Intracranial Concept

94. A client had a cerebrovascular accident (also known as a "brain attack") and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client? A. Splints B. Blocks C. Cradles D. Sandbags

Correct Answer: A Various types of splints or boots are available to keep the foot in a position of functional alignment.

78. What action should be included in the nursing care of an infant with increased intracranial pressure? A. Weighing daily before feedings B. Elevating the head higher than the hips C. Checking the reflexes at regular intervals D. Monitoring alertness with frequent stimulation

Correct Answer: B Elevation of the head helps decrease intracranial pressure by way of gravity.

46. A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is: A. Sunset eyes B. Kernig's sign C. Plantar reflex D. Homans' sign

Correct Answer: B Kernig's sign, which is an inability to completely extend the legs, is the classic sign of meningeal irritation.

65. After a craniotomy a child is returned to the postanesthesia care unit. What is the rationale for the nurse's positioning the child in the semi-Fowler position? A. Cardiac workload is decreased and oxygenation is facilitated. B. Cranial drainage is increased thus preventing cerebral fluid accumulation. C. Subdural pressure is decreased and recovery from anesthesia is enhanced. D. Thoracic cavity expansion is increased and pressure on the diaphragm is reduced.

Correct Answer: B With the semi-Fowler position, gravity aids drainage of fluid from the head, which helps prevent cerebral edema.

6. A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a: A. Contusion B. Concussion C. Nose fracture D. Basilar fracture

Correct Answer: D A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear.

98. A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply. A. Seizures B. Vomiting C. Bulging fontanels D. Subnormal temperature E. Decreased respiratory rate

Correct Answers: A,B,E Irritation of cerebral tissue can cause seizures. Pressure on vital centers can cause vomiting. Pressure on the respiratory center results in a decreased respiratory rate.

99. Carbidopa/levodopa (Sinemet) is prescribed for a client with Parkinson disease. Which side effects does the nurse expect? Select all that apply. A. Nausea B. Anorexia C. Bradycardia D. Hypertension E.Mental changes

Correct Answers: A,B,E Nausea may occur; it reflects a central emetic reaction to carbidopa/levodopa. Anorexia may occur; decreased appetite results from nausea and vomiting. Confusion, agitation, psychosis, hallucinations, and depression may occur.

91. A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The client's plan of care should include: A. Keeping the client's head turned to the right B. Approaching the client from the left side C. Teaching the client to use head movements to scan the left field of vision D. Arranging the furniture in the client's room so that the door is in the right visual field

Correct Answer: C The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field.

45. What should the nurse assess for in the immediate postoperative period after a client has brain surgery? A. Tachycardia B. Constricted pupils C. Elevated diastolic pressure D. Decreased level of consciousness

Correct Answer: D Decreased level of consciousness is a sign of increasing intracranial pressure, which may occur after a craniotomy. Bradycardia, not tachycardia, may occur. The pupils will dilate, not constrict. The systolic, not the diastolic, pressure may be elevated.

95. A client develops hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response? A. Vasospasm of adjacent cerebral arteries B. Ischemic changes in the Broca speech center C. Increased production of cerebrospinal fluid (CSF) D. Blocked absorption of fluid from the arachnoid space

Correct Answer: D Residual blood from the ruptured aneurysm may have blocked the arachnoid villi, interrupting the flow of CSF, resulting in hydrocephalus. The production of cerebrospinal fluid is not increased in this situation; increased production may result when there is a tumor of the choroid plexus

28. The signs and symptoms of increased intracranial pressure would include A. Dehydration. B. Hunger. C. Nausea. D. Vomiting.

Correct Answer: D Symptoms of increased intracranial pressure include headache, decreased consciousness, and vomiting without nausea.

68. A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. What health care provider prescription should the nurse question? A. Continue anticonvulsants B. Teach isometric exercises C. Continue osmotic diuretics D. Keep head of bed at thirty degrees

Correct Answer: This prescription should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure.

81. A client is admitted to the hospital with an altered level of consciousness. When assessing this client the nurse understands that level of consciousness extends along a continuum from being conscious to being comatose. Place the following words that describe level of consciousness in order from the most alert to the least alert.

1. Alert 2. Confused 3. Lethargic 4. Obtunded

25. Two hours after birth an area of soft swelling develops in the newborn's left parietal region. Where should the nurse find the area of involvement? A. Over the eyes B. Behind the ears C. In back of the head D. On the top of the skull

Correct Answer: D The parietal areas behind the frontal bone form the top surfaces of the cranial cavity. A swelling in one of these areas that does not cross the suture line is a cephalhematoma. The frontal area is the area over the eyes. The temporal area is the area behind the ears. The occipital area is the area at the back of the head.

117. For what complication should a nurse assess a newborn after a precipitate birth? A. Brachial palsy B. Dislocated hip C. Fractured clavicle D. Intracranial hemorrhage

Correct Answer: D A rapid birth does not give the fetal head adequate time for molding; therefore pressure against the head is increased and blood vessels may burst.

61. A nurse is caring for an infant who has undergone surgery to correct a myelomeningocele. What assessment provides data about a potential major complication for this infant? A. Daily weights B. Fluid output every 8 hours C. Blood pressure every 12 hours D. Daily head circumference measurements

Correct Answer: D Hydrocephalus, typically after surgical correction, is a major complication of myelomeningocele. Measuring the head circumference daily provides an accurate basis for day-to-day comparisons.

106. An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period? A. Encouraging the parents to stroke their infant B. Allowing the parents to hold their infant in their arms C. Referring the parents to the Spina Bifida Association of America D. Teaching the parents to use special techniques when feeding the infant

Correct Answer: A Because the infant cannot be held, tactile stimulation helps meet the infant's needs and fosters bonding with the parents.

105. A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). The nurse explains to the client that TIAs are: A. Temporary episodes of neurological dysfunction B. Intermittent attacks caused by multiple small clots C. Ischemic attacks that result in progressive neurological deterioration D. Exacerbations of neurological dysfunction alternating with remissions

Correct Answer: A Narrowing of arteries supplying the brain causes temporary neurological deficits that last for a short period. Between attacks, neurological functioning is normal.

