ICP

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? a.subdural b.intracerebral c.edpidural d.diffuse axonal

c.edpidural An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A diffuse axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brainstem.

In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client? a. risk for falls b. deficient fluid volume c.autonomic dysreflexia d. risk for infection

a. risk for falls

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. a.absence of pain response b.apnea c.coma d.absence of brain stem reflexes e.absence of deep tendon reflexes

b.apnea c.coma d.absence of brain stem reflexes The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? a. "Don't worry. The aneurysm has probably been there since birth." b."The headache can be an indication that the aneurysm is growing." c."A headache means your aneurysm is leaking blood into the brain." d."Your physician wants to evaluate the location and condition of the aneurysm."

d."Your physician wants to evaluate the location and condition of the aneurysm."

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? a.risk for aspiration b.risk for falls c.risk for impaired skin integrity d.decreased intracranial adaptive capacity

a.risk for aspiration

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? a.concussion b.contusion c.diffuse axonal injury d.intracranial hemorrhage

b.contusion Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply. a. cerebral edema b. ischemia c. infection d. seizures e. hyperthermia

a. cerebral edema b. ischemia c. infection d. seizures e. hyperthermia Secondary injury evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, and hypoxia.

The cerebral circulation receives approximately what percentage of the cardiac output? a.15% b.10% c.25% d.20%

a.15% The cerebral circulation receives approximately 15% of the cardiac output, or 750 mL per minute.

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? a.It results from inadequate delivery of nutrients and oxygen to the cells. b.It results from initial damage to the brain from the traumatic event. c.It refers to the permanent deficits seen after the rehabilitation process. d.It refers to the difficulties suffered by the client and family related to the changes in the client.

a.It results from inadequate delivery of nutrients and oxygen to the cells. Secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually as a result of cerebral edema and increased intracranial pressure. Primary injury results from initial damage related to the traumatic event.

The Monro-Kellie hypothesis refers to which of the following? a.The dynamic equilibrium of cranial contents b.Unresponsiveness to the environment c.The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure d.A condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function

a.The dynamic equilibrium of cranial contents

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as a.coma b.minimally responsive c.least responsive d.most responsive

a.coma The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)? a.epidural b.subdural c.intracerebral d.contusion

a.epidural Symptoms of the epidural hematoma are caused by the expanding hematoma. Usually a momentary loss of consciousness occurs at the time of injury, followed by an interval of apparent recovery (lucid interval). Subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid.

The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply. a.increased head circumference b.pulse rate of 60 beats/min and regular c.vomiting d.blood pressure decreased from baseline e.parent states, "my infant does not act right."

a.increased head circumference b.pulse rate of 60 beats/min and regular c.vomiting a.increased head circumference b.pulse rate of 60 beats/min and regular c.vomiting Signs of increased intracranial pressure include bulging fontanel ([fontanelle] increased head circumference), decreased pulse, vomiting, increased blood pressure and behavior changes. The nurse must listen to the parents if concerns about behavior are mentioned. The blood pressure would increase, not decrease. The nurse would alert the health care provider immediately of these signs so intervention can be started if needed.

The nurse is caring for a client with traumatic brain injury and increased intracranial pressure. What findings should the nurse report due to the risk for increasing intracranial pressure? Select all that apply. a.PaCO2 of 28 mm Hg (3.72 kPa) b.PaCO2 of 50 mm Hg (6.65 kPa) c.PaO2 of 70 mm Hg (9.31 kPa) d.pH of 7.25 e.potassium of 3.3 mEq/L (3.3 mmol/L)

b.PaCO2 of 50 mm Hg (6.65 kPa) c.PaO2 of 70 mm Hg (9.31 kPa) d.pH of 7.25 Increased carbon dioxide (greater than 45 mm Hg) causes vasodilation, which can increase intracranial pressure. Increased hydrogen ion concentrations, or acidosis, correlates with a pH less than 7.35 and also increases cerebral blood flow. Decreased oxygen concentration or hypoxia (PaO2 less than 80 mm Hg [10.64 kPa]) also increases vasodilation and cerebral blood flow, which would increase intracranial pressure. Neither a slightly low potassium level of 3.3 (normal is 3.5 to 4.5 mEq/L [mmol/L]) nor a low PaCO2 level are associated with increased intracranial pressure.

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? a.Antiemetic medications on day three of injury b.Aspiration precautions on day four of injury c.Intubation and ventilator support on day one of injury d.Anticonvulsant medications on day two of injury

d.Anticonvulsant medications on day two of injury Clients with head injury are at an increased risk for posttraumatic seizures. Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering anticonvulsant medications to clients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation. All of the other interventions are not part of the seizure prophylactic protocol nor have a specific timeline of administration

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? a. lorazepam (ativan) b.midazolam (versed) c.phenobarbital d.propofol (diprivan)

d.propofol (diprivan) If the patient is very agitated, benzodiazepines are the most commonly used sedative agents and do not affect cerebral blood flow or ICP. Lorazepam (Ativan) and midazolam (Versed) are frequently used but have active metabolites that my cause prolonged sedation, making it difficult to conduct a neurologic assessment. Propofol ( Diprivan), on the other hand, a sedative-hypnotic agent that is supplied in an intralipid emulsion for intravenous (IV) use, is the sedative of choice. It is an ultra-short acting, rapid onset drug with elimination half-life of less than an hour. It has a major advantage of being titratable to its desired clinical effect but still provides the opportunity for an accurate neurologic assessment (Hickey, 2009).

