EAQ 56 Inflammatory Condition of the Brain, Increase Intracranial Pressure, Head Injury & Brain Tumors (3 EAQ)

Which statement by the novice nurse demonstrates understanding of the care required for a patient admitted earlier today with a diagnosis of post-head injury concussion? "I can expect the pupils to be unequal in size and sluggish to respond to my pen light." "I will delegate keeping the patient awake for the next eight hours to my unlicensed assistive personnel (UAP)." "To help with post-head injury headaches, I will contact the health care provider about prescribing morphine IV." "I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

"I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy? "I will have an internal transducer inserted into my head." "I won't be able to have drugs instilled through this procedure." "It will directly measure the pressure within the ventricles of my brain." "The health care provider won't be able to get samples of my cerebrospinal fluid."

"It will directly measure the pressure within the ventricles of my brain."

When explaining neurological pathophysiology to a group of nursing students, the nurse describes the progression of increased intracranial pressure in which chronological order? 1. 2. 3. 4. 5. 6.

1. Tissue edema 2. Increased intracranial pressure 3. Compression of ventricles and blood vessels 4. Decreased cerebral blood flow 5. Decreased oxygen and death of brain cells 6. Compression of the brainstem and respiratory center

Which Glasgow Coma Scale (GCS) score would the nurse anticipate for a patient with a moderate type of head injury? 3 5 10 14

10 Rationale: The GCS 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. Patients with a severe type of head injury have a GCS score between 3 to 5. Patients who has a minor type of head injury have a GCS score of 14.

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient? 20 mm Hg 40 mm Hg 60 mm Hg 80 mm Hg

80 mm Hg Rationale: Patients with elevated ICP are at risk for lower CPP during suctioning. When suctioning, maintain the patient's CPP above 60 mm Hg to preserve cerebral perfusion.

Which observation would the nurse associate with a cerebrospinal fluid (CSF) leak when a patient with a suspected traumatic brain injury (TBI) develops a bloody nasal drainage? A halo sign on the nasal-drip pad Decreased BP and urinary output A positive reading for glucose on a test-tape strip Clear nasal drainage along with the bloody discharge

A halo sign on the nasal-drip pad Rationale: 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 BP and urinary output would not be indicative of a CSF leak.

Which patient condition contraindicates testing the doll's-eye reflex when performing a neurologic assessment? An unconscious patient An uncooperative patient A patient with cervical spine injury A patient who has intracranial lesion

A patient with cervical spine injury Rationale: 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.

Which information would the nurse provide a patient and the caregiver as discharge instructions related to care during the first three days after sustaining a head injury? You may resume driving. Restrict the sodium in your diet. Abstain from alcohol during this time. Wear a helmet when riding your bike.

Abstain from alcohol during this time. Rationale" Alcohol is a central nervous system depressant and may mask important neurologic changes related to a head injury. The patient should refrain from driving because of potential neurologic changes from the head injury. A dietary sodium restriction is not necessary unless it is related to another medical condition. Wearing a helmet is a preventive measure not specific to patients with head injuries.

Which disorder would the nurse associate with a patient who has meningitis with seizures, cranial nerve (CN) III palsy, and bradycardia? Cerebral abscess Subdural effusion Acute cerebral edema Increased intracranial pressure

Acute cerebral edema Rationale: Acute cerebral edema is a complication of meningitis that causes seizures, CN III palsy, and bradycardia. Cerebral abscess, subdural effusion, and increased intracranial pressure are complications of meningitis, but they do not cause the aforementioned symptoms

Which medication would the nurse prepare to administer to a patient admitted to the hospital with a diagnosis of viral encephalitis? Acyclovir (Zovirax) Ampicillin (Omnipen) Vidarabine (VIRA-A) Vancomycin (Vancocin)

Acyclovir (Zovirax) Rationale: Acyclovir (Zovirax) is the drug of choice for treating viral encephalitis because it has fewer side effects. Use ampicillin and vancomycin to treat bacterial meningitis. Use vidarabine to treat encephalitis, but this medication has more side effects than acyclovir.

For the patient with a brain tumor, for which diagnostic test would the nurse prepare the patient when needing to localize and detect tumor blood flow? Angiography Lumbar puncture Endocrine studies Electroencephalogram (EEG)

Angiography

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/minute, and respirations 24 breaths/minute, which subsequent vital signs would the nurse report immediately to the health care provider? BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute BP 136/84 mm Hg, pulse 88 beats/minute, respirations 26 breaths/minute BP 112/56 mm Hg, pulse 98 beats/minute, respirations 28 breaths/minute BP 126/68 mm Hg, pulse 110 beats/minute, respirations 32 breaths/minute

BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute Rationale: these values may indicate Cushing's triad or systolic hypertension with a widening pulse pressure, bradycardia, and irregular or low respirations

For the intubated and mechanically ventilated patient, the development of which potential side effect of dexmedetomidine (Precedex) would the nurse anticipate monitoring? Insomnia BP changes Hyperanxiety Sedative effect

BP changes

The patient admitted with a closed head injury is awake but lethargic, and the baseline vital signs include a BP of 120/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min. Which findings indicate deterioration of the patient's condition two hours later? The patient is sleeping but awakens in response to painful stimuli. The patient does not remember what happened during the six hours prior to the injury. BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are 20 breaths/min. BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min.

BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min. Rationale: Late signs of increased intracranial pressure include an increased systolic BP and decreasing diastolic BP (widening pulse pressure), bradycardia, and decreased respirations.

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include? BP, brain tissue, body mass index Glucose level, BP, and brain tissue BP, brain tissue, and cerebrospinal fluid BP, brain tissue, and ventricles of the brain

BP, brain tissue, and cerebrospinal fluid

Which outcome would the nurse anticipate after administering a high dose of prescribed barbiturates to the patient with an increased intracranial pressure (ICP)? The medication reduces the vasogenic edema. Barbiturates decrease the level of cerebral metabolism. The drug facilitates plasma expansion and an osmotic effect. The therapy promotes massive movement of water out of brain cells.

Barbiturates decrease the level of cerebral metabolism.

For the patient with a head injury and suspected temporal fracture, which clinical manifestations would the nurse need to assess further? Select all that apply. Optic nerve injury Periorbital ecchymosis Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region

Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region Rationale: 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). Occipital fractures involve optic nerve injuries and periorbital ecchymosis.

For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response? CN X CN V CN III CNXII

CN III Rationale: CN III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. CN XII controls tongue movement, CN X is the vagus nerve, and CN V is the trigeminal nerve.

Which cranial nerve (CN) irritation, secondary to bacterial meningitis, resulted in the patient's loss of corneal reflexes? CN II CN V CN IV CN VII

CN V Rationale: CN V is the trigeminal nerve; irritation of this nerve will lead to the loss of the corneal reflex. CN II (optic nerve) irritation leads to blindness. CN IV (trochlear nerve) irritation affects ocular movements. CN VII (facial nerve) irritation causes facial paresis.

When assessing a patient diagnosed with a brainstem tumor, which clinical manifestations would the nurse expect to identify? SATA Crossed eyes Diabetes insipidus Tinnitus and vertigo Facial muscle weakness Headache on awakening

Crossed eyes Facial muscle weakness Headache on awakening Rationale: Brainstem tumors may present with clinical manifestations of having crossed eyes, facial muscle weakness, and headache on awakening. Cerebellopontine tumors present with tinnitus, vertigo, and deafness. Tumors located in the areas of the thalamus and sella turcica present as diabetes insipidus.

Which type of encephalitis would the nurse anticipate integrating interventions into the plan of care for the patient with acquired immunodeficiency syndrome (AIDS)? La Crosse encephalitis West Nile encephalitis Cytomegalovirus encephalitis Herpes simplex virus encephalitis

Cytomegalovirus encephalitis Rationale: La Crosse encephalitis and West Nile encephalitis are epidemic diseases transmitted by ticks and mines. Herpes simplex virus encephalitis is a nonepidemic encephalitis.

Which assessment would the nurse perform to determine whether the mannitol (Osmitrol) IV treatment had the desired outcome for a patient with a head injury? Increased BP Decrease in body temperature Decreased intracranial pressure Decreased serum blood glucose

Decreased intracranial pressure

Which tests would the nurse utilize to detect cerebral spinal fluid (CSF) in a patient suspected of otorrhea after sustaining head trauma? Select all that apply. Dextrostix Litmus test Guaiac test Tes-Tape strip Imaging scans Quantitative human chorionic gonadotropin (hCG)

Dextrostix Tes-Tape strip Imaging scans Rationale: Use a Dextrostix or Tes-Tape strip to detect glucose, which is present in CSF. The appearance of a halo around blood in imaging studies may also be indicative of CSF. The litmus test analyzes the pH of the fluid, which does not provide information about CSF. The guaiac test is used to test stools for occult blood. Quantitative hCG is a test that measures the hormone hCG, which does not provide information about CSF.

A patient's systemic BP is 120/60 mm Hg and the intracranial pressure (ICP) is 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? High blood flow to the brain Normal ICP Impaired blood flow to the brain Adequate autoregulation of blood flow

Impaired blood flow to the brain Rationale: A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the ICP from the mean arterial pressure (MAP). MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm Hg + 2[60 mm Hg])/3 = 120 mm Hg + 120 mm Hg = 240 mm Hg; 240/3 = 80 MAP-ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg. The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is elevated, preventing perfusion of the brain, and requires treatment.

For the patient with a head injury, for which complication related to cerebral hemorrhage and edema would the nurse monitor potential development? Anxiety Hyperthermia Impaired physical mobility Increased intracranial pressure

Increased intracranial pressure

Which intervention would the nurse implement when a patient, receiving treatment for viral meningitis since last week, arrives at the hospital reporting a persistent severe headache? Instruct the patient to use analgesics for the headache. Inform the patient that headaches can occur after recovery. Teach the patient that a headache is not a major complication. Notify the patient that a full recovery from viral meningitis is not possible.

Inform the patient that headaches can occur after recovery.

For the patient with a basilar skull fracture, for which intervention prescribed by the health care provider would the nurse contact the prescriber for clarification? Apply soft cervical collar. Avoid flexion of hip joints. Maintain elevation of the head of bed at 30 degrees. Insert nasogastric (NG) tube and connect to low, intermittent suction.