126. A nursing assistant assigned to provide hygiene to a client who has a history of transient ischemic attacks (TIAs) asks the nurse what a TIA is. What explanation should the nurse provide? A. Temporary episodes of neurologic dysfunction. B. Transient attacks caused by multiple small emboli. C. Periods of alternating exacerbations and remissions. D. Ischemic attacks that result in progressive neurologic deterioration

Correct Answer: A Narrowing of arteries that supply the brain causes temporary neurologic deficits that last for a short period; between attacks the neurologic examination is within expected limits. Emboli may result in a brain attack (cerebrovascular accident); damage usually is permanent.

118. A health care provider prescribes phenobarbital sodium for a client who had a tonic-clonic seizure. The nurse assesses the client's knowledge after teaching about the adverse effects of this drug. What responses should the client identify as a reason for calling the health care provider? A. Loss of appetite or persistent fatigue B. Anal itching or dizziness when I stand up C. Diarrhea or a rash on the upper part of my body D. Decreased tolerance to common foods or constipation

Correct Answer: A Phenobarbital depresses the central nervous system, particularly the motor cortex, producing adverse effects such as lethargy, loss of appetite, depression, and vertigo.

123. A client who is receiving phenytoin (Dilantin) to control a seizure disorder questions the nurse regarding this medication after discharge. The nurse's best response is "This medication: A. Will probably be continued for life." B. Prevents the occurrence of seizures." C. Needs to be taken during periods of emotional stress." D. Usually can be stopped after a year's absence of seizures.

Correct Answer: A Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. Seizures may occur despite drug therapy; the dosage may need to be adjusted.

104. The nurse is caring for a client who had a brain attack (cerebrovascular accident) who has varying moods. The moods range from anger to depression to concern about the aphasia, hemiparesis, and the gavage feedings. The behavior that best indicates the client's acceptance of physical limitations is when the client: A. Performs tube feedings without assistance B. Smiles and becomes more extroverted C. Allows family members to assist with care D. Walks in the hall and sits in the lounge

Correct Answer: A The best indicator of acceptance is when the client begins to participate in self-care.

102. A ventroperitoneal shunt is inserted in a 4-month-old infant with hydrocephalus. Which signs of shunt failure should the nurse teach the parents during preparations for the infant's discharge? Select all that apply. A. Vomiting B. Dehydration C. Sunken eyeballs D. Distended fontanels E. Abdominal distention

Correct Answer: A and D Vomiting is a sign of increased intracranial pressure in an infant; a malfunctioning shunt will produce the typical signs of hydrocephalus. Bulging fontanels indicate increased cerebrospinal fluid and increased intracranial pressure in an infant.

121. A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply. A. Tense fontanels B. High-pitched crying C. Apgar score of less than 5 D. A defect in the lumbosacral area E. Head circumference 2 cm greater than the chest circumference

Correct Answer: A,B,D An excessive amount of cerebrospinal fluid associated with hydrocephalus causes tense fontanels. A shrill, high-pitched cry often accompanies progressive hydrocephalus and other neurologic problems. Infants with hydrocephalus may or may not have low Apgar scores. Hydrocephalus complicates approximately 90% of lumbosacral meningomyeloceles. Head circumference 2 cm greater than the chest circumference is expected in a newborn.

114. The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply. A. Providing adequate fluids within easy reach B. Reporting an increasing urine specific gravity C. Administering prescribed demeclocycline (Declomycin) D. Assessing for and reporting changes in neurological status E. Monitoring for constipation, weight loss, hypotension, and tachycardia

Correct Answer: A,D,E Diabetes insipidus is a condition resulting in underproduction of antidiuretic hormone. The focus of care is on maintaining fluid and electrolyte balance. Oral fluids must be easily accessible at the bedside to balance urinary losses and prevent severe dehydration. The nurse monitors for, and reports, changes in neurological status associated with hypernatremia and high serum osmolality. Constipation and weight loss indicate fluid volume deficit and must be reported. Hypotentsion and tachycardia are signs of impending shock. Massive polyuria results in dilute urine.

120. A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? A. Insert a urinary retention catheter. B. Institute measures to prevent constipation. C. Encourage an increase in the intake of caffeine. D. Suggest that a carbonated beverage be ingested daily

Correct Answer: B

116. A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask a nurse, "How much longer will my child need to take the medication?" What is the best response by the nurse? A. "Medications are continued for 3 years after the last seizure." B. "It is important that the medications be gradually decreased." C. "Medications are usually discontinued at the 2-year follow-up visit." D. "Seizure disorders are lifelong problems that require ongoing medications."

Correct Answer: B A predesigned protocol is used to wean a child off anticonvulsants gradually, because abrupt removal of the drug can result in a seizure. Anticonvulsants are discontinued gradually after a child is seizure free for 2, not 3, years and has an EEG within expected limits.

111. A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, the nurse should teach the client to: A. Shorten the stride of the unaffected extremity B. Advance the cane and the affected extremity simultaneously C. Lean the body toward the side with the cane when ambulating D. Hold the cane on the same side as the affected extremity and increase the base of support

Correct Answer: B Advancing the cane and the affected extremity simultaneously supports stability.

66. An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure? A. Sunken eyes B. Projectile vomiting C. Depressed fontanels D. Narrowing pulse pressure

Correct Answer: B Increased intracranial pressure exerts pressure on the vomiting center in the brain, resulting in projectile vomiting unrelated to feeding.

108. After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply. A. Polyuria B. Weight gain C. Hypotension D. Hyponatremia E. Decreased specific gravity

Correct Answer: B and D Excessive levels of ADH cause inappropriate free water retention; for every liter of fluid retained, the client will gain approximately 2.2 lb. Free water retention results in a hypoosmolar state with dilutional hyponatremia. Oliguria, not polyuria, occurs as ADH acts on nephrons to cause water to be reabsorbed from the glomerular filtrate. Because of water reabsorption, blood volume may increase, causing hypertension, not hypotension. This increases, not decreases, as a result of increased urine concentration.

112. A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that neurological deficits, which may be present immediately after a subarachnoid hemorrhage, are caused primarily by: A. Blood loss B. Tissue death C. Vascular spasms D. Electrolyte imbalance

Correct Answer: C In an attempt to stop the bleeding, adjacent arteries constrict; this in turn contributes to the ischemia responsible for the neurological deficits.

