renal failure, so there is no indication for hemodialysis. The primary health care provider should be notified of the increased urine output and results of the urine specific gravity, which will be low because of the diluted urine. After evaluation of the urine specific gravity, the patient requires continued close monitoring of the urine output until seen by the primary health care provider. If the patient is found to have diabetes insipidus, the IV rate should not be slowed and will likely have to be increased to prevent dehydration.

A patient who sustained a head injury received initial management and is being discharged. The nurse is teaching measures to be followed by the caregiver. Which statements made by the caregiver indicate the need for further teaching? Select all that apply. a. "I should maintain a calm environment if the patient is angry." b. "I should assist with a walker if the patient has difficulty walking." c. "I should not allow the patient to drive under the influence of morphine." d. "I should give hot baths if the patient experiences shivering and drowsiness." e. "I should report to the primary health care provider if the patient has numbness in fingers."

ANS: A B D The caregiver of a patient with a head injury should immediately report to the primary health care provider if the patient has difficulty walking and seems angry. These manifestations may indicate a deteriorating mental status. Hot baths dilate the blood vessels, bring more blood, and cause more swelling at the injury site, delaying the healing process. Opioid pain medications such as morphine cause drowsiness, and driving should be avoided. The caregiver should report to the primary health care provider if the patient has sensory disturbances such as numbness.

A patient is admitted with elevated intracranial pressure (ICP). What factors should the nurse be sure are avoided that may create further elevation in intracranial pressure? Select all that apply. a. Pain and agitation b. Extreme hip flexion c. Slow and gentle movements d. Elevation of head of the bed e. Increased intrathoracic pressure

ANS: A B E Pain and agitation cause rapid movements, which may increase the ICP. Extreme hip flexion may raise the intraabdominal pressure, which increases the ICP. Increased intrathoracic pressure may increase ICP by impeding the venous return. Slow and gentle movements will provide comfort to the patient and will not increase the ICP. Elevation of the head of the bed promotes drainage from the head, decreases the vascular congestion, and therefore decreases ICP.

A patient experienced a fall and presented to the emergency department with scalp lacerations and a depressed skull. What initial interventions should the nurse perform as emergency management? Select all that apply. a. Stabilize the cervical spine. b. Wrap the patient in tight clothing. c. Administer oxygen via a non-rebreather mask. d. Control external bleeding with a sterile pressure dressing. e. Avoid intubation if the Glasgow Coma Scale (GCS) score is less than 8.

ANS: A C D The patient with scalp lacerations and skull depression should be managed by stabilizing the cervical spine, administering oxygen via a non-rebreather mask, and controlling external bleeding with a sterile pressure dressing. Wrapping the patient in tight clothing is not appropriate. Instead, removing the patient's clothes can help. Intubation is required only if the GCS is less than 8.

An intubated and mechanically ventilated patient is ordered dexmedetomidine. Which side effect of the medication would the nurse monitor for in this patient? a. Insomnia b. Blood pressure changes c. Hyperanxiety d. Sedative effect

ANS: B Dexmedetomidine is an α 2-adrenergic agonist used for continuous intravenous sedation of intubated and mechanically ventilated patients. It activates the receptors in the brain and spinal cord and inhibits neuronal firing, which can cause both hypotension and hypertension. Dexmedetomidine does not cause insomnia, hyperanxiety, or sedation. It is used in neurologic assessment because of its anxiolytic activities.

A patient with a brain tumor reports speech disturbances and inability to write. Which part of the cerebral hemisphere may be affected by the tumor? a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe

ANS: B Parietal lobe tumors cause spatial orientation problems resulting in speech disturbances and an inability to write. Frontal lobe tumors cause visual disturbances and unilateral hemiplegia. Occipital lobe tumors cause vision disturbances and seizures. Temporal lobe tumors cause seizures and dysphagia.

A patient with a head injury has a score of five on the Glasgow Coma Scale. How should the nurse interpret the score? a. The patient is alert and oriented. b. The patient is unresponsive and comatose. c. The patient is awake but lethargic and drowsy. d. The patient responds appropriately to commands.