Insert nasogastric (NG) tube and connect to low, intermittent suction.

Which assessment findings would the nurse document regarding a patient diagnosed with a right-sided brain tumor resulting in a significantly increased intracranial pressure (ICP)? SATA Ipsilateral pupil dilation Ipsilateral hemiparesis Contralateral hemiparesis Contralateral pupil dilation Altered level of consciousness

Ipsilateral pupil dilation Contralateral hemiparesis Altered level of consciousness

Which intervention would the nurse implement to reduce the mental distortion experienced by the patient with meningitis? Provide low lighting. Elevate the head of the bed. Minimize environmental stimuli. Apply a cool cloth over the eyes.

Minimize environmental stimuli. Rationale: A patient with a mental distortion may be frightened and misinterpret the environment. Therefore, minimizing environmental stimuli may help to calm the patient. Provide low lighting if the patient experiences photophobia. Slightly elevate the head of the bed if the patient experiences head and neck pain. Apply a cool cloth over the patient's eyes to decrease photophobia.

Which intervention would the nurse implement when providing care for a patient with an increased intracranial pressure (ICP)? Place the patient in a supine position. Monitor ICP continuously. Administer D 5W IV infusions. Withhold opiates to protect respiratory status.

Monitor ICP continuously.

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy? Monitor the patient for pain. Monitor the patient for an infection. Monitor the patient for excessive bleeding or hemorrhage. Monitor the patient for increased intracranial pressure (ICP).

Monitor the patient for increased intracranial pressure (ICP). Rationale: The priority action of the nurse caring for a patient following a craniotomy is to monitor for increased ICP, which can have serious life-threatening implications. Manage the patient's pain, but pain is not an emergency. Monitor the patient for development of an infection, but the infection will not be immediately apparent. A hemorrhage will cause an increase in ICP if it is cerebral.

Of the four assigned patients with skull fractures, which type of skull fracture would the nurse associate with a low-velocity injury? Patient A Patient B Patient C Patient D

Patient A

When diagnosed with a brain tumor and acquired immunodeficiency syndrome (AIDS), which type of tumor growth would the nurse associate with this patient? Metastatic tumor Acoustic neuroma Pituitary adenoma Primary central nervous system lymphoma

Primary central nervous system lymphoma

Which medication has a rapid onset, short half-life, and would the nurse administer to treat a patient's anxiety and agitation secondary to an increased intracranial pressure? Propofol (Diprivan) Lorazepam (Ativan) Morphine sulphate (Duramorph) Cisatracurium besylate (Nimbex)

Propofol (Diprivan) Rationale: Propofol has a rapid-onset, short half-life, and is used for anxiety and agitation in the intensive care unit (ICU). Use analgesics like opioids, such as morphine sulphate (Duramorph) for pain, not anxiety and agitation. Avoid benzodiazepines such as lorazepam (Ativan) in the patient with increased intracranial pressure, unless used with neuromuscular blocking agents. A nondepolarizing neuromuscular blocking agent is a paralytic, like cisatracurium besylate (Nimbex).

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? Sims' Prone Trendelenburg Semi-Fowler's

Semi-Fowler's

Which components would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure (ICP)? Swallowing, speaking, and following verbal commands Swallowing, pupillary response, and following verbal commands Speaking, responding to stimuli, and following verbal commands Responding to stimuli, swallowing, and following verbal commands

Speaking, responding to stimuli, and following verbal commands

Which assessments would the nurse include when documenting an evaluation of a patient's central nervous system (CNS)? Select all that apply. Speech Seizures Contusions Oxygen saturation Bowel and bladder incontinence Decerebrate or decorticate posturing

Speech Seizures Bowel and bladder incontinence Decerebrate or decorticate posturing Rationale: Decerebrate or decorticate posturing, speech, bowel and bladder incontinence, and seizures are all elements that the nurse observes when assessing the CNS. Oxygen saturation is reflective of respiratory status, not the CNS, and contusions are a body surface assessment unrelated to the CNS.

Which initial interventions would the nurse implement as emergency management of a patient who fell and presented with scalp lacerations and a depressed skull? SATA Stabilize the cervical spine. Wrap the patient in tight clothing. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing. Avoid intubation if the Glasgow Coma Scale (GCS) score is less than 8.

Stabilize the cervical spine. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing.

Which characteristic would the nurse assess when performing a palmar drift (pronator drift) test during a neurologic assessment? Eye movements Pupillary reaction Strength of the legs Strength of the hands

Strength of the hands

When providing a community safety presentation, which disorder would the nurse include as a possible cause for a patient's increased intracranial pressure? Sinusitis Cor pulmonale Diabetes insipidus Subdural hematoma

Subdural hematoma

For the patient presenting with watery sanguineous nasal drainage after falling from a firstfloor roof, which diagnostic method validates the nurse's suspicion of rhinorrhea? Gram stain The halo test A Dextrostix Slide smear for presence of leukocytes

The halo test Rationale: The patient may be 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.

Which interpretation would the nurse associate with a positive Dextrostix test of the clear nasal discharge obtained from the patient who sustained head trauma? The patient has sinusitis. The patient has glaucoma. The patient has allergic rhinitis. The patient has cerebrospinal fluid (CSF) rhinorrhea

The patient has cerebrospinal fluid (CSF) rhinorrhea

For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? SATA The patient is alert and oriented. The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient has a regular respiratory rate of 14 breaths/min. The patient is vomiting without preceding nausea.

The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient is vomiting without preceding nausea.

Which interpretation would the nurse associate with a patient's Glasgow Coma Scale score of 5 after sustaining a head injury? The patient is alert and oriented. The patient is unresponsive and comatose. The patient is awake but lethargic and drowsy. The patient responds appropriately to commands.

The patient is unresponsive and comatose. Rationale: The Glasgow Coma Scale ranges from 3 to 14. A score of 7 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 7.

How many doses of the meningococcal conjugate vaccine (MCV4) (Menactra) are recommended for the prevention of bacterial meningitis? One Two Three Four

Two Rationale: The MCV4 is given in two doses to prevent bacterial meningitis. The first dose is recommended for all 11 to 12-year-olds, with a booster dose given at age 16.

For which surgical techniques and procedures would the nurse prepare the patient scheduled for localizing brain tumors intraoperatively? SATA X-ray Ultrasound Cortical mapping Electroencephalogram (EEG) Computer-guided stereotactic biopsy Functional MRI

Ultrasound Cortical mapping Computer-guided stereotactic biopsy Functional MRI Rationale: To localize brain tumors intraoperatively, providers utilize techniques like ultrasound, functional MRI, cortical mapping, and the computer-guided stereotactic biopsy. To rule out a seizure disorder, use the EEG. X-rays show changes in the skull but may not show soft tissue changes due to brain tumor.

Which clinical manifestation would the nurse report immediately to the health care provider when providing care for a patient with a traumatic brain injury and an increased intracranial pressure (ICP)? ICP of 20 mm Hg Urine output of 1000 mL in one hour Respiratory rate of 24 breaths/minute Pulse of 100 beats/minute

Urine output of 1000 mL in one hour Rationale: An increased urine output of 1000 mL in one hour could cause critical fluid and electrolyte imbalance issues and needs prompt attention; this indicates a decline in the patient's condition. An ICP of 20 mm Hg, respiratory rate of 24 breaths/minute, and pulse of 100 beats/minute do not indicate a need for the nurse to call the health care provider.

For the patient with a resolved head injury, which prevention interventions would the nurse include when providing discharge instructions? Select all that apply. Use of carpooling Use of car seat belts Use of tinted glasses Use of child car seats Use of helmets by cyclists

Use of car seat belts Use of child car seats Use of helmets by cyclists

Which type of cerebral edema would the nurse associate with a diagnostic report indicating edema of the white matter and characterized by a leakage of large molecules from the capillaries into the surrounding space? Interstitial cerebral edema Vasogenic cerebral edema Hypoxic cerebral edema Cytotoxic cerebral edema

Vasogenic cerebral edema Rationale: Vasogenic cerebral edema occurs mainly in the white matter and is the most common type characterized by leakage of large molecules from the capillaries into the surrounding space. Interstitial cerebral edema is usually a result of hydrocephalus. Hypoxia is a lack of oxygen to the brain and does not cause cerebral edema, though the edema may cause the hypoxia. Cytotoxic cerebral edema results from disruption of the integrity of the cell membranes from lesions or trauma.

Which population has the highest rate of malignant brain tumors? White males Asian males Hispanic males African American males

White males Rationale: Of these groups, white males have the highest incidence of malignant brain tumors. Asian and Hispanic males have a lower incidence of brain tumors. African American males have a higher incidence of benign tumors.

Which statements reflect understanding by the newly licensed registered nurse providing care for a patient with recent placement of a ventricular shunt? Select all that apply. "I need to wear sterile gloves whenever I palpate the patient's incision site." "I should be concerned if my patient begins to vomit or dry heave and has a headache." "I will compare my current assessment findings with the patient's preoperative assessments." "I informed the unlicensed assistive personnel (UAP) to reposition the patient quickly to prevent headaches." "With placement of the ventricular shunt, I do not need to monitor the patient's intracranial pressures (ICPs) because they are now normal."

"I need to wear sterile gloves whenever I palpate the patient's incision site." "I should be concerned if my patient begins to vomit or dry heave and has a headache." "I will compare my current assessment findings with the patient's preoperative assessments."

Which statements made by the caregiver of a patient who sustained a head injury indicate understanding of the patient's needs? SATA "I should maintain a calm environment if the patient becomes angry." "I should assist with a walker if the patient experiences difficulty walking." "I should not allow the patient to drive when under the influence of morphine." "I should provide hot baths if the patient experiences shivering and drowsiness." "I should notify the health care provider if the patient develops finger numbness."

"I should not allow the patient to drive when under the influence of morphine." "I should notify the health care provider if the patient develops finger numbness."

When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid? 1. Open the ventriculostomy system when ICP is greater than the prescribed pressure. 2. Close the stopcock to return the ventriculostomy to a closed system. 3. Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 4. Allow the CSF to drain for two to three minutes into the collection bag.

1. Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 2. Open the ventriculostomy system when ICP is greater than the prescribed pressure. 3. Allow the CSF to drain for two to three minutes into the collection bag. 4. Close the stopcock to return the ventriculostomy to a closed system.

Which Glasgow Coma Scale score would the nurse assign to the patient who sustained a motor-vehicle crash concussion and who is fully alert upon arrival to the emergency department? 3 6 8 15

15 Rationale: 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 at the 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.

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and BP of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number

39 mm Hg Rationale" The CPP is calculated by subtracting the ICP from the MAP; 64 - 25 = 39. Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As CPP decreases, autoregulation fails and cerebral blood flow is decreased.

When assessing a patient's level of consciousness, which potential Glasgow Coma Scale (GCS) scores indicate the patient is in a comatose state? SATA 4 5 6 9 11

4 5 6 Rationale: A GCS score of 8 or less generally indicates coma. Scores of 9 or 11 are greater than 8, and do not indicate coma.

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data? 5 to 15 mm Hg 25 to 35 mm Hg 45 to 60 mm Hg 80 to 120 mm Hg

5 to 15 mm Hg

Which Glasgow Coma Scale (GCS) score would the nurse assign an unconscious patient who opens the eyes in response to pain but who does not respond to any other stimulus, moans to any verbal communication, and demonstrates flexion withdrawal? 4 6 8 10

8 Rationale: The 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 merits a score of 2. Expressing incomprehensible words such as moaning merits 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.

For the patient who sustained a head injury in a motor vehicle crash, which primary injury interventions would the nurse include in the patient's plan of care? Select all that apply. Anticipate intubation. Administer oxygen. Maintain neck alignment. Maintain normothermia. Administer fluids cautiously. Establish/maintain IV access.

Administer oxygen. Maintain neck alignment. Establish/maintain IV access. Rationale: Administration of oxygen, assuming neck injury with head injury, and establishing IV access are priority interventions to ensure the health and safety of the patient. Maintaining normothermia, anticipating intubation, and administering fluids cautiously are part of ongoing monitoring to help to prevent secondary injury; these interventions can take place after the priority interventions have been administered.

For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the health care provider? An ICP of 5 mm Hg An ICP of 10 mm Hg An ICP of 15 mm Hg An ICP of 20 mm Hg

An ICP of 20 mm Hg Rationale: A sustained pressure of 20 mm Hg is abnormally high and requires treatment. Normal ICP is 5 to 15 mm Hg, so ICPs of 5 mm Hg, 10 mm Hg, and 15 mm Hg do not require reporting.

Which patient would the charge nurse assign to the nurse floating from the acute care medical-surgical unit to the neurologic intermediate care unit? A patient just returning from a craniotomy for evacuation of subdural hematoma The patient scheduled to transfer to a rehabilitative facility with a traumatic brain injury in two hours An alert patient with viral encephalitis who needs an IV access for a scheduled acyclovir An unconscious patient with bacterial meningitis who needs another lumbar puncture for repeat cultures

An alert patient with viral encephalitis who needs an IV access for a scheduled acyclovir

Which clinical manifestation would the nurse associate with a patient reporting a headache, with disturbed consciousness, and whose imaging studies indicate cerebral edema in the white matter? An intact blood-brain barrier is present. A decreased oxygen supply to the brain exists. An increase in the cerebral extracellular fluid volume occurred. Something caused abnormal accumulations of cerebrospinal fluid in the brain.

An increase in the cerebral extracellular fluid volume occurred. Rationale: 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 volume. Cerebral hypoxia or decreased oxygen supply is seen in cytotoxic cerebral edema. An intact bloodbrain barrier is seen in cytotoxic cerebral edema. Hydrocephalus or abnormal accumulation of cerebrospinal fluid in the brain is seen in interstitial cerebral edema.

Which pathophysiologic processes would the nurse suspect when a patient with a head injury develops a temperature of 103 F (39.4 C)? Select all that apply. The patient's metabolic rate decreased. An increased cerebral blood flow is occurring. The patient's intracranial pressures have decreased. The metabolic wastes are increasing due to the head injury. A decreased blood flow decreased the amount of cerebral blood volume.

An increased cerebral blood flow is occurring. The metabolic wastes are increasing due to the head injury. Rationale: Hyperthermia occurs when there is an injury or inflammation in the hypothalamus. The body temperature of 103° F (39.4° C) of a patient who has a head injury indicates an injury to the hypothalamus. Injury to the hypothalamus can increase 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.

Which diagnosis would the nurse associate with a patient's cerebrospinal fluid (CSF) culture findings of a white blood cell (WBC) count of 1200 cells/ μL, protein 600 mg/dL, and glucose 25 mg/dL? Brain abscess Viral meningitis Viral encephalitis Bacterial meningitis

Bacterial meningitis Rationale The normal range of WBC count is 0 to 5 cells/μL, the normal range of protein is 15 to 45 mg/dL, and the normal range of glucose is 40 to 70 mg/dL in the CSF. An increased WBC count, increased protein, and decreased glucose are signs of bacterial meningitis. A patient with a brain abscess would have an increased WBC count, normal protein levels, and a decrease or absence of glucose. In viral meningitis, the CSF reflects an increased WBC count and protein level, along with decreased or absent glucose. In viral encephalitis, the CSF reflects an increased WBC count, slightly increased protein level, and normal glucose levels.

Which interventions would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply. Keep the patient in a hypovolemic fluid state. Begin parenteral nutrition if oral intake is not adequate. Initiate nutritional replacement within three days after injury. If comatose, wait at least seven days to begin nutritional replacement. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

Begin parenteral nutrition if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

Which clinical manifestations would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt? SATA Cough Blurred vision Gaseous distention Headache and vomiting Decreased level of consciousness

Blurred vision Headache and vomiting Decreased level of consciousness Rationale: Blurred vision, headache and vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant.

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? SATA Bradycardia Weak pulse Irregular respirations Increasing systolic BP Decreasing systolic BP

Bradycardia Irregular respirations Increasing systolic BP Rationale: Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The systolic BP increases, not decreases.

For the patient admitted with a subdural hematoma following a motor vehicle accident, which vital sign change would the nurse interpret as a clinical manifestation of an increasing intracranial pressure (ICP)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

Bradycardia Rationale: Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. The triad consists of increasing systolic pressure (not hypotension) with a widening pulse pressure (not narrowing), bradycardia with a full and bounding pulse, and irregular respirations (not tachypnea).

Which clinical manifestations are characteristics of Cushing's triad? Select all that apply. Tachycardia Bradycardia Systolic hypotension Systolic hypertension Widening pulse pressure Narrowing pulse pressure

Bradycardia Systolic hypertension Widening pulse pressure Rationale: Cushing's triad is a neurologic emergency characterized by a widening pulse pressure, bradycardia, and systolic hypertension. The heart rate slows, so Cushing's triad does not include tachycardia. Systolic BP increases, so hypotension is not present. Pulse pressure widens, not narrows, with Cushing's triad.

Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled? Prepare the patient and assist with the lumbar puncture. Reschedule the lumbar puncture for the next business day. Administer IV fluids before the lumbar puncture. Cancel the lumbar puncture and contact the prescribing provider.

Cancel the lumbar puncture and contact the prescribing provider.

After sustaining a head injury, for which clinical manifestation would the nurse monitor potential development in a patient scheduled for a lumbar puncture? Cerebral edema Myelosuppression Total body collapse Cerebral herniation

Cerebral herniation Rationale: 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.

Which type of hematoma would the nurse suspect when an older adult patient fell and hit their head on the coffee table two weeks ago? Epidural hematoma Intracerebral hematoma Acute subdural hematoma Chronic subdural hematoma

Chronic subdural hematoma Rationale: In older adults, due to the presence of a potentially larger subdural space caused by brain atrophy, chronic subdural hematomas are the most commonly seen hematoma.

Which type of herniation would the nurse associate with imaging studies indicating the presence of lateral displacement of the patient's brain tissue beneath the falx cerebri? Uncal herniation Central herniation Tentorial herniation Cingulate herniation

Cingulate herniation

What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces? Linear Depressed Compound Comminuted

Comminuted Rationale: A comminuted skull fracture has multiple linear fractures with fragmentation of bone into many pieces. A depressed fracture is an inward dentation of the skull. A linear fracture is a break in continuity of the bone, and a compound skull fracture involves a depressed skull fracture and scalp lacerations.

Which type of skull fracture would the nurse associate with an x-ray report indicating multiple linear fractures and the presence of a fragmented bone? Linear type Depressed type Compound type Comminuted type

Comminuted type

When the unlicensed assistive personnel (UAP) reports the vital signs (VS) of a patient with a suspected brain injury as temperature = 101.6° F (38.7° C) orally, heart rate = 58 beats/minute, respiratory rate = 14 breaths/minute, and BP = 162/48 mm Hg, which action would the nurse implement first? Ask the UAP to repeat the BP. Validate the VS by repeating the measurements. Compare the current VS to recorded baseline VS. Administer prescribed acetaminophen (Tylenol) for fever.

Compare the current VS to recorded baseline VS. Rationale: Increasing pressure on the thalamus, hypothalamus, pons, and medulla changes a patient's VS. Manifestations, such as Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations), are often late signs of markedly increased intracranial pressure (ICP).

Which interventions would the nurse implement for the patient with bacterial meningitis who develops seizures? Select all that apply. Convey an attitude of caring. Administer antiseizure medications. Forbid the patient from seeing visitors. Use a commanding voice to give explanations. Keep a familiar person at the patient's bedside.

Convey an attitude of caring. Administer antiseizure medications. Keep a familiar person at the patient's bedside. Rationale: Administration of antiseizure medications decreases the frequency of seizures. Convey an attitude of caring when a patient is having mental distortion. Keep a familiar person at the bedside of a patient to help the patient to calm down. Utilize a soothing voice to convey unhurried gentleness toward the patient with mental distortion.