107. After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, the nurse should teach the client range-of-motion exercises, specifically: A. Eversion B. Supination C. Opposition D. Circumduction

Correct Answer: C Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand.

103. A client is admitted to the emergency department after an automobile collision. After the health care provider determines that the client sustained a head injury, the nurse observes blood coming from the client's ear. What should the nurse do next? A. Turn the client to the unaffected side. B. Cleanse the client's ear with sterile gauze. C. Place sterile cotton loosely in the external ear of the client. D. Test drainage from the client's ear with a glucose reagent strip.

Correct Answer: C Placing sterile cotton loosely in the external ear will absorb the drainage without causing further trauma. Turning the client to the unaffected side will allow fluid to collect in the ear. Cleansing of the ear may cause further injury. Testing the drainage with a glucose reagent strip might be done if the drainage were serous, to determine if it is cerebrospinal fluid.

122. The nurse is caring for a client who has a tumor of the cerebellum. The client most likely will exhibit: A. Frequent loss of consciousness B. Absence of the knee-jerk reflex C. Inability to execute smooth movements D. Inability to execute voluntary movements

Correct Answer: C The cerebellum is involved in the synergistic control of muscle action; it functions to produce smooth, steady, coordinated, and efficient movements. The cerebrum, not cerebellum, is responsible for the level of consciousness.

113. After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow the nurse should: A. Clear the ear of draining fluid B. Discontinue anticonvulsant therapy C. Elevate the head of the bed 30 degrees D. Monitor serum carbon dioxide levels routinely

Correct Answer: D Controlled ventilation induces hypocapnia; subsequently, it causes vasoconstriction and reduced cerebral blood flow.

109. A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. What complication does the nurse suspect? A. Tetany B. Spina bifida C. Hyperkalemia D. Intracranial hemorrhage

Correct Answer: D Intracranial bleeding may occur in the subdural, subarachnoid, or intraventricular spaces of the brain, causing pressure on vital centers; clinical signs are related to the area and degree of cerebral involvement.

125. The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, the nurse should A. Place a pillow under the thighs B. Elevate the knee gatch of the bed C. Encourage active range of motion D. Maintain the feet at right angles to the legs

Correct Answer: D Maintaining the feet at right angles to the legs produces dorsiflexion of the feet and prevents the tendons from shortening, preventing footdrop. Placing a pillow under the thighs and elevating the knee gatch of the bed will not prevent plantar flexion; it can promote hip and knee flexion contractures.

36. The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response? A. Emotional lability is associated with brain trauma. B. Their presence allows the client to express feelings. C. The client is depressed about the loss of functional abilities. D. Nonverbal expressions of feelings are more accurate than verbal ones.

Correct Answer: A Emotional lability is associated with brain trauma from ischemia or injury. The frontal lobe, hypothalamus, thalamus, and cortical limbic system are involved in expression of emotions.

10. A 12-year-old child is admitted to the hospital for observation after sustaining a head injury. Twelve hours after the injury the child has none of the signs or symptoms of a head injury. What is the nurse's priority intervention at this time? A. Assessing the level of consciousness every hour B. Promoting rest by fostering a quiet environment C. Asking about the circumstances that led to the injury D. Administering the prescribed opioid for complaints of a headache

Correct Answer: A Evidence of a subdural hemorrhage may take hours or days to develop; a diminishing level of consciousness is an early indication of neurological damage.

119. The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? Select all that apply. A. Ability of the client's pupils to react to light B. Degree of purposeful movement by the client C. Appropriateness of the client's verbal responses D. Stimulus necessary to cause the client's eyes to open E. Symmetry of muscle strength of the client's extremities

Correct Answers: B,C,D The scale measures best motor response. The scale measures best verbal response. The scale measures eye opening response. Although the ability of the client's pupils to react to light is part of a neurologic assessment, it is not part of the Glasgow Coma Scale.

115. How should a nurse assess a client's trigeminal nerve function? A. Observing pupil constriction. B. Identifying corneal sensation. C. Determining the ability to smell. D. Determining the ability to shrug the shoulders.

Correct Answer: B The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea.

124. Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply A. Irritability B. High-pitched cry C. Depressed fontanels D. Decreased urinary output E. Ineffective feeding behavior

Correct Answers: A, B, E Pressure on the cerebral structures influences the central nervous system, resulting in irritability. A high-pitched cry is common in neonates with increased ICP. Ineffective feeding behavior is typical of neonates with increased ICP. The fontanels are bulging, not depressed, with increased ICP.

54. A client is scheduled for a computed tomography (CT) of the brain with contrast. Upon review of the client's medical record, what significant finding should the nurse report to the health care provider before the diagnostic procedure? The client: A. Takes metformin (Glucophage) daily. B. Has not been nothing by mouth (NPO). C. Reports an allergy to gadolinium. D. Was not prescribed a bowel prep.

Correct Answer: A A CT often requires a contrast agent to be administered. The contrast agent can cause temporary changes in kidney function. This change in kidney function can cause clients on metformin to have an increased risk of developing a serious side effect called lactic acidosis.

5. A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt? A.By palpating the anterior fontanel B. By determining the frequency of voiding C. By assessing the child for periorbital edema D. By assessing the symmetry of the Moro reflex

Correct Answer: A A bulging fontanel is the most significant sign of increased intracranial pressure in an infant.

101. A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of an infratentorial brain tumor. What presenting sign does the nurse anticipate when assessing the child? A. Ataxia B. Papilledema C. Cranial enlargement D. Generalized seizures

Correct Answer: A An early sign of an infratentorial tumor is ataxia. The parents describe it as clumsiness that becomes progressively worse.

110. After a head injury a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider about the response to secretion of ADH before assessing this client? A. Serum osmolarity increases B. Urine concentration decreases C. Glomerular filtration decreases D. Tubular reabsorption of water increases

Correct Answer: D Reabsorption of sodium and water in the kidney tubules decreases urinary output and retains body fluids.

35. A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit, and they obviously are upset by the crying. The nurse explains to the family members that the client is: A. Having difficulty controlling emotions. B. Demonstrating a premorbid personality. C. Mourning the loss of functional abilities. D. Conveying unhappiness about the situation.