ANS: B The Glasgow Coma Scale ranges from 3 to 14. A score of seven or less indicates that a patient is in a coma. The lower the score, the more serious the patient's condition. A patient who is alert and orient, awake but lethargic, or responding appropriately to commands has a Glasgow Coma Scale score higher than seven.

The nurse is caring for a patient with a head injury that has a temperature of 103° F. Which pathophysiologic processes does the nurse suspect are occurring? Select all that apply. a. The metabolism is decreased. b. The metabolic waste is increased. c. The cerebral blood flow would be increased. d. The intracranial pressure would be decreased. e. The cerebral blood volume would be decreased.

ANS: B C Hyperthermia occurs when there is an injury or inflammation in the hypothalamus. The body temperature of 103° F of a patient who has a head injury indicates an injury to the hypothalamus. Injury to the hypothalamus can increase the metabolic waste because of increased metabolism secondary to hyperthermia. Hyperthermia causes an increase in cerebral flow because of increased metabolic demands. Hyperthermia associated with a head injury causes increased metabolism and increased intracranial pressure because of increased cerebral blood flow.

The nurse is preparing to administer a hypertonic saline infusion to a patient to manage increased intracranial pressure (ICP). Which parameters require frequent monitoring? Select all that apply. a. Blood glucose b. Serum sodium c. Blood pressure d. Level of sedation e. Gastrointestinal disturbances

ANS: B C Hypertonic saline solutions are used to treat increased ICP. Hypertonic saline infusions increase the intravascular fluid volume, which may alter the serum sodium levels and blood pressure in the body. Blood glucose monitoring is required if the patient is given corticosteroids. Sedation is monitored if the patient is administered barbiturates. Gastrointestinal disturbances are monitored if the patient is administered corticosteroids.

When assessing the outcome of surgery in a patient with a brain tumor, which factors should the nurse consider? Select all that apply. a. Surgery provides complete cure. b. Surgery can reduce the tumor mass. c. Surgery can provide relief of symptoms. d. Surgery can help to extend survival time. e. Surgery can increase intracranial pressure (ICP).

ANS: B C D Surgery can reduce the tumor mass, provide relief of symptoms, and can help to extend survival time. These factors should be considered while assessing the outcome of surgery in a patient with a brain tumor. Surgery does not provide a complete cure, or, in most cases, completely remove a tumor. However, surgery helps to decrease the ICP by removing the tumor mass.

A patient is prescribed temozolomide as a treatment for a brain tumor. Which factors should the nurse evaluate prior to administering the medication? Select all that apply. a. Temozolomide causes photosensitivity. b. Temozolomide causes myelosuppression. c. Temozolomide can cross the blood-brain barrier. d. Temozolomide can convert to an agent that directly interferes with tumor growth. e. Temozolomide interacts with other drugs usually taken by brain tumor patients.

ANS: B C D Temozolomide can cross the blood-brain barrier. The drug is also known to cause myelosuppression; therefore, absolute neutrophil counts and platelet counts should be checked before starting the therapy. Temozolomide does not require metabolic activation to exert its effects and therefore can convert to an agent that directly interferes with tumor growth. It is not known to cause photosensitity or interact with other drugs usually taken by brain tumor patients.

The nurse is performing an initial assessment on a patient to obtain baseline data about the patient's neurologic status. Which actions should the nurse perform relevant to a neurologic assessment? Select all that apply. a. Assess patient's temperature and pulse rate. b. Assess patient when performing daily activities. c. Assess patient's integrated function and balance. d. Assess patient's weight, height, and waist-to-hip ratio. e. Assess patient's level of consciousness and motor abilities.

ANS: B C E A neurologic assessment includes assessment of the patient when performing daily activities, assessment of integrated function and balance, and assessment of the level of consciousness and motor abilities. Assessing the patient's temperature and pulse rate and assessing the patient's weight, height, and waist-to-hip ratio are general measurements and are not included for neurologic status measurement.