For which procedure would the nurse prepare the patient who has loose bone fragments from a skull fracture? Cranioplasty Craniotomy Craniectomy Conservative treatment

Craniotomy Rationale: A skull fracture with loose fragments of bone requires a craniotomy to elevate the depressed bone and remove the bone fragments. A cranioplasty is a surgical repair of the bone. The health care provider (HCP) performs a craniectomy when destruction of large amounts of the bone occurs. In this procedure, removal of the bone occurs. Less significant fractures require conservative treatment.

Which interventions would the nurse implement to comfort the patient with a brain tumor who is experiencing disorientation and confusion due to perceptual problems? SATA Create a routine. Use reality orientation. Provide increased stimuli. Make the patient drive a vehicle. Minimize environmental stimuli.

Create a routine. Use reality orientation. Minimize environmental stimuli.

Which clinical manifestations would the nurse anticipate identifying in a patient suspected of having a disruption of motor fibers in the midbrain after sustaining a head injury? Projectile vomiting Tentorial herniation Decorticate posturing Decerebrate posturing

Decerebrate posturing Rationale: Decerebrate posturing is an expected clinical finding resulting from the disruption of motor fibers in the midbrain. Projectile vomiting is related to increased intracranial pressure (ICP). Tentorial herniation is a complication of increased ICP. Decorticate posturing is a result of the interruption of voluntary motor tracts in the cerebral cortex.

Which response would the nurse document when a patient with a brain injury experiences the motor function changes depicted in the image? Decorticate posturing Decerebrate posturing Sinusoidal posturing Opisthotonic posturing

Decorticate posturing

Which type of waveform would the nurse document for a patient receiving intracranial pressure (ICP) monitoring and the waveform represents venous pulsations? Tidal wave Dicrotic wave Rebound wave Percussion wave

Dicrotic wave Rationale: 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.

To obtain an accurate brain tumor diagnosis, for which prescribed diagnostic procedures would the nurse anticipate preparing the patient? SATA Lumbar puncture Electron microscopy Immunohistochemical stains CT scan Computer-guided stereotactic biopsy

Electron microscopy Immunohistochemical stains Computer-guided stereotactic biopsy

Which intervention would the nurse implement when a patient has cerebrospinal fluid (CSF) rhinorrhea? Elevate the head of the patient's bed to 30 degrees. Have the patient blow the nose on a sterile 4x4 gauze. Pack the nasal cavity with 4x4 gauze to stop the flow of CSF. Insert a nasogastric tube with low, intermittent wall suction

Elevate the head of the patient's bed to 30 degrees.

Which intervention would the nurse implement when a patient has cerebrospinal fluid (CSF) rhinorrhea? Elevate the head of the patient's bed to 30 degrees. Have the patient blow the nose on a sterile 4x4 gauze. Pack the nasal cavity with 4x4 gauze to stop the flow of CSF. Insert a nasogastric tube with low, intermittent wall suction.

Elevate the head of the patient's bed to 30 degrees.

Which interventions would the nurse implement for a patient who is unable to eat, secondary to a brain tumor? Select all that apply. Encourage the patient to eat. Ensure adequate nutritional intake. Assess the patient's nutritional status. Advise the patient to reduce water intake. Advise the patient to consume a low-calorie diet.

Encourage the patient to eat. Ensure adequate nutritional intake. Assess the patient's nutritional status.

After sustaining head trauma from skiing, the patient briefly lost consciousness, then was awake and alert. Which head trauma complication would the nurse associate with this patient when bleeding between the dura and the inner surface of the skull develops? Contusion Epidural hematoma Subdural hematoma Intracerebral hematoma

Epidural hematoma Rationale: An epidural hematoma is bleeding between the dura and the inner surface of the skull. The patient may lose consciousness followed by a period of being awake and alert. A subdural hematoma is bleeding between the dura and the arachnoid layer of the meninges. An intracerebral hematoma is bleeding into the brain tissue. A contusion is bruising of the brain tissue within a focal area.

Which intervention would the nurse implement when a patient, admitted with head trauma, has 300 mL/hr of urine output for the each of the last four hours, dry skin, and dry mucous membranes? Evaluate the urine's specific gravity. Prepare the patient for acute hemodialysis. Continue to monitor urine output over the next hour. Slow the IV rate and notify the health care provider

Evaluate the urine's specific gravity. Rationale: The patient is experiencing manifestations of diabetes insipidus related to a decrease in the pituitary gland production of antidiuretic hormone (ADH) secondary to the head injury. Without an adequate amount of ADH, the kidneys are unable to conserve water, and therefore large fluid losses occur.

Which factors would the nurse evaluate before administering temozolomide (Temodar) as treatment for a patient's brain tumor? Select all that apply. The medication temozolomide causes photosensitivity in cancer patients. Evidence indicates that temozolomide is able to cross over the blood-brain barrier. Myelosuppression occurs and requires an absolute neutrophil count before giving. Other medication usually taken by brain tumor patients interact with temozolomide. Temozolomide directly interferes with tumor growth by converting to a reactive agent.

Evidence indicates that temozolomide is able to cross over the blood-brain barrier. Myelosuppression occurs and requires an absolute neutrophil count before giving. Temozolomide directly interferes with tumor growth by converting to a reactive agent. Rationale: Temozolomide can cross the blood-brain barrier. The drug is also known to cause myelosuppression; therefore, check absolute neutrophil counts and platelet counts before starting the therapy.

Which assessments would the nurse perform when utilizing the Glasgow Coma Scale (GCS) to assess a patient admitted with a head injury and requiring regular neurologic and vital sign assessments? Select all that apply. Judgment Eye opening Abstract reasoning Best verbal response Best motor response Cranial nerve function

Eye opening Best verbal response Best motor response

Which clinical manifestations would the nurse expect to identify when assessing a patient with a brain abscess within the occipital lobe? SATA Visual field defects Headache and fever Nausea and vomiting Psychomotor seizures Visual impairment and hallucinations

Headache and fever Nausea and vomiting Visual impairment and hallucinations Rationale: An occipital abscess commonly presents with the clinical manifestations of headache and fever, as well as nausea and vomiting. Visual impairment and hallucinations may accompany an occipital abscess. Abscesses of the temporal lobe present with visual field defects and psychomotor seizures.

Which common causes would the nurse consider when assessing the patient reporting a headache that is worse in the morning and aggravated with movement, results in vomiting without preceding nausea, and is suspected of having an increased intracranial pressure? SATA Sinusitis Glaucoma Hematoma Head injury Brain tumor

Hematoma Head injury Brain tumor Rationale: 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.

After performing a patient's assessment, which condition supports the nurse's intervention to decline IV administration of mannitol (Osmitrol) to the patient? Cerebral edema Cerebral tissue swelling Increased serum osmolality Increased intracranial pressure (ICP)

Increased serum osmolality Rationale: Mannitol increases the osmotic effect and may cause neurologic complications; contraindications include administering to a patient with an increased serum osmolality. Use mannitol to treat cerebral edema, cerebral tissue swelling, and increased ICP because of its diuretic effect.

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? Select all that apply. Keep suction equipment readily available at the patient's bedside. Provide sufficient stimulation of the patient to avoid comatose behaviors. Implement seizure treatment only after confirming the seizure diagnosis. Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first seven days after injury.

Keep suction equipment readily available at the patient's bedside. Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first seven days after injury.

When assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first? Dim vision Papilledema Body temperature Level of consciousness

Level of consciousness

During the patient's initial assessment upon awakening after being comatose for seven hours, which clinical manifestations would the nurse anticipate identifying? SATA Decreased apathy Loss of concentration Loss of social restraint Increase in personal drive Euphoria and mood swings

Loss of concentration Loss of social restraint Euphoria and mood swings

When providing care for a patient who sustained a traumatic brain injury, which condition indicates the need to maintain closure of the patient's eyes as a nursing intervention? Diplopia Otorrhea Periorbital ecchymosis Loss of the corneal reflex

Loss of the corneal reflex Rationale: Loss of the corneal reflex may cause corneal abrasions. Taping of the eyes is necessary to protect them. Use an eye patch in patients with diplopia. Use a loose collection pad over the ears for patients with otorrhea. Use cold and warm compresses for patients with periorbital ecchymosis.

Which interventions would the nurse implement to promote optimal outcomes for the patient with an increased intracranial pressure (ICP)? SATA Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Lower the head of the bed and turn the patient to one side. Wait for the respirations to improve before beginning with ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position.

Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position.

After 72 hours of intravenous (IV) fluid therapy for a patient who suffered a diffuse axonal traumatic brain injury (TBI), which rationale supports the nurse seeking an enteral feeding prescription? Administration of free water is avoided in the setting of TBI. Electrolytes and fluids can be managed more efficiently. Enteral feedings assist with avoiding dehydration. Malnutrition promotes continued cerebral edema.

Malnutrition promotes continued cerebral edema.

Which intervention would the nurse implement when providing care for a patient experiencing an increased intracranial pressure (ICP)? Monitor fluid and electrolyte disturbances carefully. Position the patient in a high Fowler's position. Administer vasoconstrictors to maintain cerebral perfusion. Maintain physical restraints to prevent episodes of agitation.

Monitor fluid and electrolyte disturbances carefully.

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? Select all that apply. Monitor fluid intake and sodium levels regularly. Monitor patient's sleep and diet routine regularly. Perform blood glucose monitoring at least every six hours. Avoid taking any antacids along with corticosteroid treatment. Initiate concurrent treatment with antacids or proton pump inhibitors.

Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Initiate concurrent treatment with antacids or proton pump inhibitors.

While monitoring a patient's intracranial pressure (ICP) via an intracranial device in the neurologic intensive care unit, which aspect of care requires collaborative actions by the nurse? Using aseptic technique for intracranial device care Monitoring the intracranial device for greater than five days Assessing the intracranial device insertion site routinely Monitoring the cerebrospinal fluid (CSF) for a change in color

Monitoring the intracranial device for greater than five days

When a patient's clinical manifestations include visual disturbances and seizures, which area of the brain would the nurse identify as the most likely location of the diagnosed brain tumor? Subcortical Parietal lobe Occipital lobe Temporal lobe

Occipital lobe Rationale: 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), dystopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures and dysphagia.

When developing the plan of care for a patient with an elevated intracranial pressure (ICP), which factors guide the nursing interventions? Select all that apply. Pain and agitation may elevate the patient's ICPs. Elevating the head of the patient's bed increases ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return. Slow and gentle movements exhausts the patient's energy reserve.

