Chapter 23

Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)? a. Occurrence is greater in men than women younger than the age of 40 years old. b. Occurrence is greater in men than women older than the age of 40 years old. c. 90% of SAHs are caused by traumatic injury. d. Patients with SAHs have a better survival rate than patients with arteriovenous malformations.

ANS: A Among people younger than 40 years, more men than women are likely to have subarachnoid hemorrhages (SAHs); among those older than 40 years, more women have SAHs. Hemorrhage from arteriovenous malformation rupture has a better chance of survival and is associated with an overall mortality rate of 10% to 15%. Ninety percent of aneurysms are congenital, the cause of which is unknown. The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial vessel) or infectious material.

A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and symptoms might the patient exhibit? a. Right-sided hemiplegia and receptive aphasia b. Left-sided hemiplegia and tactile agnosia c. Decorticate posturing and unequal pupils d. Unilateral neglect and dressing apraxia

ANS: A Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills.

A patient has had an ischemic stroke and now having difficulty with speech. The nurse knows the patient is experiencing what problem? a. Expressive aphasia b. Global aphasia c. Receptive aphasia d. Apraxia

ANS: A Expressive aphasia, also known as motor, Broca, or nonfluent aphasia, is primarily a deficit in language output or speech production. Global aphasia results when a massive lesion affects the motor and sensory speech areas. The patient cannot transform sounds into words and cannot comprehend spoken words. Receptive aphasia, also referred to as sensory, Wernicke, or fluent aphasia, occurs when the connection between the primary auditory cortex in the temporal lobe and the angular gyrus in the parietal lobe is destroyed. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily.

How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown? a. 2 hours b. 4 hours c. 8 hours d. 12 hours

ANS: A Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist.

Which medication is a fast-acting, short-duration agent used for breakthrough seizures? a. Lorazepam b. Phenytoin c. Phenobarbital d. Midazolam

ANS: A Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.

Which patient has the best prognosis based on the cause of coma? a. A 36-year-old man with closed head injury b. A 50-year-old woman with hepatic encephalopathy c. A 46-year-old woman with subarachnoid hemorrhage d. A 72-year-old man with hypertensive intracerebral hemorrhage

ANS: A Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.

The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods? a. First 24 hours b. 4 to 12 days c. 3 to 4 weeks d. 3 to 6 months

ANS: A Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%.

Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)? a. Mannitol b. Furosemide c. Urea d. Glycerol

ANS: A The most widely used diuretic is mannitol, a large-molecule agent that is retained almost entirely in the extracellular compartment and has little of the rebound effect observed with other osmotic diuretics. Administration of mannitol increases cerebral blood flow and thus induces cerebral vasoconstriction as part of the brain's autoregulatory response to keep blood flow constant.

Downward displacement of the hemispheres, basal ganglia, and diencephalon through the tentorial notch is indicative of what type of herniation? a. Central b. Uncal c. Cingulate d. Infratentorial

ANS: A These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri. The two infratentorial herniation syndromes are upward transtentorial herniation and downward cerebellar herniation.

The extrusion of cerebral tissue through the cranium is what type of herniation? a. Transcalvarial b. Uncal c. Cingulate d. Transtentorial

ANS: A Transcalvarial herniation is the extrusion of cerebral tissue through the cranium. In the presence of severe cerebral edema, transcalvarial herniation occurs through an opening from a skull fracture or craniotomy site. These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri.

Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)? a. Decreasing the ventilator rate b. Decreasing noxious stimuli c. Frequent orientation checks d. Administration of loop diuretics

ANS: B A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing intracranial pressure.

A male patient post right-sided stroke is experiencing hemiagnosia. This is evidenced by which finding? a. The patient only reads the right side of the newspaper. b. The patient refuses to acknowledge the left side of his body. c. The patient is hyperresponsive when approached on the right side. d. The patient attempts to comb his hair with a toothbrush.

ANS: B Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. This denial may range from inattention to refusing to acknowledge a paralysis by neglecting the involved side of the body or by denying ownership of the side, attributing the paralyzed arm or leg to someone else. The neglect also may extend to extrapersonal space. This defect most often results from right hemispheric brain damage that causes left hemiplegia.

Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study? a. Magnetic resonance imaging b. Noncontrast computed tomography c. Contrast computed tomography d. Lumbar puncture

ANS: B Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. In addition to excluding intracranial hemorrhage, CT can assist in identifying early neurologic complications and the cause of the insult. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

A patient becomes flaccid with fixed and dilated pupils. The patient's intracranial pressure (ICP) falls from 65 to 12 mm Hg. What should the nurse suspect is happening? a. The patient is having a seizure. b. The patient's brain has herniated. c. The patient's cerebral edema is resolving. d. The patient is excessively dehydrated from the mannitol.