A patient is diagnosed with a brain abscess. When performing an assessment on this patient, what causes does the nurse determine for the development of this problem? Select all that apply. a. Acne or skin abscess b. Prior brain trauma or surgery c. Prior leg fracture or ligament tears d. Distant spread from a pulmonary infection e. Direct extension from an ear or sinus infection

ANS: B D E Prior brain trauma or surgery can result in a brain abscess. A distant spread from a pulmonary infection and direct extension from an ear or sinus infection are primary causes of a brain abscess. Acne or skin abscess and a prior leg fracture or ligament tears do not cause brain abscess.

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS)? Select all that apply. a. Judgment b. Eye opening c. Abstract reasoning d. Best verbal response e. Best motor response f. Cranial nerve function

ANS: B D E The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

The nurse is performing a neurologic assessment for a patient after a motor vehicle crash. Which patient condition may be a contraindication for testing the doll's-eye reflex? a. An unconscious patient b. An uncooperative patient c. A patient with cervical spine injury d. A patient who has intracranial lesion

ANS: C A doll's-eye reflex test is performed to determine the oculocephalic reflex. It increases the risk of brainstem injury with a cervical spine problem. A doll's-eye reflex test can be performed in an unconscious and uncooperative patient. This test is used to determine the presence of intracranial lesions due to increased intracranial pressure.

The nurse is caring for a patient that has developed hydrocephalus. Which surgical procedure does the nurse prepare the patient for? a. Drainage of abscess b. Excision of malformation c. Placement of a ventriculoatrial shunt d. Debridement of fragments and necrotic tissue

ANS: C Hydrocephalus occurs due to overproduction of cerebrospinal fluid, which can be treated by placing a ventriculoatrial shunt, allowing excess cerebrospinal fluid to drain. Drainage of abscess is a surgical procedure indicated for brain abscess. Excision of malformation is a surgical procedure indicated for arteriovenous malformation. Debridement of fragments and necrotic tissue is a surgical procedure indicated for skull fractures.

The nurse is caring for a patient that had a craniotomy. In planning long-term care for the patient, what must the nurse include when teaching the patient, family, and caregiver? a. Seizure disorders may occur in weeks or months. b. The family will be unable to cope with role reversals. c. There are often residual changes in personality and cognition. d. Referrals will be made to eliminate residual deficits from the damage.

ANS: C In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition, because these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

A patient with a brain tumor presents with symptoms of visual disturbances and seizures. When evaluating the patient, the nurse knows that this tumor is most likely located in which area of the brain? a. Subcortical b. Parietal lobe c. Occipital lobe d. Temporal lobe

ANS: C Manifestations of tumors in the occipital lobe include vision disturbances and seizures. Manifestations of tumors in the subcortical region include hemiplegia; other symptoms may depend on area of infiltration. Tumors in the parietal lobe present with speech disturbance (if the tumor is in the dominant hemisphere), dyscopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures, and dysphagia.

The laboratory reports of a patient with a brain tumor, who reports uncontrolled urination and excessive thirst, show high sodium levels. The nurse also observes involuntary eye movements and suspects which type of brain tumor? a. Subcortical tumors b. Cerebellopontine tumor c. Thalamus and sellar tumor d. Fourth ventricle and cerebellar tumors

ANS: C Thalamus and sellar tumors may induce diabetes insipidus. This causes symptoms of diabetes insipidus such as excessive urine production, thirst, and elevated sodium and potassium levels. Tumors in the hypothalamic region may cause nystagmus or involuntary eye movements. Subcortical tumors cause hemiplegia. Cerebellopontine tumors cause tinnitus and vertigo. Fourth ventricle and cerebellar tumors cause headache, nausea, and papilledema.

What will be the Glasgow Coma Scale score of a patient who has a moderate type of head injury? a. 3 b. 5 c. 10 d. 14

ANS: C The Glasgow Coma Scale range for patients with a moderate type of head injury is 9 to 12. Therefore for the patient with a moderate type of head injury, a score of 10 is suitable. A score of 3 or 5 is given for a patient with a severe type of head injury. A score of 14 is given for a patient who has a minor type of head injury.

A nurse from the acute care unit is reassigned for the shift to the neurologic intermediate care unit. An appropriate assignment would include which patient? a. A patient just returning from a craniotomy for evacuation of subdural hematoma. b. A patient with traumatic brain injury who is being transferred to a rehabilitative facility. c. An alert patient with viral encephalitis who has a scheduled dose of intravenous (IV) acyclovir. d. An unconscious patient with bacterial meningitis who is needing another lumbar puncture for repeat cultures.

ANS: C The nurse from a medical-surgical unit would have the skills to perform an IV piggyback medication, as well as basic neurologic assessment skills. A patient just returning from surgery for a neurologic problem will need a staff member who is experienced with assessment of potential complications. A patient with an altered level of consciousness is more acute then one who is alert. Although the medical-surgical nurse may be familiar with assisting with a lumbar puncture, the fact the patient is unconscious requires a more experienced nurse. A patient being transferred to a rehabilitative facility is more involved, requiring appropriate documentation, nurse-to-nurse report, and instructions to the patient and family, with which the medical-surgical nurse may not be familiar.

A patient with a head injury is scheduled for a lumbar puncture. What should the nurse closely monitor this patient for? a. Cerebral edema b. Myelosuppression c. Total body collapse d. Cerebral herniation

ANS: D A lumbar puncture involves removal of cerebrospinal fluid from the lumbar region. This can raise the intracranial pressure, resulting in cerebral herniation. Cerebral edema is associated with radiation therapy. Myelosuppression is associated with temozolomide drug therapy. Total body collapse is associated with a ventricular shunt.

A patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). The patient has been maintained on intravenous (IV) fluids for two days. The nurse seeks enteral feeding for this patient based on what rationale? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be avoided better with feedings. d. Malnutrition promotes continued cerebral edema.

ANS: D A patient with diffuse axonal injury is unconscious, and with increased ICP is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within three days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.

The nurse is caring for a patient with increased intracranial pressure (ICP). Why will the nurse question an order for a benzodiazepine prescribed by the health care provider? a. It may cause sedation. b. It may increase the pain. c. It increases anxiety levels. d. It causes a hypotensive effect.

ANS: D Benzodiazepine can cause hypotension as a side effect and may worsen the patient's condition by causing a sudden decrease in blood pressure. Benzodiazepines are used as sedatives; however, they are not avoided because of their sedative action. Benzodiazepines do not cause pain and anxiety.

An older adult patient fell and hit their head on a coffee table 2 weeks previously. What type of hematoma should the nurse suspect may have occurred in this patient? a. Epidural hematoma b. Intracerebral hematoma c. Acute subdural hematoma d. Chronic subdural hematoma

ANS: D Chronic subdural hematoma is most commonly seen in older adults due to the presence of a potentially larger subdural space caused by brain atrophy. Atrophy increases tension in the brain even though it is attached to the supportive structures, and it is subjected to tearing. Epidural hematoma, intracerebral hematoma, and acute subdural hematoma are common in all age groups.

The nurse is reviewing a patient's imaging studies, which show the presence of lateral displacement of brain tissue beneath the falx cerebri. Which type of herniation does the nurse suspect may be present? a. Uncal herniation b. Central herniation c. Tentorial herniation d. Cingulate herniation

ANS: D Lateral displacement of brain tissue beneath the falx cerebri results in cingulate herniation. Lateral and downward herniation results in uncal herniation. Forces caused by a mass lesion in the cerebrum cause downward movement of the brain, which results in central herniation or tentorial herniation.

The nurse is caring for a patient that sustained a traumatic brain injury in a motor vehicle crash. Which condition indicates to the nurse when planning the care of the patient to maintain closure of the eyes? a. Diplopia b. Otorrhea c. Periorbital ecchymosis d. Loss of the corneal reflex

ANS: D Loss of the corneal reflex may cause abrasion, and taping of the eyes is necessary to protect the eyes. An eye patch is used in patients with diplopia. A loose collection pad is used over the ear in patients with otorrhea. Cold and warm compresses are used in patients with periorbital ecchymosis.