Pain and agitation may elevate the patient's ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return.

When developing the plan of care for a patient with an elevated intracranial pressure (ICP), which factors guide the nursing interventions? Select all that apply. Pain and agitation may elevate the patient's ICPs. Elevating the head of the patient's bed increases ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return. Slow and gentle movements exhausts the patient's energy reserve

Pain and agitation may elevate the patient's ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return.

The nurse suspects that a patient with bacterial meningitis is experiencing cranial nerve II irritation based on which assessment finding? Facial paresis Papilledema and blindness Ptosis, unequal pupils, and diplopia Sensory loss and loss of corneal reflex

Papilledema and blindness Rationale: Irritation of cranial nerve II can cause papilledema and blindness. Facial paresis would result from irritation of cranial nerve VII. Ptosis, unequal pupils, and diplopia can indicate involvement of cranial nerves III, IV, and VI. Sensory loss and loss of corneal reflex can occur with irritation of cranial nerve V.

When experiencing speech disturbances and an inability to write, which part of the patient's cerebral hemisphere would the nurse associate with the patient's brain tumor? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Parietal lobe Rationale: 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.

Which factors would the nurse consider when evaluating surgical therapy as treatment for the patient with a brain tumor? SATA Complete removal of all types, sizes, and location of tumors can occur. Partial removal of the ore invasive gliomas and medulloblastomas occurs. Complete removal of more invasive gliomas and medulloblastomas occurs. Complete removal of meningiomas and oligodendrogliomas can occur. The outcome of surgical therapy depends on the type, size, and location of tumor.

Partial removal of the ore invasive gliomas and medulloblastomas occurs. Complete removal of meningiomas and oligodendrogliomas can occur. The outcome of surgical therapy depends on the type, size, and location of tumor.

Which clinical manifestations would the nurse anticipate identifying in a patient who is comatose? SATA. Patient can cough and swallow. Patient has bowel and bladder control. Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent.

Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent.

When hydrocephalus develops, for which surgical procedure would the nurse begin preparing the patient? Drainage of abscess Excision of malformation Placement of a ventriculoatrial shunt Debridement of fragments and necrotic tissue

Placement of a ventriculoatrial shunt Rationale: Hydrocephalus occurs due to overproduction of cerebrospinal fluid, which can be treated by placing a ventriculoatrial shunt, allowing excess cerebrospinal fluid to drain.

Which potential factors would the nurse associate with explaining a patient's pupils becoming fixed and unresponsive to light stimulus? SATA Previous eye surgery Administration of diuretics Increased intraocular pressure Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)

Previous eye surgery Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III) Rationale: A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eyedrops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.

Which type of brain injury would the nurse associate with the patient who sustained a subdural hematoma from a motor vehicle crash? Anoxia Primary Cerebral Secondary

Primary Rationale: Primary injuries are those that occur at the time of the injury (e.g., blunt force trauma, car accident); the subdural hematoma is itself an example of this. Secondary injuries are those injuries resulting from the primary injury; for instance, increased intracranial pressure may result from the hematoma. A cerebral injury is damage to the cerebrum, and an anoxia injury results from a lack of oxygen to the brain.

For the patient diagnosed with a brain abscess, which events would the nurse associate with the development of the abscess? SATA Acne or skin abscess Prior brain trauma or surgery Prior leg fracture or ligament tears Distant spread from a pulmonary infection Direct extension from an ear or sinus infection

Prior brain trauma or surgery Distant spread from a pulmonary infection Direct extension from an ear or sinus infection

Which primary goals would the nurse identify when planning the care of a patient with a brain tumor? SATA Making the patient walk Removing the tumor mass Managing the patient's family Identifying the tumor type and location Managing increased intracranial pressure (ICP)

Removing the tumor mass Identifying the tumor type and location Managing increased intracranial pressure (ICP) Rationale: 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 would instruct the patient recovering from a head injury and his or her caregiver to report the development of which symptoms immediately to the health care provider? SATA Sneezing Seizures Stiff neck Constipation Increased drowsiness

Seizures Stiff neck Increased drowsiness

When preparing to administer a hypertonic saline infusion to a patient with an increased intracranial pressure (ICP), which parameters would the nurse monitor frequently? SATA Blood glucose Serum sodium BP Level of sedation Gastrointestinal disturbances

Serum sodium BP Rationale: Use hypertonic saline solutions to treat increased ICP. Hypertonic saline infusions increase the intravascular fluid volume, which may alter the serum sodium levels and BP in the body. If administering corticosteroids to a patient, monitoring includes blood glucose levels. Monitor sedation levels if administering barbiturates to the patient. Monitor gastrointestinal disturbances if administering corticosteroids to the patient.

When preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF), which surgical consent would the nurse obtain from the patient or immediate family member? Burr hole Craniotomy Shunt placement Stereotactic procedure

Shunt placement Rationale: Shunt procedures use a tube or implanted device to provide an alternate pathway to redirect CSF when its absorption is impaired. A burr hole removes localized fluid and blood beneath the dura. Craniotomy removes a lesion or repairs a damaged area. Use of the stereotactic procedure is for biopsy, radiosurgery, or dissection.

Which rationale supports the nurse contacting the prescribing health care provider regarding an order of benzodiazepine for a patient with an increased intracranial pressure (ICP)? The medication may cause sedation. The patient's pain scores may increase. Anxiety levels increase as a side effect. Side effects include a hypotensive effect

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

Which pupil comparisons would the nurse perform when completing a neurologic assessment of the eyes? Select all that apply. Size Shape Reactivity Movement Visual acuity Corneal reflex

Size Shape Reactivity Movement Rationale: When performing a neurologic assessment, compare the pupils for reactivity, size, shape, and movement. Eliciting a corneal reflex provides information about cranial nerves V and VII, not neurologic functioning. A visual acuity assessment determines the smallest letters viewed by the patient, but this does not provide information about neurologic functioning.

To achieve the best outcome when providing care for a patient with an increased intracranial pressure (ICP) secondary to a mass lesion in the brain, which treatment information would the nurse provide the patient? Surgery Cimetidine Craniectomy Corticosteroids

Surgery

For which treatment modality would the nurse prepare a patient whose MRI revealed the presence of a brain tumor? Surgery Chemotherapy Radiation therapy Biologic drug therapy

Surgery Rationale: Surgical removal is the preferred treatment for brain tumors. The blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance limit the treatment of chemotherapy and biologic drug therapy. Radiation therapy may be used as a follow-up measure after surgery.

Which factors would the nurse consider when assessing the surgical outcome of a patient with a brain tumor? Select all that apply. Surgery provides a complete cure. Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time. Surgery can increase intracranial pressure (ICP).

Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time.

Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? SATA Raise the head of bed above 30 degrees Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Rotate the patient to a side-lying position to prevent skin breakdown. Follow protocol standards to maintain a head-up position for the patient.

Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Follow protocol standards to maintain a head-up position for the patient.

Which type of brain tumor would the nurse associate with a patient's clinical manifestations of uncontrolled urination, excessive thirst, high serum sodium levels, and involuntary eye movements? Subcortical tumors Cerebellopontine tumors Thalamus and sellar tumors Fourth ventricle and cerebellar tumors

Thalamus and sellar tumors Rationale: 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.

Of the four assigned patients on the acute care unit, which patient has the highest risk for developing bacterial meningitis? The patient with a skull fracture The patient with prior brain trauma The patient with a pulmonary infection The patient with bacterial endocarditis

The patient with a pulmonary infection Rationale: The other patients are at risk for developing brain abscess.

When teaching the patient, family, and caregiver about long-term care of the patient who had a craniotomy, which instruction would the nurse include? Seizure disorders may occur within weeks or months. The family will be unable to cope with role reversals. There are often residual changes in personality and cognition. We initiate a referral to eliminate residual deficits from the damage.

There are often residual changes in personality and cognition.

Which response occurs in the brain when a patient's systemic arterial pressure begin to deviate from the normal range? The intracranial pressure decrease The intracranial pressure increase There is an increase in brain compliance

There is an increase in brain compliance Rationale: autoregulation is a normal response occurring in the brain when systemic arterial pressure alter.

When preparing to administer temozolomide (Temodar) to a patient with a brain tumor, which rationale supports the nurse's need to assess the patient's absolute neutrophil count to verify a count >1500/μL? To reduce nausea and vomiting To prevent metabolic inactivation To prevent immune-related complications To prevent drug interactions with corticosteroids

To prevent immune-related complications Rationale: 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. Administer temozolomide to patients with an empty stomach to prevent nausea and vomiting. The medication does not require activation because it is a metabolically active drug. This drug does not react with corticosteroids.

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intracranial pressures (ICP) caused by a brain tumor? Administer IV mannitol (Osmitrol). Maintain hyperoxygenation through use of a ventilator. Use strict aseptic technique with all procedural dressing changes. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

Use strict aseptic technique with all procedural dressing changes.

For the patient admitted for surgical removal of a brain tumor, for which potential complications would the nurse integrate assessment interventions into a patient's plan of care? SATA Vision loss Cerebral edema Pituitary dysfunction Parathyroid dysfunction Focal neurologic deficits Diabetes mellitus

Vision loss Cerebral edema Pituitary dysfunction Focal neurologic deficits Rationale: 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 and cerebral edema appear. The cerebral cortex or the pituitary gland do not regulate the parathyroid gland. Trauma to the brain, or tumors of the thalamus and sellar tumors, may cause development of diabetes insipidus, not diabetes mellitus.

For the patient with bacterial meningitis who has a severe headache, which clinical manifestations would the nurse monitor to identify potential complications? SATA Skin rash Vomiting Irritability Photophobia Neck stiffness

Vomiting Irritability Rationale: Monitor the patient for vomiting and irritability because he or she might be accompanied with a severe headache. Vomiting may cause discomfort to the patient, and irritability of cranial nerves leads to serious neurologic symptoms. Skin rashes, photophobia, and neck stiffness are associated with bacterial meningitis and are not complications.