ANS: B Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs and symptoms of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.

The patient has uncontrolled intracranial pressure and now is receiving high-dose barbiturate therapy. The nursing management plan for this patient should include monitoring the patient for what complication? a. Hypothermia b. Hypotension c. Myocardial depression d. Dehydration

ANS: B Hypotension, the most common complication in barbiturate therapy, results from peripheral vasodilation and can be compounded in an already dehydrated patient who has received large doses of an osmotic diuretic in an attempt to control intracranial pressure. Myocardial depression results from cardiac muscle suppression and can be avoided by frequent monitoring of fluid status, cardiac output, and serum drug levels.

A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract computed tomography (CT) findings are negative. The patient is being prepared for a lumbar puncture. What appearance does the nurse anticipate that the cerebrospinal fluid (CSF) would look? a. Cloudy b. Bloody c. Xanthochromic d. Clear

ANS: B If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH.

A female right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. While assisting with personal care, the nurse notes that the patient is unable to comb her hair with her left hand. The nurse suspects the patient may be experiencing which complication? a. Agnosia b. Apraxia c. Broca aphasia d. Wernicke aphasia

ANS: B Lesions in the parietal lobe, as well as in other cortical structures, can result in apraxia, an inability to perform a learned movement voluntarily.

A patient's ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Given that the practitioner has left appropriate orders, which action should the nurse take next? a. No action is required. b. Administer mannitol 1 to 2 g/kg IV. c. Place the patient supine and flat in bed. d. Suction the patient.

ANS: B Mannitol is an osmotic diuretic and will pull swelling out of edematous brain tissue, thereby decreasing intracranial pressure (ICP). Having the patient lie flat in bed will impair venous drainage from the head and worsen ICP. Suctioning will cause increased intrathoracic pressure, which will also worsen the already elevated ICP.

Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival? a. Decorticate posturing b. Absent pupillary light reflexes c. Decerebrate posturing d. Central hyperventilation

ANS: B Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy.

Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms? a. 1 b. 3 c. 6 d. 10

ANS: B National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and Stroke rtPA Stroke Study. This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours of onset of the stroke was an effective and safe therapy for ischemic stroke. This time frame has now been expanded from 3 to 4.5 hours with additional excursion criteria.

Which nursing intervention will help prevent spikes in intracranial pressure in the post-neurosurgical patient? a. Keep the head of the bed elevated 45 to 90 degrees. b. Administer an antiemetic to prevent vomiting. c. Provide fluid restriction. d. Help with turn, cough, and deep breathe exercises.

ANS: B Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP) in the postoperative neurosurgical patient. Antiemetics are administered as soon as nausea is apparent. Fluid restriction may be ordered as a routine measure to lessen the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of inappropriate antidiuretic hormone secretion. Most craniotomy patients can be turned from side to side within these restrictions, using pillows for support, except in some cases of extensive tumor removal, cranioplasty, and when the bone flap is not replaced. Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications. To prevent dangerous elevations in ICP, this care measure must be performed using proper technique and at time intervals that are adequately spaced from other patient care activities.

After neurosurgery, the patient is at risk of developing what problem? a. Aspiration b. Diabetes mellitus c. Seizures d. Corneal abrasions

ANS: C After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery, patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema.

When an object is placed in the hand of a patient with neurologic impairment during assessment, the patient is unable to recognize the placement. What is this complication called? a. Homonymous hemianopsia b. Aphasia c. Agnosia d. Apraxia

ANS: C Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. Tactile agnosia is a perceptual disorder in which a patient is unable to recognize an object that has been placed in his or her hand by touch alone. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily. Optic radiations extend back to the occipital lobes. Visual defects restricted to a single field, right or left, are called homonymous hemianopsia. Aphasia is a loss of language abilities caused by brain injury, usually to the dominant hemisphere.

Which intervention should be considered LAST in treating uncontrolled intracranial hypertension? a. Sedatives b. Analgesics c. Barbiturates d. Hyperventilation

ANS: C Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not responded to the conventional treatments previously described. The two most commonly used drugs in high-dose barbiturate therapy are pentobarbital and thiopental. The goal with either of these drugs is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.

What is one cause of metabolic coma? a. Trauma b. Ischemic stroke c. Drug overdose d. Intracerebral hemorrhage

ANS: C Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.

Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention? a. Administering osmotic diuretics and vasodilator agents b. Providing the patient with a quiet environment c. Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg d. Keeping the patient's central venous pressure at 5 to 8 mm Hg

ANS: C Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures.

Which medication is prescribed to decrease cerebral vasospasm? a. Phenytoin b. Phenobarbital c. Nimodipine d. Vecuronium

ANS: C Nimodipine is used to decrease cerebral vasospasm.