The nurse is reviewing the medical records of a patient with acquired immunodeficiency syndrome (AIDS) that has been diagnosed with a brain tumor. What tumor growth is associated with AIDS? a. Metastatic tumor b. Acoustic neuroma c. Pituitary adenoma d. Primary central nervous system lymphoma

ANS: D Lymphocyte production is affected in patients with AIDS. Primary central nervous system lymphoma originates from lymphocytes and, therefore, is seen in patients with AIDS. Metastatic tumors are malignant types that originate in the lungs and breasts. Acoustic neuroma is a low-grade malignancy, which originates from cells that form myelin sheath. Pituitary adenoma is usually benign and originates from the pituitary gland.

The nurse is reviewing the interventions prescribed by the health care provider for a patient with a basilar skull fracture. The nurse should collaborate with the health care provider about which intervention? a. Apply soft cervical collar. b. Avoid flexion of hip joints. c. Keep head of bed elevated to 30 degrees at all times. d. Insert nasal gastric tube and connect to low, intermittent suction.

ANS: D Patients who need gastric decompression following a basilar skull fracture should have an oral gastric tube inserted. The nurse should collaborate with the health care provider about this intervention because of the risk of meningitis. An oral feeding is recommended, with placement of either an oral tube or nasogastric (NG) tube under fluoroscopy. The use of a soft cervical collar to maintain anatomical alignment, avoiding flexion of hip joints, and elevating the head of the bed are all measures to decrease intracranial pressure by promoting venous return.

The nurse preceptor is working with the newly licensed registered nurse in caring for a patient with a newly placed ventricular shunt. What statement made by the new nurse requires immediate intervention by the preceptor? a. "I need to wear sterile gloves whenever I palpate the incision site." b. "I should be concerned if my patient begins to vomit and has a headache." c. "I need to compare my assessment findings now with preoperative assessments." d. "I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches."

ANS: D Rapid decompression of intracranial pressure (ICP) can cause total body collapse, weakness, and headache by rapid position change. To prevent this, the patient should be gradually moved into an upright position. Infection of shunts can occur, so the nurse should use sterile precautions when assessing incision sites. To recognize changes in neurologic status, the nurse should compare postoperative findings with baseline to quickly recognize complications or establish improvement from the surgical intervention. Headache, vomiting, change in level of consciousness (LOC), restlessness, and visual disturbances are all indications of increased ICP from malfunction of the shunt.

A nurse is assessing four patients with different types of skull fractures. Which patient would have a low-velocity injury as the cause of skull fracture? Patient A: linear type of fracture Patient B: depressed type of fracture Patient C: comminuted type of fracture Patient D: compound type of fracture

ANS: A A low-velocity injury, seen in Patient A, is the most common cause of a linear fracture of the skull bone. A depressed type of skull fracture, seen in Patient B, is caused by a powerful blow that creates an inward indentation of the skull. Patient C has a comminuted type of skull fracture, which is caused by a direct high momentum impact and multiple linear fractures with fragmentation of the bone. Patient D has a compound type of skull fracture, which is associated with a depressed skull fracture and scalp laceration and is caused by a severe head injury.

A patient reports a headache, which is worse in the morning and aggravated with movements, as well as vomiting without any preceding nausea. When assessing the patient, which common causes should the nurse consider when suspecting increased intracranial pressure? Select all that apply. a. Sinusitis b. Glaucoma c. Hematoma d. Head injury e. Brain tumor

ANS: C D E Common causes of increased intracranial pressure include a mass-like hematoma or tumor and cerebral edema due to brain tumors or hydrocephalus, head injury, or brain inflammation. Sinusitis and glaucoma do not cause an increase in intracranial pressure.

A patient is diagnosed with a brainstem tumor. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. a. Crossed eyes b. Diabetes insipidus c. Tinnitus and vertigo d. Facial muscle weakness e. Headache on awakening

ANS: A D E Crossed eyes, facial muscle weakness, and headache on awakening can be seen in brainstem tumors. Cerebellopontine tumors present with tinnitus, vertigo, and deafness. Diabetes insipidus is seen in thalamus and sellar tumors.

The nurse is preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF). What surgery should the nurse ensure the consent is signed for? a. Burr hole b. Craniotomy c. Shunt placement d. Stereotactic procedure

ANS: C Shunt procedures use a tube or implanted device to provide an alternate pathway to redirect CSF when its absorption is impaired. A burr hole is used to remove localized fluid and blood beneath the dura. Craniotomy is done to remove a lesion or repair a damaged area. Stereotactic procedure is used for biopsy, radiosurgery, or dissection.

Which findings will the nurse suspect in a patient who reports a headache and disturbed consciousness and whose imaging studies indicate cerebral edema in the white matter? a. Decreased oxygen supply to brain b. Presence of intact blood-brain barrier c. Increase in the extracellular fluid volume d. Abnormal accumulation of cerebrospinal fluid in brain

ANS: C Vasogenic cerebral edema mainly occurs in the white matter of the brain. In this type of cerebral edema, there is an increase in the permeability of the blood-brain barrier, which causes increase in the extracellular fluid (ECF) volume. Cerebral hypoxia or decreased oxygen supply is seen in cytotoxic cerebral edema. An intact blood-brain barrier is seen in cytotoxic cerebral edema. Hydrocephalus or abnormal accumulation of cerebrospinal fluid in brain is seen in interstitial cerebral edema.

The nurse is assessing the clear nasal discharge from a patient that sustained head trauma and notes that it is positive to a Dextrostix test. What does the nurse concur from this finding? a. The patient has sinusitis. b. The patient has glaucoma. c. The patient has allergic rhinitis. d. The patient has cerebrospinal fluid (CSF) rhinorrhea.

ANS: D A positive Dextrostix test indicates that CSF is leaking from the nose or ear. The fluid from the nose generally leaks due to a cerebrospinal leak and results in CSF rhinorrhea. A Dextrostix test will not give positive results for sinusitis, glaucoma, or allergic rhinitis.

A patient is brought to the emergency room with a head injury and is at risk of developing increased intracranial pressure. Which is the most reliable indicator that the nurse should use for assessing the patient's neurologic status? a. Dim vision b. Papilledema c. Body temperature d. Level of consciousness

ANS: D The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Dim vision can occur due to dysfunction of cranial nerves. Papilledema, which is an edematous optic disc seen on retinal examination, can be noted and is a nonspecific sign associated with persistent increases in intracranial pressure (ICP). A change in body temperature may also occur because increased ICP affects the hypothalamus.

The nurse is caring for a patient with increased intracranial pressure (ICP) resulting from a mass lesion in the brain. About what treatment option does the nurse educate the patient that will have the best outcome? a. Surgery b. Cimetidine c. Craniectomy d. Corticosteroids

ANS: A An increase in ICP because of a mass lesion such as a tumor or hematoma can be treated by surgery. Cimetidine is an antihistamine that prevents gastrointestinal bleeding and ulcers associated with corticosteroids. Craniectomy is a treatment done only in very aggressive situations. Corticosteroids are used to treat cerebral edema.

The nurse is caring for a patient with a brain tumor. Which diagnostic test would the nurse prepare the patient for to further localize and detect blood flow? a. Angiography b. Lumbar puncture c. Endocrine studies d. Electroencephalogram (EEG)

ANS: A For a patient with brain tumor, angiography can be used to localize the tumor and determine blood flow. EEG helps to detect seizures. Lumbar puncture does not detect the blood flow to the tumor and involves additional risk. Endocrine studies are helpful when a pituitary adenoma is suspected.

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need to be prepared for which treatment modality? a. Surgery b. Chemotherapy c. Radiation therapy d. Biologic drug therapy

ANS: A Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

A patient presents with a head injury and is suspected to have a temporal fracture. Which manifestations should the nurse assess further? Select all that apply. a. Optic nerve injury b. Periorbital ecchymosis c. Boggy temporal muscle d. Cerebrospinal fluid (CSF) otorrhea e. Oval-shaped bruise in the mastoid region

ANS: C D E A temporal fracture may manifest as CSF otorrhea, boggy temporal muscle due to extravasation of blood, and an oval-shaped bruise behind the ear in the mastoid region (Battle's sign). Optic nerve injury and periorbital ecchymosis are found in occipital fracture.