When performing an initial baseline assessment and subsequent assessments, which actions would the nurse implement specific to the patient's neurologic status? SATA Perform temperature and pulse rate assessments. When performing daily activities, assess the patient. Assess patient's integrated function and balance. Determine the patient's weight, height, and waist-to-hip ratio. Monitor level of consciousness and motor abilities.

When performing daily activities, assess the patient. Assess patient's integrated function and balance. Monitor level of consciousness and motor abilities.

Which response would the nurse use to reply to the family of a patient admitted 12 hours ago with suspected meningitis who states, "We do not understand. We thought the spinal tap 'looked good,' according to the health care provider. Why is everyone still wearing gowns and masks?" - "I apologize. The isolation should have been discontinued." - "These precautions need to be continued as long as the patient is in the hospital." - "I will check with the health care provider and see whether we can get the isolation discontinued." - "The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."

"The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available." Rationale: Patients suspected of having meningitis should be placed in respiratory isolation until the spinal fluid cultures are negative or effective antibiotic therapy has been in place for 24 to 48 hours. The earliest release of culture reports is 24 hours. Standard precautions are still essential when removing the patient from isolation. There is no need to contact the health care provider because infection control policies dictate the necessity of isolation. Even if the patient has a diagnosis of meningitis, discontinuing respiratory isolation occurs once effective antibiotic therapy has been in place for a specified period.

To determine the amount of cerebral spinal fluid to drain from a patient's ventricle catheter, the nurse calculates the cerebral perfusion pressure (CPP) of an unconscious patient whose BP is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. Identify the patient's CPP. Record your answer using a whole number

58 mm Hg Rationale: The nurse calculates the CPP by subtracting the ICP from the mean arterial pressure (MAP). The MAP is [162 + 2(58)]/3 = 92.66. The nurse subtracts 35 from 93 to determine that the patient's CPP is 58 mm Hg.

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition? Encephalitis Brain abscess Viral meningitis Bacterial meningitis

Brain abscess Rationale: The absence of glucose in cerebrospinal fluid indicates a brain abscess. The glucose would be normal in encephalitis, would be normal or low (>40 mg/dL) in viral meningitis, and would be decreased (5 to 40 mg/dL) in bacterial meningitis.

The nurse is caring for a patient who is diagnosed with bacterial meningitis. What are the priority actions by the nurse? Select all that apply. - Administer a corticosteroid along with the first dose of IV antibiotics. - Wait and watch until the fever lowers or additional symptoms begin to appear. - Collect specimens for a culture to confirm the diagnosis of bacterial meningitis. - Wait for a confirmed diagnosis of bacterial meningitis before starting antibiotics. - Initiate antibiotic therapy after obtaining specimen but prior to confirming diagnosis

Administer a corticosteroid along with the first dose of IV antibiotics. Collect specimens for a culture to confirm the diagnosis of bacterial meningitis. Initiate antibiotic therapy after obtaining specimen but prior to confirming diagnosis Rationale: Collecting specimens to confirm the diagnosis and administering corticosteroids and antibiotics are the measures that must be taken immediately because bacterial meningitis is a medical emergency. Waiting and watching until the fever reduces and the addition symptoms of meningitis appear and waiting for a confirmed diagnosis before starting antibiotics are not advisable because they may aggravate the condition and become life-threatening.

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)? Steady vital signs Reports of a headache Increased motor function An altered level of consciousness (LOC)

An altered level of consciousness (LOC) Rationale: Changes in the LOC are a result of impaired cerebral blood flow, which causes oxygen deprivation to the cerebral cortex and reticular activating system, so this is the most sensitive and reliable manifestation of ICP. A decrease (not an increase) in motor function occurs as the ICP increases. A headache could indicate compression but is potentially attributed to other causes. An increased ICP can cause changes in vital signs; however, they will not necessarily remain steady.

Which objective data would the nurse record when assessing a patient with a head injury? SATA Headache Battle's sign Projectile vomiting Past health history Mechanism of injury Cranial nerve deficits

Battle's sign Projectile vomiting Cranial nerve deficits Rationale: Battle's sign, projectile vomiting, and cranial nerve deficits are objective data that the nurse will record when assessing a patient with a head injury. A headache is subjective data. While the mechanism of injury may be helpful information, it is not part of the assessment itself. A patient's past health history is subjective data.

For the patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression? CN V CN IV CN III CN VIII

CN III Rationale: Compression of CN III, the oculomotor nerve, is a result of the brain shifting from midline, compressing the trunk of the CN III, and paralyzing the muscles controlling pupillary size and shape. CN IV is the trochlear nerve, which moves the eye inward, down, and laterally. CN V (trigeminal nerve) is responsible for sensation in the face and motor functions such as biting and chewing. CN VIII is the vestibulocochlear nerve, which is responsible for hearing and balance.

After treatment for meningitis, which disorder would the nurse associate with a patient's unresolved clinical manifestations of left upper and lower limb weakness, reduced vision, and slurred speech? Cerebral abscess Acute cerebral edema Neurologic dysfunction Increased intracranial pressure

Cerebral abscess Rationale: Weakness of the left upper limb and lower limb (hemiparesis), blurred speech (dysphasia), and reduced vision (hemianopsia) are symptoms that typically resolve after meningitis treatment. If these symptoms persist, suspect a cerebral abscess. After receiving treatment for meningitis, acute cerebral edema, neurologic dysfunction, and increased intracranial pressure do not persist and are symptoms of a cerebral abscess.

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? Stroke Epileptic seizure Decorticate posturing Decerebrate posturing

Decorticate posturing Rationale: Decorticate posturing—described as flexion of the arms, wrists, and fingers—and adduction of the upper extremities indicate damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior.

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis? Decrease in neutrophils Decrease in lymphocytes Decrease in glucose level Decrease in protein level

Decrease in glucose level Rationale: There is a decrease in glucose levels in the cerebrospinal fluid in a patient with bacterial meningitis. An increase in neutrophils, lymphocytes, and protein levels would be relative to bacterial meningitis.

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg? Normal intracranial pressure (ICP) Increased ICP Decreased cerebral blood flow (CBF) Increased cerebral perfusion pressure (CPP)

Decreased cerebral blood flow (CBF) Rationale: A MAP below 70 mm Hg results in a decreased CBF. It will not result in an increased or normal ICP. The cerebral perfusion pressure will be decreased. A MAP below 70 mm Hg does not necessarily guarantee a normal ICP.

While utilizing the Glasgow Coma Scale (GCS) to assess a patient's level of consciousness, which potential responses would the nurse document under best motor response? SATA Flexion withdrawal Localization of pain Obedience of command Disorganized use of words Opening the eyes in response to sound

Flexion withdrawal Localization of pain Obedience of command

For the febrile patient diagnosed with meningitis, which parameter would the nurse monitor to prevent development of potential complications? Fluid intake Urine output BP Respiratory rate

Fluid Intake Rationale: A patient with a fever may develop dehydration, so assess the patient's fluid intake. Elevated temperatures may alter a patient's urine output, BP, and respiratory rate, but monitoring these parameters would not help to prevent any complications in a patient with meningitis.

When a nurse is reviewing the plan of care for a patient with meningitis with a newly employed registered nurse, which treatment outcomes would the plan include? Pain controlled prior to discharge Hearing restored prior to discharge Facial movements restored prior to discharge Neck stiffness resolved prior to discharge

Hearing restored prior to discharge Rationale: Hearing loss caused by irritation of cranial nerve VIII (vestibulocochlear nerve) may be permanent after the treatment; thus, the outcome is not realistic. Control of pain after the treatment, restored facial movement after facial paresis, and neck stiffness caused by cranial nerve irritation and neurologic dysfunction are possible.

Which inflammatory condition would the nurse associate to the common cause of acute nonepidemic encephalitis? St. Louis encephalitis Eastern equine encephalitis Western equine encephalitis Herpes simplex virus encephalitis

Herpes simplex virus encephalitis Rationale: Herpes simplex virus encephalitis is the most common cause of acute nonepidemic viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western equine cause epidemic encephalitis.

When managing a patient with a brain injury, of which potential secondary intracranial injuries would the nurse monitor development? Select all that apply. Hypoxia Ischemia Hypotension Blunt force trauma Impact of the car accident Increased intracranial pressure

Hypoxia Ischemia Hypotension Increased intracranial pressure Rationale: Ischemia, increased intracranial pressure, hypoxia, and hypotension are components of a secondary intracranial injury. The impact of a car accident and blunt force trauma are primary components.

Which interventions would the nurse implement to promote positive outcomes for the patient experiencing increased intracranial pressures (ICPs) in the neurologic intensive care unit? Select all that apply. Monitor ICP. Perform a cerebral angiography. Elevate the head of the bed to 30 degrees. Maintain PaO 2 of 90 mm Hg or greater. Obtain a patient history and physical examination. Maintain systolic arterial pressure of 100 to 160 mm Hg.

Monitor ICP. Elevate the head of the bed to 30 degrees. Maintain systolic arterial pressure of 100 to 160 mm Hg. Rationale: Elevating the head of the bed 30 degrees, ICP monitoring, and maintaining a systolic arterial pressure of 100 to 60 mm Hg are components of the expected management for a patient with increased ICP. Cerebral angiography, history, and a physical are diagnostic assessment tools rather than interventions. The PaO should be maintained at 100 mm Hg or greater.

Which factors would the nurse consider when preparing to administer the pharmacologic therapy for a patient with an increased intracranial pressure (ICP)? Select all that apply. Use benzodiazepines as a standalone treatment for sedation. Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous IV sedatives. Use nondepolarizing neuromuscular blocking agents alone for better outcomes. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous IV sedatives. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings? When flexing the neck, eye movement is in the upward direction. Movement of the eye is in the opposite direction of the turned head. When extending the neck, eye movement is in the downward direction. Movement of the eye in the sideward direction occurs, with neck extension.

Movement of the eye in the sideward direction occurs, with neck extension.