What is one of the earliest signs of increased intracranial pressure (ICP)? a. Cushing triad b. Decerebrate posturing (abnormal extension) c. Change in level of consciousness d. Increase in pupillary size

ANS: C One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness.

Which patient position is optimal to prevent elevated intracranial (ICP) pressures? a. The head of the bed elevated 30 to 40 degrees b. Supine with the patient's neck in a neutral alignment c. Individualized head position to minimize ICP measurements d. The head of the bed elevated with flexion of the hips

ANS: C The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements.

A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy? a. Instillation of mannitol b. Drainage of subdural hematoma c. Brain tissue sampling d. Cerebrospinal fluid drainage

ANS: D Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.

What is a pathologic consequence of an unruptured cerebral aneurysm? a. It shunts blood away from the surrounding tissues. b. It leaks blood into the subarachnoid space. c. It causes damage the middle layer of the arterial wall. d. It places pressure on the surrounding tissues.

ANS: D An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.

A patient has been admitted post craniotomy for a brain tumor. The nursing management plan should include monitoring the patient for what complication? a. Diabetes mellitus b. Fluid retention c. Intracranial hypotension d. Surgical hemorrhage

ANS: D Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, and deep venous thrombosis.

A patient has been told he has a nonencapsulated tumor that has infiltrated the brain tissue. Why type of tumor does the nurse suspect the patient has? a. Angioma b. Pituitary adenoma c. Meningioma d. Glioma

ANS: D Gliomas are nonencapsulated; tend to infiltrate brain tissue; arise in any part of brain connective tissue; infiltrate primarily cerebral hemisphere tissue; are not well outlined, so they are difficult to excise completely; and grow rapidly. Angiomas arise from vascular structures and are usually difficult to resect. Pituitary adenomas arise from various tissues. Meningiomas arise from meningeal coverings of brain and are usually encapsulated.

A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a. Hemorrhagic stroke b. Intracerebral hemorrhages c. Subarachnoid hemorrhages d. Ischemic stroke

ANS: D Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.

Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit? a. The demyelination process of the peripheral nerves is irreversible. b. The demyelination process is limited to the peripheral nervous system only. c. The paralysis associated with the syndrome occurs in a descending pattern. d. The most common cause of death is respiratory arrest.

ANS: D Most patients with Guillain-Barré syndrome (GBS) do not require admission to the critical care unit. However, the prototype of GBS, known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), involves a rapidly progressive, ascending peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure. Because of the need for ventilatory support, AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment.

What is the target range for PaCO2 in the patient with intracranial hypertension? a. 25 to 30 mm Hg b. 25 to 35 mm Hg c. 35 to 40 mm Hg d. 33 to 37 mm Hg

ANS: D The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings.

Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents? a. Epinephrine, hydrocortisone, and Benadryl b. Dopamine, 10% dextrose in distilled water, and calcium chloride c. Mannitol, dexamethasone, and sodium bicarbonate d. Thiamine, glucose, and opioid antagonist

ANS: D The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.

What are the most common medications used in high-dose barbiturate therapy? a. Phenytoin and fosphenytoin b. Mannitol and nimodipine c. Lidocaine and phenobarbital d. Pentobarbital and thiopental

ANS: D The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained. Phenytoin and fosphenytoin are anticonvulsants. Mannitol is an osmotic diuretic, lidocaine is a local anesthetic, and nimodipine is a calcium channel blocker.

Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome? a. Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients or increased metabolic demand b. Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c. Risk for aspiration d. Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment

ANS: D The most common cause of death of patients with Guillain-Barré syndrome (GBS) is respiratory arrest; thus, the highest nursing priority for a patient with GBS is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.

The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The provider requests the drainage be tested for the presence of glucose. Why did the physician order this test? a. To assess for an infection b. To check for a shift in osmolality c. To check for occult blood d. To assess for a cerebrospinal fluid leak

ANS: D To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater.

A ventriculoperitoneal shunt may be placed in a post-stroke patient to treat which complication? a. Hyponatremia b. Intracerebral hemorrhage c. Spontaneous intracerebral hemorrhage d. Hydrocephalus

ANS: D Treatment for hydrocephalus consists of placing a drain to remove cerebrospinal fluid. This can be accomplished temporarily by inserting a ventriculostomy or permanently by placing a ventriculoperitoneal shunt. Treatment for hyponatremia is sodium replenishment with isotonic fluids.

A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) of the patient's head reveals a large left parietal area bleed. Patient assessment includes temperature (T), 98.7° F; pulse (P), 98 beats/min and thready; respirations (R), 8 breaths/min; and blood pressure (BP), 168/100 mm Hg. Initial management of the patient includes which intervention? a. Placing the patient in the Trendelenburg position b. Administering an antihypertensive agent c. Initiating induced hypertensive therapy d. Intubating and ventilating the patient

Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg.