Head Injury/ICP
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B) Emergent; the client is poorly oxygenated. C) Normal D) Significant; the client has alveolar hypoventilation.
A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). (A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.)
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A) Laceration of the middle meningeal artery B) Rupture of the carotid artery C) Thromboembolism from a carotid artery D) Venous bleeding from the arachnoid space
A) Laceration of the middle meningeal artery (Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.)
After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A) Quadriplegia with gross arm movement and diaphragmatic breathing B) Quadriplegia and loss of respiratory function C) Paraplegia with intercostal muscle loss D) Loss of bowel and bladder control
A) Quadriplegia with gross arm movement and diaphragmatic breathing (A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.)
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? A) Reposition the client to avoid neck flexion B) Administer 1 g Mannitol IV as ordered C) Increase the ventilator's respiratory rate to 20 breaths/minute D) Administer 100 mg of pentobarbital IV as ordered.
A) Reposition the client to avoid neck flexion (The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.)
Which of the following respiratory patterns indicate increasing ICP in the brain stem? A) Slow, irregular respirations B) Rapid, shallow respirations C) Asymmetric chest expansion D) Nasal flaring
A) Slow, irregular respirations (Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.)
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A) Unequal pupil size B) Decreasing systolic blood pressure C) Tachycardia D) Decreasing body temperature
A) Unequal pupil size (Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.)
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? A) Count the rate to be sure the ventilations are deep enough to be sufficient B) Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. C) Call the physician to adjust the ventilator settings. D) Check deep tendon reflexes to determine the best motor response
B) Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. (Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.)
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? A) Keeping the client flat on one side or the other B) Elevating the head of the bed to 30 degrees C) Log rolling or turning as a unit when turning D) Keeping the head in neutral position
B) Elevating the head of the bed to 30 degrees (Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.)
A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). A. Check for bladder distention B. Raise the head of the bed C. Contact the physician D. Loosen tight clothing on the client E. Administer an antihypertensive medication B, D, A, C, E. A) A, B, C, D, E B) B, D, A, C, E. C) C, A, D, E, B D) C, D, A, B, E
B, D, A, C, E. (Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.)
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A) "Watch him for keyhole pupil the next 24 hours." B) "Expect profuse vomiting for 24 hours after the injury." C) "Wake him every hour and assess his orientation to person, time, and place." D) "Notify the physician immediately if he has a headache."
C) "Wake him every hour and assess his orientation to person, time, and place." (Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.)
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? A) Extent of intracranial bleeding B) Sites of brain injury C) Activity of the brain D) Percent of functional brain tissue
C) Activity of the brain (An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Percent of functional brain tissue would be determined by a series of tests.)
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? A) Give the client a warming blanket B) Administer low-dose barbiturate C) Encourage the client to hyperventilate D) Restrict fluids
C) Encourage the client to hyperventilate (Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.)
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: A) Skull fracture B) Concussion C) Subdural hematoma D) Epidural hematoma
D) Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.