For which complication would the nurse monitor potential development while providing care for a patient with meningitis and ventricle adhesions that prevent the normal flow of cerebrospinal fluid? Cerebral abscess Acute cerebral edema Cranial nerve irritation Noncommunicating hydrocephalus

Noncommunicating hydrocephalus Rationale: Adhesions preventing the normal flow of cerebrospinal fluid lead to an obstruction of the foramen magnum, which causes noncommunicating hydrocephalus. Cerebral abscess is an accumulation of pus within the brain tissue. An acute cerebral edema is an abnormal increase in water content within the extracellular fluid of the brain. The condition occurs due to hydrocephalus. Cranial nerve irritation is caused by neurologic dysfunctions because of increased intracranial pressure.

Which intervention would the nurse implement to prevent cranial nerve (CN) III palsy in a patient with meningitis? Provide low lighting. Administer antibiotics. Elevate the head of the bed. Perform cooling techniques.

Perform cooling techniques. Rationale: Fever may increase cerebral edema, which may cause CN III palsy. Therefore, any fever should be treated vigorously by performing cooling techniques. Low lighting should be provided if the patient develops hallucinations and delirium. Administration of antibiotics is to treat the infection, not prevention of CN III palsy. Elevation of the head of the bed provides relief from head and neck pain.

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to Provide the most comfort? SATA Provide the patient a quiet and calm environment. Minimize procedures that potentially produce agitation. Facilitate an increased number of family visits to the patient. Encourage the patient's family to increase patient interactions. Observe the patient for signs of agitation or irritation and intervene.

Provide the most comfort? Provide the patient a quiet and calm environment. Observe the patient for signs of agitation or irritation and intervene.

Which interventions would the nurse implement when managing a fever for a patient with acute meningitis? Select all that apply. Reduce fever with the use of acetaminophen. Reduce body temperature rapidly to provide relief. Use a cooling blanket on the patient to reduce fever. Encourage shivering in the patient to help to reduce fever. Lower temperature by using tepid-water sponge baths.

Reduce fever with the use of acetaminophen. Use a cooling blanket on the patient to reduce fever. Lower temperature by using tepid-water sponge baths. Rationale: Use of a cooling blanket to reduce fever, use of acetaminophen to reduce fever, and tepid-water sponge baths may be effective in lowering temperature. Prevent shivering because it may cause a rebound effect and increase the temperature. Rapidly reducing temperature may result in shivering and is not advisable.

Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis? Restrain the patient in bed. Increase the patient's fluid intake. Maintain the patient in a flat, supine position. Reduce the patient's environmental stimuli as much as possible.

Reduce the patient's environmental stimuli as much as possible. Rationale: When a patient has bacterial meningitis, the meninges are inflamed and easily irritated by sensory input. For this reason, keep environmental stimulation to a minimum to avoid causing seizures and neurologic discomforts. Patients with bacterial meningitis do not necessarily require restraints or an increase in fluid intake. The position of comfort for a patient with bacterial meningitis is supine with the head of bed elevated 30 to 45 degrees.

For the mechanically ventilated patient, which response would the nurse use when family members inquire as to the benefit of maintaining the propofol (Diprivan) drip? Propofol facilitates efficient fluid replacement. The treatment reduces the body's BP. The drug maintains electrolyte balance effectively. The medication has a short half-life and rapid onset of action

The medication has a short half-life and rapid onset of action.

Which factors would the nurse associate with the use of hypertonic saline as a treatment for the patient with an increased intracranial pressure (ICP)? Select all that apply. The nurse would closely monitor the patient's blood sugar levels. The nurse would frequently monitor the BP and sodium levels. Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. The nurse should ensure administration of an antacid prior to administration to prevent gastrointestinal complications.

The nurse would frequently monitor the BP and sodium levels. Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP.

Of the four assigned patients in the intensive care unit (ICU), which patient with an infection has the highest risk for developing cerebral edema? The patient diagnosed with encephalitis The patient experiencing cerebral thrombosis The patient who sustained a contusion from a fall The patient with hydrocephalus from a malfunctioning shunt

The patient diagnosed with encephalitis Rationale: Encephalitis is a cerebral viral infection that can cause cerebral edema. Hydrocephalus is the buildup of cerebrospinal fluid (CSF) in the brain. A contusion is bruising. A thrombosis is a blood clot in the circulatory system.

Which treatment outcome would the nurse expect when administering antibiotic therapy and symptomatic treatment of a patient with bacterial meningitis? The patient will experience muscle aches. The patient will return to maximal neurologic function. The patient will have a chance of recurrence of infection. The patient will experience some discomfort while performing daily activities.

The patient will return to maximal neurologic function. Rationale: The expected treatment outcome for the patient is to return to his or her maximal neurologic function after receiving treatment for meningitis. Relief of muscle aches after the treatment is an expected outcome. Recurrence of the infection after the treatment is not an expectation. The patient should not experience any discomfort while performing daily activities.

When would the nurse schedule and prepare the patient with meningitis for a prescribed lumbar puncture procedure? SATA After the blood culture test Before starting the antibiotic therapy After the CT scan Before the MRI scan Before the culture test of nasopharyngeal secretions Immediately after the triage admission to the emergency department

After the blood culture test Before starting the antibiotic therapy After the CT scan Before the MRI scan Rationale: Schedule the diagnostic lumbar puncture procedure after obtaining blood cultures because it may help to assess infection. Administer the antibiotic therapy after the lumbar puncture, while awaiting the results of cerebrospinal fluid analysis. CT and MRI scans reveal increased intracranial pressure (ICP) and cerebral edema. If there is ICP, do not perform a lumbar puncture. Thus, do not schedule or assist with a lumbar puncture before obtaining the results of these CT or MRI scans. Do not perform a lumbar puncture before any culture tests of nasopharyngeal secretions. The potential for increased ICP must be ruled out prior to performing a lumbar puncture; do not perform immediately after the triage admission to the unit.

Which medication is an osmotic diuretic that the nurse would prepare to administer when needing to lower a patient's intracranial pressure (ICP)? Mannitol Cimetidine Dexamethasone Hypertonic saline

Mannitol Rationale: Mannitol is an osmotic diuretic given via IV to decrease ICP. Hypertonic saline is an IV solution used to help to reduce cerebral swelling. Dexamethasone is a corticosteroid used to treat vasogenic edema. Cimetidine is a histamine (H ) receptor blocker given to a patient receiving corticosteroids to prevent gastrointestinal ulcers and bleeding.

The initial assessment of a patient in the postanesthesia care unit recovering from a brain tumor resection included a temperature of 100°F (37.7°C), BP of 130/76 mm Hg, pulse 64 beats/min, a urinary catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One hour later, which assessment finding would the nurse immediately report to the surgeon? Presence of a gag reflex Urine output of 50 mL during the past hour BP of 148/58 mm Hg and pulse 48 beats/min Temperature of 99.8°F (37.6°C) and pulse of 96 beats/min

BP of 148/58 mm Hg and pulse 48 beats/min Rationale: Associate a BP with a widening pulse pressure, bradycardia, and irregular respirations with an increasing intracranial pressure (ICP) known as the Cushing's triad, which should be reported immediately. Presence of a gag reflex, urine output of 50 mL over an hour, and temperature of 99.8°F (37.6°C) and pulse of 96 beats/min are acceptable assessment findings in a postoperative patient.

Which interventions would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? SATA Consider administering light sedation agents. Observe the skin area under the restraints. Use a stimulating environment in the room. Keep family members away from the patient. Use effective restraints in an agitated patient

Consider administering light sedation agents. Observe the skin area under the restraints. Use effective restraints in an agitated patient

For the patient recovering from cranial surgery involving a bone flap, which interventions would the nurse implement to prevent an increased intracranial pressure (ICP)? SATA Assess the patient's weight loss after surgery. Frequently assess the patient's neurologic status. Monitor the patient's serum creatinine and lipid profile. Do not position the patient's surgical site in a dependent position. Closely monitor fluid and electrolyte levels and serum osmolality.

Frequently assess the patient's neurologic status. Do not position the patient's surgical site in a dependent position. Closely monitor fluid and electrolyte levels and serum osmolality.

For which potential disorder would the nurse monitor the urine output of a patient with an increased intracranial pressure and diabetes insipidus? Hypernatremia Decreased urine output Dilutional hyponatremia Elevated blood glucose level

Hypernatremia Rationale Hypernatremia is a symptom of diabetes insipidus, so the nurse must monitor this patient's urine output carefully. Elevated blood glucose levels are not measured via urine output but rather with blood tests. Urine output is increased, not decreased, in the setting of diabetes insipidus because of the decreased antidiuretic hormone. Dilutional hyponatremia is not a symptom of diabetes insipidus; rather, hypernatremia is.

When developing the plan of care for a patient diagnosed with meningitis, which interventions would the nurse include? Select all that apply. Monitor temperature. Check for muscle pains. Check for retinal damage. Assess intraocular pressure. Assess the eye for sensitivity to light.

Monitor temperature. Check for muscle pains. Assess the eye for sensitivity to light. Rationale: The clinical manifestations associated with meningitis include fever, muscle pains, and photophobia. Thus, temperature, muscle pains, and sensitivity to light should be monitored in a patient with meningitis. Retinal damage and intraocular pressure are not associated with meningitis.

Which dietary discharge instructions would the nurse provide a patient recovering from meningitis? Select all that apply. Include chicken and lean meat in your diet. Avoid eating peanuts, peanut butter, or peanut oils. Include whole grains, potatoes, and cereals in the diet. Divide your three main meals into small, frequent feedings. Consume moderate quantities of alcohol and caffeinated beverages.

Include chicken and lean meat in your diet. Include whole grains, potatoes, and cereals in the diet. Divide your three main meals into small, frequent feedings. Rationale: As a part of home care, the nurse should provide instructions regarding the importance of adequate nutrition, with an emphasis on a high-protein and high-calorie diet. Whole grains, potatoes, and cereals are packed with calories and should be included in the diet. Chicken and lean meats are good sources of protein and should be an important component of the meal. The meals should be small and given more often at frequent intervals. Peanuts and peanut butter should also be included in the diet because they are good sources of protein and are calorie-dense. Alcohol and caffeinated beverages should be excluded from the diet.