Correct Answer: A A common complication of a brain attack is an inability to control emotional affect; clients may be depressed or apathetic and have a lability of mood.

84. The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern? A. Marked irritability B. Complaints of pain C. Pulse of 100 beats/min D. Temperature of 99.4° F (37.4° F)

Correct Answer: A Marked irritability may be a sign of malfunction of the shunt or infection and should be reported immediately. Complaints of pain are expected after surgery. A low-grade fever is expected after the stress of surgery.

23. After three months of rehabilitation after a craniotomy, a client continues to have motor speech difficulties. To promote the client's use of speech the nurse should: A. Support the client's efforts to communicate B. Correct verbal mistakes immediately C. Use simple words with short sentences D. Explain why the client is having difficulty speaking

Correct Answer: A Recognition of effort is motivating. Correcting mistakes may decrease both self-esteem and motivation.

49. A client develops a seizure disorder as a result of a traumatic fall. When the client returns to the clinic for a routine visit, the client states, "I have not had a seizure in two years. When can I stop taking my anti-seizure medications?" What is the nurse's best response? A. "A gradual reduction in seizure medication may be considered." B. "You will require medication for the rest of your life." C. "Enough time has passed since the last seizure. The medication probably will be discontinued at this visit." D. "A minimum of 10 years without seizures is necessary before discontinuation of medications is considered."

Correct Answer: A Specific protocols are designed to gradually reduce the dosage of anti-seizure medications after a client is seizure free, provided the electroencephalogram (EEG) is within acceptable limits. The client is monitored for seizure activity because recurrence is greatest within the first year after drug withdrawal. Depending on the status of the client, anti-seizure medications may not be necessary for life. Medications must be withdrawn slowly to prevent an abrupt reduction in serum drug levels, which may precipitate a seizure.

42. A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA).The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? A. Place the head and neck in alignment. B. Administer 1 gram mannitol intravenously (IV) as prescribed. C. Increase the ventilator's respiratory rate to 20 breaths/minute. D. Administer 100 mg of pentobarbital IV as prescribed.

Correct Answer: A The nurse should first attempt nursing interventions, such placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the health care provider, who may prescribe mannitol.

73. When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? A. Third B. Fourth C. Second D. Seventh

Correct Answer: A The third cranial nerve (oculomotor) contains autonomic fibers that innervate the smooth muscle responsible for constriction of pupils.

2. The parents of a school-aged child with fever, headache, and a stiff neck ask that the child be tested for meningitis. Which test should the nurse tell the parents is used to confirm the diagnosis of meningitis? A. Blood culture B. Lumbar puncture C. Meningomyelogram D. Peripheral skin smear

Correct Answer: B A culture of cerebrospinal fluid (CSF), obtained through lumbar puncture, reveals the presence of the causative microorganism (e.g., Pneumococcus, tubercle bacillus, Meningococcus, Streptococcus).

96. In which position should the nurse initially place a client who has experienced a cerebrovascular accident (also known as a "brain attack")? A. Prone B. Lateral C. Supine D. Trendelenburg

Correct Answer: B Absence of a gag reflex is common after a brain attack. To prevent aspiration, the client is positioned on the side to allow gravity to drain mucus in the nasopharyngeal area away from the trachea.

21. A client is taking phenytoin (Dilantin) to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which action should the nurse take? A. Hold the medication and notify the health care provider. B. Administer the next dose of the medication as prescribed. C. Hold the next dose and then resume administration as prescribed. D. Call the health care provider to obtain a prescription with an increased dose.

Correct Answer: B Administering the next dose of the medication as prescribed is within therapeutic range of 10 to 20 mg/L; the nurse should administer the drug as prescribed. The phenytoin level is within the therapeutic range of 10 to 20 mg/L; there is no need to hold the dose and notify the health care provider. (Anticonvulsant)

89. A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs? A. Lubricating the skin with baby oil B. Suctioning the oropharynx routinely C. Elevating the head of the bed 20 degrees D. Cleansing the eyes every four hours with normal saline

Correct Answer: B Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure. Lubricating the skin keeps the skin from drying, which helps prevent skin breakdown. Elevating the head of the bed promotes venous return to the heart and is used to limit increased intracranial pressure. Instilling artificial tears every two hours is the appropriate intervention. The corneal reflex may be absent in the unconscious client; a dry cornea is prone to injury.

38. A client is admitted to the hospital for cranial surgery. The nurse develops the preoperative plan of care and includes: A. Helping the client put on a wig before the client's visitors arrive B. Obtaining the client's consent for shaving the head C. Braiding the client's hair to keep it contained during surgery D. Instructing the client that with all cranial surgeries the head is shaved after anesthesia has been administered

Correct Answer: B Because of cosmetic concerns, consent must be obtained before a client's head is shaved. The hair will be shaved to help prevent contamination of the surgical site. Shaving the client's hair may be done before or after being anesthetized.

60. A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? A. Offering clear fluids whenever the child is awake B. Checking the child's level of consciousness hourly C. Assessing the child's blood pressure every 4 hours D. Administering the prescribed oral antibiotic medication

Correct Answer: B Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation.

37. An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? A. A reduction of confusion B. An activated partial thromboplastin (APTT) twice the usual value C. An absence of ecchymotic areas D. A decreased viscosity of the blood

Correct Answer: B Desired anticoagulant effect is achieved when the activated partial thromboplastin time is 1.5 to 2 times normal.

55. A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? A. History of hypertensive disease B. Emboli associated with atrial fibrillation C. Developmental defect of the arterial wall D. Inappropriate paroxysmal neural discharge

Correct Answer: B Emboli, occurring from atrial fibrillation, cause complete occlusion of vessels; usually middle cerebral arteries are involved. The infarct may cause hemiplegia, aphasia, or spatial perceptual deficits.

11. A client had spinal anesthesia for surgery. On the second day after surgery the client complains of a headache. How should the nurse respond? A. Begin an early ambulation program B. Encourage the client to drink 3 L of fluids in 24 hours C. Remove antiembolic stockings being worn D. Assist the client to sit at the bedside with the feet dangling

Correct Answer: B Encouraging fluids will hydrate the client and contribute to the restoration of cerebrospinal fluid, which cushions the brain; this should ease the pain. The client should be maintained on bed rest and kept quiet. Strict bed rest for 24 to 48 hours may be recommended.