The nurse reviews the x-ray reports of a patient who has a skull fracture, which reveals multiple linear fractures and the presence of a fragmented bone. Which type of skull fracture does the nurse suspect? a. Linear type b. Depressed type c. Compound type d. Comminuted type

ANS: D Skull fractures associated with multiple linear fractures along with fragmented bone indicate a comminuted type of skull fracture. A linear fracture is a break in continuity of the bone without alteration of other parts. A depressed type of skull fracture is caused by a powerful blow, which causes inward indentation of the skull. A compound type of skull fracture is associated with a depressed skull fracture and scalp laceration and is caused by a severe head injury.

What is the appropriate action by the nurse if an assessment of a patient scheduled for a lumbar puncture reveals increased intracranial pressure (ICP)? a. Cancel the lumber puncture. b. Schedule the lumbar puncture for the next day. c. Perform the lumbar puncture immediately. d. Administer intravenous fluids before the lumber puncture.

ANS: A Lumbar puncture may cause cerebral herniation due to the sudden release of pressure in the skull from the area above the punctured site and is contraindicated in a patient with increased ICP, so it should be cancelled. Scheduling the lumbar puncture for the next day may not reduce the risk of cerebral herniation. Performing the lumbar puncture immediately may cause cerebral herniation. Administering intravenous fluids does not reduce the risk of cerebral herniation.

A patient with a brain tumor reports inability to eat. What appropriate actions should the nurse perform? Select all that apply. a. Encourage the patient to eat. b. Ensure adequate nutritional intake. c. Assess the patient's nutritional status. d. Advise the patient to reduce water intake. e. Advise the patient to consume a low-calorie diet.

ANS: A B C To improve the patient's nutritional status, the nurse should encourage the patient to eat and ensure an adequate nutritional intake. The nurse should also assess the patient's nutritional status to take corrective actions. Water intake should be adequate to maintain bladder activity. A low-calorie diet may not meet the caloric requirements of the patient.

A patient is diagnosed with a brain tumor. Which surgical techniques and procedures will the nurse prepare the patient for in order to localize brain tumors intraoperatively? Select all that apply. a. X-ray b. Ultrasound c. Cortical mapping d. Electroencephalogram (EEG) e. Computer-guided stereotactic biopsy f. Functional magnetic resonance imaging (MRI)

ANS: B C E F Techniques like ultrasound, functional MRI, cortical mapping, and computer-guided stereotactic biopsy can be used to localize brain tumors intraoperatively. EEG is used to rule out seizure disorder. X-ray is used to show the changes in the skull but may not show soft tissue changes due to brain tumor.

When planning the care of a patient with a brain tumor, which goals should the nurse select as primary goals? Select all that apply. a. Making patient walk b. Removing tumor mass c. Managing patient's family d. Identifying the tumor type and location e. Managing increased intracranial pressure (ICP)

ANS: B D E Removing tumor mass, identifying the tumor type and location, and managing the ICP are the primary goals of treatment of a patient with brain tumor. Assisting the patient with walking and managing the patient's family are not appropriate primary goals.

The nurse is preparing to administer temozolomide to a patient with a brain tumor and assesses the patient's neutrophil count to verify it is greater than 1500/µL. What is the rationale behind this nursing intervention? a. To reduce nausea and vomiting b. To prevent metabolic inactivation c. To prevent immune-related complications d. To prevent drug interactions with corticosteroids

ANS: C Temozolomide can cross the blood-brain barrier and is used to treat brain tumors. It causes myelosuppression in patients with low levels of neutrophils. Therefore the neutrophil count of the patient should be greater than or equal to 1500/µL before administering temozolomide to prevent immune-related complications. Temozolomide should be taken on an empty stomach to prevent nausea and vomiting. It does not require activation, because it is a metabolically active drug. This drug does not react with corticosteroids.