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14? Increased systolic BP, increased pulse, GCS score of 12 Decreased diastolic BP, decreased pulse, and GCS score of 13 Increased systolic and diastolic BP, increased pulse, GCS score of 9 Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4

Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4 Rationale: One classic sign of increasing intracranial pressure and neurologic deterioration is an increased systolic BP and decreased diastolic BP (resulting in a widening pulse pressure) accompanied by bradycardia. Cushing's triad includes hypertension (elevated systolic pressure and widening pulse pressure), bradycardia, and bradypnea. Increased systolic BP, increased pulse, and GCS of 12 and decreased diastolic BP, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic BP, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the BP and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score, reflecting a fully awake, alert, and oriented patient. Any patient scoring less than 8 on the GCS is comatose.

Which intervention would the nurse implement as the highest priority after determining that a patient's Glasgow Coma Scale (GCS) score is 5? Notify the charge nurse. Continue to monitor the patient. Reassess the patient in an hour. Notify the rapid response team.

Notify the rapid response team. Rationale: The nurse must first notify the rapid response team. A GCS score of 5 or less generally indicates coma and the need to consider mechanical ventilation. The nurse needs to notify the charge nurse, but the rapid response team is the priority. Continuing to monitor and reassess the patient within the hour is delaying proper management of the patient.

Upon hearing a patient with an increased intracranial pressure (ICP) begin to snore, the nurse relates the sound to which potential finding upon assessment? Obstruction Oversedation Normal finding Decreasing ICP

Obstruction Rationale: Snoring sounds in a patient who has increased ICP is indicative of an obstruction, and this is an emergency. The ICP will not decrease with snoring, and snoring is not a normal finding with increased ICP. Snoring in a patient with increased ICP is not an indication of oversedation.

When the patient experiences visual impairment and hallucinations, in which lobe of the brain would a CT scan indicate the presence of an abscess? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Occipital lobe Rationale: An abscess in the occipital lobe may lead to visual impairment and hallucinations. Abscesses in the frontal and parietal lobe may result in a local or systemic infection. A temporal lobe abscess can cause psychomotor seizures.

Which rationale would the nurse use to explain to family members why older adult patients who fall have a high risk for developing a chronic subdural hematoma? - Older adult patients have larger subdural spaces. - Changes in vasculature occurs with older adult patients. - Older adult patients experience a decrease in sensing their pain. - There is a decreased level of consciousness in the older adult patient.

Older adult patients have larger subdural spaces. Rationale: Chronic subdural hematomas are more common in older adults because of the potentially larger subdural space because of brain atrophy. With aging, a reduction in sensing pain sensation may occur, but this is not the physiologic cause for the risk of a chronic subdural hematoma. Changes in vasculature occur in the elderly as well but do not put the patient at risk for a subdural hematoma from a fall. The older adult patient does not normally experience a decreased level of consciousness; this is an alteration in mental status and is a pathologic symptom unrelated to the risk for chronic subdural hematoma.

For the patient who developed hydrocephalus, which pathophysiologic event would the nurse associate with the diagnosis? Select all that apply. Overproduction of cerebrospinal fluid (CSF) Underproduction of CSF Defective reabsorption of CSF Obstruction of CSF flow in the brain Rupture of cerebral blood vessels added to CSF volume

Overproduction of cerebrospinal fluid (CSF) Defective reabsorption of CSF Obstruction of CSF flow in the brain Rationale: Hydrocephalus is the accumulation of CSF, which can be caused due to obstruction to flow of CSF and defective reabsorption and overproduction of CSF. Rupture of blood vessels causes intracranial bleeding. Underproduction of CSF is not a cause of hydrocephalus.

Which intracranial pressure waveform supports the nurse's assessment of a compromise occurring with the patient's intracranial compliance? P3 wave is lower than P1 wave P2 wave is higher than P1 wave P2 wave is higher than P3 wave P1, P2, and P3 resemble a staircase

P2 wave is higher than P1 wave Rationale: The P2 wave represents the intracranial compliance, and the P2 wave should be lower than the P1 wave. The presence of a higher P2 wave than the P1 wave indicates increased intracranial pressure and compromised intracranial compliance. During normal conditions, the P3 wave is the lowest wave; the P2 wave is higher than the P3 wave; and P1, P2, and P3 waves are in order and resemble a staircase.

For the patient with an increased intracranial pressure, who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcomes indicate an effective intervention? SATA PaO 2 of the patient is 80 mm Hg. PaO 2 of the patient is 90 mm Hg. PaO 2 of the patient is 110 mm Hg. PaCO 2 of the patient is 40 mm Hg. PaCO 2 of the patient is 30 mm Hg.

PaO 2 of the patient is 110 mm Hg. PaCO 2 of the patient is 40 mm Hg Rationale: The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO of the patient greater than or equal to 100 mm Hg with PaCO in the range of 35 to 45 mm Hg. Therefore the PaO value of 110 mm Hg and PaCO value of 40 mm Hg indicate effective treatment. A PaO of less than 100 and PaCO of less than 35 mm Hg indicate ineffective treatment

Which factors would the nurse consider when evaluating the lumbar puncture results of a patient with bacterial meningitis? Select all that apply. -Lumbar puncture may require injection of contrast dye. - Lumbar puncture helps to confirm a diagnosis of brain tumor. - Perform a lumbar puncture after ruling out an obstruction in the foramen magnum. - Lumbar puncture usually helps to confirm the diagnosis of bacterial meningitis. - Lumbar puncture obtains cerebrospinal fluid (CSF) for analysis in case of bacterial meningitis.

Perform a lumbar puncture after ruling out an obstruction in the foramen magnum. Lumbar puncture usually helps to confirm the diagnosis of bacterial meningitis. Lumbar puncture obtains cerebrospinal fluid (CSF) for analysis in case of bacterial meningitis. Rationale: Lumbar puncture obtains CSF for analysis in case of bacterial meningitis and is performed after ruling out an obstruction in the foramen magnum to prevent a fluid shift resulting in herniation. Lumbar puncture usually helps to verify the diagnosis of bacterial meningitis. Lumbar puncture does not involve injection of contrast medium or dye. The procedure does not help to confirm the diagnosis of brain tumor.

Which potential findings would the nurse identify in a patient suspected of developing Waterhouse-Friderichsen syndrome secondary to meningococcal meningitis? Select all that apply. Diplopia Petechiae Pulmonary effusion Adrenal hemorrhage Disseminated intravascular coagulation (DIC)

Petechiae Adrenal hemorrhage Disseminated intravascular coagulation (DIC) Rationale: Waterhouse-Friderichsen syndrome is a complication of meningococcal meningitis and is manifested by petechiae, adrenal hemorrhage, DIC, and circulatory collapse. Waterhouse-Friderichsen syndrome does not cause diplopia or a pulmonary effusion.

Which method of measurement is the gold standard for obtaining intracranial pressures (ICPs)? Ventriculostomy Fiberoptic catheter Air pouch/pneumatic Transcranial Doppler

Ventriculostomy Rationale: A ventriculostomy is the gold standard for measurement of ICP. A fiberoptic catheter and air pouch/pneumatic are other measures for monitoring ICP, but they are not considered the gold standard. A transcranial Doppler evaluates blood flow in the brain.

Which interventions would the nurse implement when providing care for a patient with a diagnosis of acute meningitis? Select all that apply. Lower the head of the bed to 40 degrees and maintain. Place the patient in a comfortable position. Instruct the patient to ambulate or walk around the room. Position the patient in a curled-up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture.

Place the patient in a comfortable position. Position the patient in a curled-up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture. Rationale: In acute meningitis, the nurse should assist the patient to a comfortable position, often curled up with the head slightly extended is best. The head of the bed should be slightly elevated when permitted after lumbar puncture. Lowering the head of bed may increase headaches in the patient. Making the patient walk in the room is not advisable because movement can aggravate the head and neck pain. The patient with meningitis may have delirium and making the patient walk may increase risk for injury.

Which factors would the nurse associate with influencing a patient's intracranial pressure (ICP) readings? Select all that apply. Posture Swallowing Drowsiness Temperature Carbon dioxide levels Intraabdominal pressure

Posture Temperature Carbon dioxide levels Intraabdominal pressure Rationale: Posture, temperature, intraabdominal pressure, and carbon dioxide levels all influence ICP. Swallowing does not affect ICP. Drowsiness may be a sign of increased ICP, but it does not influence it.

Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating? Presence of fixed unresponsive pupils Sluggish reaction of pupil in response to light Brisk constriction of pupil in response to light Slight constriction in the opposite pupil in response to light

Presence of fixed unresponsive pupils

Which expected outcome would the nurse anticipate after administering phenytoin (Dilantin) for a patient with an increased intracranial pressure (ICP)? Lowered ICP readings Prevention of seizures Decreased systolic pressures Prevention of gastrointestinal (GI) ulcers

Prevention of seizures Rationale: Use phenytoin to control seizures for which this patient is at risk. Use histamine (H receptor antagonists), not phenytoin, to prevent GI ulcers. Phenytoin will not affect systolic pressure. Use mannitol to help to decrease ICP.

Which outcome would the nurse expect after administration of IV mannitol (Osmitrol) prescribed for a patient experiencing an increased intracranial pressure (ICP)? Increased urine output Decreased BP Reduced ICP Increased intracranial perfusion

Reduced ICP Rationale: Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules to increase the uptake of water and dieresis by the kidneys, which specifically helps to relieve cerebral edema, thereby decreasing ICP.

When assessing a patient presenting with clinical manifestations of meningeal irritation and nuchal rigidity, which description would the nurse use to explain nuchal rigidity to the patient? Tonic spasms of the legs Curling into a fetal position Arching the neck and back Resistance to flexion of the neck

Resistance to flexion of the neck Rationale: Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

After assessing the breathing patterns of four assigned patients, which patient would the nurse suspect of having a lesion in the medulla of the brain? The patient with cluster breathing The patient with apneustic breathing The patient with Cheyne-Stokes breathing The patient with central neurogenic hyperventilation

The patient with cluster breathing Rationale: Lesions in the medulla may affect the breathing pattern, resulting in clustered breathing with irregular pauses in between. Lesions on mid or lower pons cause apneustic breathing. Bilateral hemispheric disease causes a Cheyne-Stokes pattern of breathing. Lesions on the brainstem between lower midbrain and upper pons cause central neurogenic hyperventilation.