26. The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurological assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. What is the first action the nurse should take? A. Notify the health care provider. B. Assess the client's airway. C. Place pads on the side rails to prevent injury. D. Insert a padded tongue blade to prevent injury.

Correct Answer: B Ensuring an airway is the first action in emergency response to any client. The health care provider will be notified as soon as the nurse ensures the client's safety and has a patent airway. For a client admitted with a head injury, the nurse would have already implemented seizure precautions; therefore the side rails already will have been padded.

79. A client with a supratentorial tumor is scheduled for external radiation therapy to the brain. What should the nurse plan to teach the client? A. A low-residue diet will be prescribed. B. Feelings of extreme tiredness will occur. C. The standard amount of radiation is given. D. Loss of memory will occur after therapy begins.

Correct Answer: B External radiation causes fatigue, regardless of the site; myelosuppression and its resultant anemia occur more frequently when radiation therapy involves the skull, pelvic region, sacrum, ribs, shoulder region, sternum, and thoracic and lumbar vertebrae.

47. When performing a neurological check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. Appropriate nursing care for a client with an absent corneal reflex includes: A.Irrigating the eye routinely B. Instilling artificial tears frequently C. Checking the corneal reflex every hour D. Taping the eyelids open during the day

Correct Answer: B Instilling artificial tears frequently lubricates the eye and prevents drying of the cornea.

83. A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? A. Nausea B. Lethargy C. Sunset eyes D. Hyperthermia

Correct Answer: B Lethargy is an early sign of a changing level of consciousness; it is one of the first signs of increased intracranial pressure.

78. A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When planning care for this client, what should the nurse do first? A. Place an airway and restraints at the bedside. B. Obtain a history of seizure type and incidence. C. Ask the client to remove any dentures and eyeglasses. D. Observe the client for increased restlessness and agitation.

Correct Answer: B Phenytoin is an anticonvulsant most effective in controlling tonic-clonic seizures. Data collection before planning nursing care for a client with a seizure disorder should always include a history of the seizures (e.g., type and incidence).

8. After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected? A. Frontal B. Parietal C. Occipital D. Temporal

Correct Answer: B Sensory impulses from temperature, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area. -The frontal area is the area of abstract thinking and muscular movements. -The occipital area is the area where nerve impulses are translated into sight. -The temporal area is the area where nerve impulses are translated into sound.

14. What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants? A. Drowsiness B. Seizure activity C. Fluid imbalance D. Suicidal ideation

Correct Answer: B Stimulants increase the excitatory neurotransmitters (e.g., adrenaline and dopamine), lowering the seizure threshold. A person who is under the heavy influence of stimulants will be unable to rest and sleep because of stimulation of the sympathetic nervous system.

34. A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. What is the most appropriate next question the nurse should ask the client? A. "Did you pass out?" B. "Can you take off your sunglasses?" C. "Are you injured anywhere else?" D. "How many feet did you fall?"

Correct Answer: B The nurse cannot quickly assess the client for raccoon eyes unless the sunglasses are removed. Raccoon eyes is periorbital ecchymosis around the eyes. If bilateral, it is highly suggestive of basilar skull fracture. It is caused by rupture of the meninges causing the venous sinuses to bleed into the arachnoid villi and cranial sinuses, resulting in pooling of blood around the eyes. It most often is associated with fractures of the anterior cranial fossa and requires immediate attention.

41. A 7-year-old child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. The nurse concludes that the presence of the oculocephalic reflex in an unconscious child is: A. Unusual B. Expected C. Suppressed D. Hyperactive

Correct Answer: B This reflex indicates the functional integrity of the brainstem in unconscious individuals. It is not unusual in the unconscious child; it is absent in conscious individuals, whose extraocular movements are controlled voluntarily. Extraocular movements are not suppressed in unconscious individuals. This reflex is not hyperactive in the unconscious individual.

16. A nurse is caring for a client who had a brain attack (cerebrovascular accident) two weeks ago. What should the nurse do to help the client develop independence? A. Establish long-range goals for the client. B. Reinforce success in tasks accomplished. C. Point out errors in performance on which to focus. D. Explain ways the client can regain independence in activities.

Correct Answer: B To aid in motivation, the nurse should focus on positive aspects of the client's progress. Short-term, not long-term, attainable goals provide positive reinforcement; the nurse should assist the client to set goals. Negative reinforcement may result in discouragement. Return demonstration by the client is more effective than telling or showing what to do.

69. A nurse in the emergency department is assessing a 10-month-old infant who was injured in an automobile collision. The infant, who is quiet but does not appear lethargic, has a large hematoma on the left temporal area. What sign of neurological involvement is the most critical to identify? A. Babinski reflex B. Persistent vomiting C. Heart rate of 110 beats/min D. Temperature of 99.6° F (37.6° C)

Correct Answer: B Vomiting frequently accompanies a head injury because of increased intracranial pressure and stimulation of the vomiting reflex.

15. A client arrives at the emergency department with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? Select all that apply. A. Pupil response to light B. Verbal response to speech C. Eye opening in response to speech D. Deep tendon reflexes in response to percussion E. Motor activity in response to a verbal command

Correct Answer: B,C,E Assessing a client's verbal response to the nurse's speech is one of the three criteria for determining level of consciousness with the Glasgow Coma Scale. Assessing eye opening in response to the nurse's speech is one of the three criteria for assessing level of consciousness with the Glasgow Coma Scale. Assessing a client's motor response to a verbal command is one of the three criteria for assessing level of consciousness with the Glasgow Coma Scale.

12. A nurse is performing a neurological assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of a client? A. Tuning fork B. Ophthalmoscope C. Tongue depressor D. Cotton and a straight pin

Correct Answer: C A tongue depressor is used to depress the tongue to observe the pharynx and larynx, and to assess soft palate symmetry and the presence of the gag reflex; the information obtained provides data about cranial nerve X (vagus). -A tuning fork is used to assess cranial nerve VIII (auditory). -An ophthalmoscope is used to assess cranial nerve II (optic). -Cotton and a straight pin are used to assess sensory function: light touch and pain.