The nurse is assessing the health status of a patient who is unconscious. While assessing, the nurse finds that the patient is opening the eye in response to pain but not to any other stimulus. The patient is moaning to any verbal communication and is showing flexion withdrawal. What is the Glasgow Coma Scale value for this patient? a. 4 b. 6 c. 8 d. 10

ANS: C The Glasgow Coma Scale (GCS ) is a quick, practical, and standardized system for assessing loss of consciousness. According to this scale, the patient's ability to open his or her eyes in response to only pain stimulus is given a score of 2. Expressing incomprehensible words such as moaning is given a score of 2; and for flexion withdrawal, a score of 4 is given. Therefore, 2 + 2 + 4 = 8 indicates the value for the GCS for this patient.

A patient with a head injury presents to the emergency department. For which potential complication related to cerebral hemorrhage and edema should the nurse evaluate this patient? a. Anxiety b. Hyperthermia c. Impaired physical mobility d. Increased intracranial pressure

ANS: D Increased intracranial pressure can occur as a potential complication related to cerebral hemorrhage and edema. Anxiety can result from an abrupt change in health status, being in a hospital environment, and having an uncertain future. Hyperthermia can occur due to increased metabolism, infection, and hypothalamic injury. Impaired physical mobility is related to a decreased level of consciousness.

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? a. A halo sign on the nasal drip pad b. Decreased blood pressure and urinary output c. A positive reading for glucose on a test-tape strip d. Clear nasal drainage along with the bloody discharge

ANS: A When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF leak.

The nurse is caring for a patient admitted for surgical removal of a brain tumor. The nurse will plan interventions for this patient based on the knowledge that brain tumors can lead to which complications? Select all that apply. a. Vision loss b. Cerebral edema c. Pituitary dysfunction d. Parathyroid dysfunction e. Focal neurologic deficits

ANS: A B C E Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

A patient with a tumor of the frontal lobe is reported to have disorientation and confusion due to perceptual problems. What actions should the nurse perform to comfort the patient? Select all that apply. a. Create a routine. b. Use reality orientation. c. Provide increased stimuli. d. Make the patient drive a vehicle. e. Minimize environmental stimuli.

ANS: A B E Creating a routine, using reality orientation, and minimizing environmental stimuli are appropriate actions to comfort the confused patient and to familiarize the confused patient with the environment. Providing increased stimuli and making the patient drive a vehicle are not advisable because they increase the risks for confusion.

The nurse is assessing a comatose patient. Which findings does the nurse anticipate observing? Select all that apply. a. Patient can cough and swallow. b. Patient has bowel and bladder control. c. Patient does not respond to painful stimuli. d. Patient has incontinence of urine and feces. e. Patient's corneal and pupillary reflexes are absent.

ANS: C D E A coma is the deepest state of unconsciousness in which the corneal and pupillary reflexes are absent. A comatose patient is also incontinent of urine and feces and does not respond to painful stimuli. The comatose patient is not able to cough and swallow and does not have any bowel and bladder control.

A patient sustained a concussion after a motor vehicle crash and is fully alert when arriving at the emergency department. What does the nurse document that the Glasgow Coma Scale score is? a. 3 b. 6 c. 8 d. 15

ANS: D The Glasgow Coma Scale is a quick, practical, and standardized system for assessing the level of consciousness in a patient. According to the Glasgow Coma Scale, the score of a fully alert patient will be 15. This includes 4 for spontaneous response of the patient when approached to bedside, 5 for appropriate response during verbal questioning, and 6 for obedience of commands. The lowest possible score according to the Glasgow Coma Scale is 3, which indicates severe coma conditions. A score of 6 or 8 indicates coma.

The nurse is educating a patient that is being discharged with a resolved head injury about prevention of further injury. What measures should the nurse include when discussing this? Select all that apply. a. Use of carpooling b. Use of car seat belts c. Use of tinted glasses d. Use of child car seats e. Use of helmets by cyclists

ANs: B D E Using car seat belts, using child car seats, and using helmets by cyclists can help to prevent head injuries. Use of carpooling and use of tinted glasses do not help to reduce the rate of head injuries.