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? a. report of headache off and on for the past month b.no BM since yesterday c.nausea d.frequent voiding

c.nausea Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Report of headache for past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? a.herniation b.autoregulation c.cushing's syndrome d.monro-kellie hypothesis

a.herniation Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. a.making nursing assessments b.setting priorities for nursing interventions c.anticipating needs and complications d.initiating rehabilitation e.ensuring that the patient regains full brain function

a.making nursing assessments b.setting priorities for nursing interventions c.anticipating needs and complications d.initiating rehabilitation The nursing interventions for the patient with a head injury are extensive and diverse. They include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.

The nurse is caring for a child who was injured in a bike accident. The nurse determines that a child is experiencing late signs of increased intracranial pressure based on which assessment findings? Select all that apply. a.bradycardia b.fixed dilated pupils c.irregular respirations d.increase BP e.sunset eyes

a.bradycardia b.fixed dilated pupils c.irregular respirations Late signs of increased intracranial pressure include bradycardia, fixed and dilated pupils, and irregular respirations. Increased blood pressure and sunset eyes are early signs of increased intracranial pressure.

An 82-year-old client is admitted for observation after a fall. Due to the client's age, the nurse knows that the client is at increased risk for what complication of his injury? a. hematoma b.skull fracture c.embolus d.stroke

a. hematoma Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the client's risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture. Strokes are more common among older adults, but not typically as a complication of falls.

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? a.Apply elastic stockings to lower extremities. b.Take care not to jar the bed or cause unnecessary activity. c.Assist the patient with frequent ambulation. d.Elevate patient's head or follow the physician's directive for body position.

a.Apply elastic stockings to lower extremities. To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? a. hyperthermia b.tachycardia c.hypertension d.bradypnea

a. hyperthermia Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply. a.lowered systolic BP b.resp irregularities c.slow bounding pulses d.increased cerebral perfusion e.widened pulse pressure

b.resp irregularities c.slow bounding pulses e.widened pulse pressure In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. This is typically accompanied by a slow, bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure, with a widening of the pulse pressure and cardiac slowing.

The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? a.promoting adequate circulation b.treating the child's increased ICP c.assessing secondary brain injury d.preserving brain homeostasis

d.preserving brain homeostasis All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely secondary to the broader goal of preserving brain homeostasis.

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: a. smell and identify a nonirritating aromatic odor b.read an eye chart from a distance of 20 c.elevate the shoulders, both with and without resistance d.stick out the tongue and move it rapidly from side to side and in and out

d.stick out the tongue and move it rapidly from side to side and in and out To test cranial nerve XII, which controls tongue movement, the nurse should instruct the client to stick out the tongue and move it rapidly from side to side and in and out. The nurse would ask the client to smell and identify a nonirritating, aromatic odor when testing the function of cranial nerve I, the olfactory cranial nerve. Asking the client to read an eye chart is part of assessing cranial nerve II, the optic cranial nerve. Having the client elevate the shoulders with and without resistance is part of assessing cranial nerve XI, the spinal accessory cranial nerve that innervates the sternocleidomastoid muscle and the upper portion of the trapezius muscle.

A 13-year-old adolescent is being released from the hospital following examination for a concussion. The parent has agreed to monitor the adolescent at home for the next 24 hours. Which instruction(s) should the nurse provide? Select all that apply. a. Assess the adolescent's level of consciousness every 1 to 2 hours while awake. b.Wake the adolescent once during the night to assess consciousness. c.Ask the adolescent to name a familiar object. d.Ask the adolescent to state where he or she lives. e.Wake the adolescent every hour during the night to assess for consciousness. f.Do not let the adolescent sleep during the first 24 hours.

a. Assess the adolescent's level of consciousness every 1 to 2 hours while awake. b.Wake the adolescent once during the night to assess consciousness. c.Ask the adolescent to name a familiar object. d.Ask the adolescent to state where he or she lives. An adolescent can be observed at home by a parent if the parent is able to assess the adolescent's level of consciousness every 1 to 2 hours while awake. The parents usually are instructed not to keep waking the adolescent during the night, because multiple wakings are disorienting and can make it difficult to tell whether the adolescent is confused. The parent should wake the adolescent at least once during the night, however, to be certain the adolescent is conscious, ask the adolescent to name a familiar object (e.g., favorite toy, name the color of some object shown to the adolescent). Being able to tell the parent one's name or where one lives is equally revealing. There is an old belief that, if an adolescent falls asleep after a head injury, the adolescent will die in one's sleep; this belief can cause the parent to keep shaking the adolescent awake or making the adolescent walk continually. The nurse should make certain the parent understands it is all right for the adolescent to sleep, but the parent must wake the adolescent at least once to assess status.

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action? a.immediate craniotomy b.an order for a head CT scan c.intubation and mechanical ventilation d.IV administration of propofol

a.immediate craniotomy The client is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure (ICP) emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the client is awake and conversant. During this lucid interval, the expanding hematoma is compensated for by rapid absorption of cerebrospinal fluid and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The client then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? a.The client has periorbital edema and ecchymosis. b.The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. c.The client's level of consciousness has improved. d.The client prefers to rest in the semi-Fowler's position.

b.The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.

A football player collides violently with the helmet of another player. The helmet protected him from the initial impact, but the movement of the brain in his cranium resulted in bruised and torn tissue with many small hematomas. What term most accurately describes the type of injury this client incurred? a.coup b.contrecoup c.coup-contrcoup d.cerebral hemorrhage

b.contrecoup The player incurred a contrecoup injury due to the sloshing of his brain against the back of his skull. The direct contusion of the brain at the site of external force is referred to as a coup injury, whereas the rebound injury on the opposite side of the brain is the contrecoup injury. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas. A CVA is a stroke.