24. A client who had a cerebrovascular accident (CVA, also known as "brain attack") is starting to eat lunch. What client behavior indicates to the nurse that the client may be experiencing left hemianopsia? A. Asks to have food moved to the left side of the tray. B. Drops the coffee cup when trying to use the right hand. C. Ignores the food on the left side of the tray when eating. D. Complains about not being able to use the left arm to help eat.

Correct Answer: C Clients with left hemianopsia cannot see whatever is in the left field of vision.

76. A client is admitted with a head injury. The nurse identifies that the client's urinary retention catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? A. Increased serum glucose B. Deficient renal perfusion C. Inadequate antidiuretic hormone (ADH) secretion D. Excess amounts of intravenous (IV) fluid

Correct Answer: C Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body and excess amounts of urine are produced.

70. A client who had a brain attack (cerebral vascular accident) several months ago is readmitted to the hospital for a complication of immobility. The nurse reviews the client's laboratory test results, obtains vital signs, and performs a physical assessment. Data reveal elevated white blood cells (WBCs), fever of 101.2, and crackles upon auscultation of the bases bilaterally. Based on the results of the client's work-up, which prescribed medication should the nurse consider the priority at this time? A. Warfarin (Coumadin) B. Ferrous sulfate (Feosol) C. Levofloxacin (Levaquin) D. Acetaminophen (Tylenol)

Correct Answer: C Increased WBC, temperature, and respirations suggest the development of pneumonia, which interferes with oxygenation and can be life threatening; levofloxacin is an antibiotic to treat pneumonia.

7. The mother of a 7-year-old boy arrives at the emergency department with her son. The child reports that he hit his head after falling from his treehouse, and he says that he saw stars. Later he complains of a headache and feeling sick to his stomach. The nurse assesses his motor responses by evaluating his ability to: A. Draw a picture. B. Balance on one foot. C. Squeeze the nurse's hand. D. Walk slowly around the room

Correct Answer: C Motor responses are tested by assessing the strength of the hand grasps, movement, and strength of the upper and lower extremities.

30. A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for: A. Labored breathing B. Edema of the neck C. Difficulty in swallowing D. Alteration in blood pressure

Correct Answer: C Muscles used for swallowing are innervated by the ninth (glossopharyngeal) and tenth (vagus) cranial nerves.

64. The day after brain surgery a 9-year-old child with type 1 diabetes has a temperature of 103.0° F (39.4° C). What does the nurse suspect as the probable cause of the fever? A. Infection usually develops in children with diabetes after surgery. B. High temperatures are expected in children after surgical procedures. C. Cerebral edema after brain surgery exerts pressure on the hypothalamus. D. Excessive viscid secretions resulted in inadequate respiratory ventilation.

Correct Answer: C Pressure on the hypothalamus, the temperature-regulating mechanism of the brain, causes temperature imbalances.

74. A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The client's plan of care should include: A. Keeping the client's head turned to the right B. Approaching the client from the left side C. Teaching the client to use head movements to scan the left field of vision D. Arranging the furniture in the client's room so that the door is in the right visual field

Correct Answer: C The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field.

27. An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication of this type of surgery should the nurse explain to the home caregivers to prepare them for the patient's discharge? A. Excessive fluid accumulation in the abdomen. B. Eyes with sclera visible above the irises. C. Fever accompanied by decreased responsiveness. D. Violent involuntary muscle contractions.

Correct Answer: C The most common complication of surgery would be infection as evidenced by fever and decreased responsiveness. This is true for a patient of any age.

71. After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. The main reason the nurse places the infant in this position after this particular surgery is that it: A. Prevents aspiration B. Promotes respiration C. Reduces intracranial pressure D. Maintains cleanliness of the suture site

Correct Answer: C The side-lying position with the head slightly elevated promotes venous return by gravity, which helps reduce intracranial pressure, a problem after myelomeningocele repair.

13. A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. What does the nurse identify as the main reason that this medication is administered? A. It acts as a diuretic. B. It has a sedative effect. C. It acts as an anticonvulsant. D. It has an antihypertensive effect.

Correct Answer: C The target tissue of magnesium sulfate is the myoneural junction; it decreases secretion of acetylcholine, thereby depressing neuromuscular transmission, which prevents seizures.

51. A client has left hemiplegia because of a cerebrovascular accident (also known as "brain attack"). What can the nurse do to contribute to the client's rehabilitation? A. Begin active exercises. B. Make a referral to the physical therapist. C. Position the client to prevent contractures. D. Avoid moving the affected extremities unless necessary.

Correct Answer: C To prevent contractures after a brain attack, the client should be positioned in functional alignment and passive range-of-motion exercises should be performed.

85. A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a: A. Contusion B. Concussion C. Nose fracture D. Basilar fracture

Correct Answer: D A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear.

33. A nurse is caring for a client who had a hypophysectomy. For which complication specific to this surgery should the nurse assess the client for early clinical manifestations? A. Urinary retention B. Respiratory distress C. Bleeding at the suture line D. Increased intracranial pressure

Correct Answer: D Because the pituitary gland is located in the brain, edema after surgery may result in increased intracranial pressure. Early signs include decreased visual acuity, papilledema, and unilateral pupillary dilation.

93. A client with a cerebrovascular accident (also known as a "brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? A. Routine hygiene B. Liquid formula diet C. Prevention of aspiration D. Effective communication

Correct Answer: D Clients with dysarthria have difficulty communicating verbally, and an alternate means of communication may be indicated.

88. What should the nurse assess for in the immediate postoperative period after a client has brain surgery? A. Tachycardia B. Constricted pupils C. Elevated diastolic pressure D. Decreased level of consciousness

Correct Answer: D Decreased level of consciousness is a sign of increasing intracranial pressure, which may occur after a craniotomy.

80. A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis, but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are: A. Inflammed peripheral nerves B. Temporary and will go away with time C. Relieved by resting before performing activities D. Caused by blood pooling in the lower extremities

Correct Answer: D Dilation of blood vessels causes dependent pooling when the client moves to an upright position, resulting in cerebral hypoxia. The client can limit feelings of lightheadedness and dizziness by moving gradually when changing positions.

20. An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home? A. Visibility of the sclerae above the irises B. Violent involuntary muscle contractions C. Excessive fluid accumulation in the abdomen D. Fever accompanied by decreased responsiveness

Correct Answer: D Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus.

22. A client with a head injury has been receiving dexamethasone (Decadron). The health care provider plans to reduce the dosage gradually and to continue a lower maintenance dosage. Which effect associated with the gradual dosage reduction of the drug should the nurse explain to the client? A. Builds glycogen stores in the muscles B. Produces antibodies by the immune system C. Allows the increased intracranial pressure to return to normal D. Promotes return of cortisone production by the adrenal glands

Correct Answer: D Hormone therapy must be withdrawn slowly to allow the adrenal glands to adjust and resume production of their hormone.

1. The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next? A. Turn the client to the unaffected side B. Cleanse the client's ear with sterile gauze C. Place sterile cotton loosely in the external canal of the left ear D. Test the drainage from the client's ear with a glucose reagent strip

Correct Answer: D If a basilar skull fracture has occurred, the cerebrospinal fluid (CSF) may drain through the client's ears or nose. This clear fluid may be tested with a glucose reagent strip; if the result is positive for glucose, then the fluid might be CSF. However, this test is not always reliable.

31. A client is admitted to the hospital with the diagnosis of a right-sided brain attack (stroke). The client is right-handed. Which task will be most difficult for this client? A. Eating meals B. Writing letters C. Combing the hair D. Dressing every morning

Correct Answer: D If the client is right-handed there will be difficulty with dressing because it requires the use of two hands, and some clothing requires movement of both sides of the body when dressing. A right-handed client is able to continue to use the right hand for eating meals, writing letters, and combing the hair because it is the left side that is affected by a lesion on the right side of the brain.

48. A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure? A. Hypervigalence B. Constricted pupils C. Increased heart rate D. Widening pulse pressure

Correct Answer: D Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated. Decrease in heart rate.

87. A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The health care provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client? A. Physical therapy B. Psychosocial support C. Nutritional management D. Antimicrobial administration

Correct Answer: D Preventing infection through the use of prophylactic antibiotics is the priority.

57. A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI? A. By checking the gag reflex B. By asking the adolescent to swallow C. By stroking the plantar surface of the foot D. By telling the adolescent to shrug the shoulders

Correct Answer: D The accessory nerve (cranial nerve XI) innervates the sternocleidomastoid and trapezius muscles; the nurse evaluates this nerve by asking the client to shrug the shoulders.

18. A nurse in the pediatric clinic is assessing an infant who had a revision of a ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial pressure has increased? A. Increased pulse rate B. Hypoactive reflexes C. Decreased blood pressure D. Tension of the anterior fontanel

Correct Answer: D The anterior fontanel will be widened and tense because of the increased volume of cerebrospinal fluid. -The pulse rate will be decreased with increased intracranial pressure. -The reflexes will be hyperactive with increased intracranial pressure. -The blood pressure will be higher with increased intracranial pressure.

50. A client comes into the emergency department with neurologic deficits after falling off a ladder. What client assessment is included in the Glasgow Coma Scale? A. Breathing patterns B. Deep tendon reflexes C. Eye accommodation to light D. Motor response to verbal commands

Correct Answer: D The three areas of assessment to determine the level of consciousness using the Glasgow Coma Scale are motor response to verbal commands, eye-opening in response to speech, and verbal response to speech.

97. A client is diagnosed as having a right-sided brain attack (cerebrovascular accident) and is admitted to the hospital. When preparing to care for this client, the nurse should: A. Apply elastic stockings to prevent flaccid leg muscles B. Use a bed cradle to prevent dorsiflexion of the feet C. Implement passive range-of-motion (ROM) exercises to prevent muscle atrophy D. Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures

Correct Answer: D Using a hand roll while supporting the left upper extremity on a pillow to prevent contractures will maintain the affected left arm in functional alignment; the left side of the body will be affected with a right-sided brain attack. Passive ROM exercises prevent contractures rather than muscle atrophy; the institution of ROM exercises should be discussed with the health care provider because activity during the acute phase can increase intracranial pressure and should be avoided.

9. The nurse, caring for a 3-year-old child with meningitis, should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply. A. Vomiting B. Headache C. Irritability D. Tachypnea E. Hypotension

Correct Answer: A,B,C Increased intracranial pressure can precipitate vomiting because of its effect on the chemoreceptor trigger zone in the medulla. Because the cranial sutures are closed by this age, increased pressure can cause headache. Irritability results from increased pressure in the cranium and as a response to related discomforts.

29. Which of the following processes have the strongest links to intracranial regulation? (Select all that apply): A. Cognition. B. Mobility. C. Oxygenation. D. Perfusion. E. Safety.

Correct Answer: A,B,C,D Cognition, mobility, oxygenation, and perfusion have the strongest links to intracranial regulation and include processes that are essential for the nurse to consider when caring for a patient with intracranial concerns. Cognitive function is dependent on an optimally functioning brain. Mobility is frequently affected by intracranial regulation problems, with the most common example being a cerebrovascular accident. Perfusion and oxygenation are intimately involved with intracranial regulation, and without adequate perfusion and oxygenation, the brain cannot function.

100. When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Select all that apply. A. Breathing B. Pulse rate C. Fat metabolism D. Blood vessel diameter E. Temperature regulation

Correct Answer: A,B,D The medulla, part of the brainstem just above the foramen magnum, is concerned with vital functions such as respirations.

53. An older adult who was in a motor vehicle collision is brought to the emergency department via ambulance. The client exhibits a decreased level of consciousness, and the nurse identifies serosanguinous drainage from the client's left ear. What should the nurse do? A. Irrigate the ear with normal saline. B. Place a sterile pad over the external ear. C. Wipe away the drainage in the ear canal. D. Pack a cotton ball in the external meatus of the ear.

Correct Answer: B A lowered level of consciousness indicates a potential head injury, and drainage from an ear may be cerebrospinal fluid; a sterile pad gently affixed over the ear will absorb drainage and prevent infection.

40. Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive? A. Pons B. Medulla C. Midbrain D. Thalamus

Correct Answer: B The medulla contains the vital respiratory, cardiac, and vasomotor centers. The pons conducts impulses; it contains reflex centers for cranial nerves V, VI, VII, and VIII (trigeminal, abducent, facial, and vestibulocochlear, respectively). The midbrain is associated with sensory input from the eyes and ears. The thalamus relays sensory impulses to the cerebral cortex.

17. A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin (Dilantin) for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? A. "Did you forget to take your medication?" B. "You are worried about having more seizures?" C. "You must be under a lot of stress right now." D. "Don't be too concerned because your medication needs to be increased."

Correct Answer: B The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication.

59. A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? Select all that apply. A. Taste B. Breathing C. Heart rate D. Fluid balance E. Voluntary movement

Correct Answer: B and C The medulla, part of the brain stem just above the foramen magnum, is concerned with vital functions, such as breathing. The medulla is concerned with vital functions, such as heart rate.

92. Two hours after birth an area of soft swelling develops in the newborn's left parietal region. Where should the nurse find the area of involvement? A. Over the eyes B. Behind the ears C. In back of the head D. On the top of the skull

Correct Answer: D The parietal areas behind the frontal bone form the top surfaces of the cranial cavity.

56. A 4-year-old child is admitted to the pediatric neurological service with a seizure disorder. Shortly after admission, while in bed, the child has a generalized seizure. What nursing actions are most appropriate? Select all that apply. A. Assessing the seizure B. Taking the child's vital signs C. Turning the child on the side D. Pulling the padded side rails up E. Initiating oxygen administration

Correct Answers: A,C,D Therapeutic management is based on an accurate description of the seizure. Turning the child on one side or the other allows drainage of secretions that cannot be swallowed during the seizure. The first safety precaution is to prevent injury by raising the padded side rails. It is impossible to take vital signs during a seizure. Administering oxygen is useless because the child does not breathe during a seizure.

62. A nurse is caring for a client who sustained trauma to the head. What criteria should a nurse evaluate to determine the client's score on the Glasgow Coma Scale (GCS)? Select all that apply. A. Degree of incontinence B. Pupillary reaction to light C. Quality of verbal response D. Ability to follow commands E. Stimulus needed to open the eyes

Correct Answers: C,D,E Best verbal response is included in the GCS; it ranges from oriented to no response. Best motor response is included in the GSC scale; it ranges from obeys commands to no response. Eye opening response is included in the GCS; it ranges from spontaneous to no response.

72. When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by the: A. Medulla B. Cerebellum C. Hypothalamus D. Cerebral cortex

Correct Answer: A The medulla oblongata contains the respiratory center, and the neurons that supply the respiratory muscles originate here; they produce the rhythmic pattern of inspiration and expiration.

52. A 1-month-old infant with hydrocephalus is scheduled to have surgery for the insertion of a ventriculoperitoneal shunt. What is the primary focus of nursing interventions for this infant? A. Maintaining a satisfactory comfort level to limit crying B. Applying bandages to the infant's head to protect it from injury C. Establishing a fixed feeding schedule to ensure appropriate hydration D. Providing play objects to maintain age-appropriate stimulation for the child

Correct Answer: A Preventing crying will avoid sudden increases in intracranial pressure.

82. A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. The nurse recognizes that it is important to identify restrictions of mobility or neuromuscular abnormalities because: A. Shortening and eventual atrophy of the muscles will occur. B. Hypertrophy of the muscles eventually will result from disuse. C. Rigid extension can occur, making therapy painful and difficult. D. Decreased movement on the affected side predisposes the client to infection.

Correct Answer: A Shortening and eventual atrophy of muscles occur, resulting in contractures.

58. A client with a cerebrovascular accident (also known as a "brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? A. Routine hygiene B. Liquid formula diet C. Prevention of aspiration D. Effective communication

Correct Answer: D Clients with dysarthria have difficulty communicating verbally, and an alternate means of communication may be indicated.

75. An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. What should the nurse do when caring for the infant during the initial postoperative period? A. Change the dressing when soiled. B. Offer the infant fluids to increase fluid intake. C. Place the infant flat with the head on the unaffected side. D. Encourage the parents to hold their infant to help prevent crying.

Correct Answer: C A flat position helps prevent complications associated with too-rapid reduction of intracranial fluid.

90. A client has left hemiplegia because of a cerebrovascular accident (also known as "brain attack"). What can the nurse do to contribute to the client's rehabilitation? A. Begin active exercises. B. Make a referral to the physical therapist. C. Position the client to prevent contractures. D. Avoid moving the affected extremities unless necessary.

Correct Answer: C To prevent contractures after a brain attack, the client should be positioned in functional alignment and passive range-of-motion exercises should be performed.

19. A client is admitted to the emergency department with a head injury. Assessment findings include restlessness, cool and damp skin, equal and reactive pupils, and the ability to move all extremities on command. A computed tomography (CT) scan shows a subdural hematoma. The nurse understands that this condition means there is: A. Fluid in the subdural space B. Blood in the subarachnoid space C. Fluid between the dura and the skull D. Blood between the dura mater and the arachnoid layer

Correct Answer: D A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges.

43. A 6-year-old child undergoes supratentorial craniotomy for evacuation of a subdural hematoma. In what position should the nurse place the child during the first 24 hours after surgery? A. At a 45-degree angle B. At a 90-degree angle C. In the supine position D. In the side-lying position

Correct Answer: A A potential problem after supratentorial surgery is increasing intracranial pressure; elevating the head of the bed facilitates cerebral drainage by way of gravity. Sitting upright is uncomfortable after surgery. Keeping the child flat in bed, either supine or side-lying, inhibits cerebral drainage and contributes to increasing intracranial pressure.

67. A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. The nurse documents this response as: A. Anomia B. Apraxia C. Dysarthria D. Dysphagia

Correct Answer: A Clients with anomia cannot remember names of objects.

86. Which observation during a developmental appraisal of a 6-month-old infant is most important to the nurse in light of a diagnosis of hydrocephalus? A. Head lag B. Babinski reflex C. Inability to sit unsupported D. Absence of the grasp reflex

Correct Answer: A Head lag in an infant who is 6 months old is abnormal and is frequently a sign of cerebral damage.

63. A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 and a blood pressure (BP) of 120/80. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? A. Pulse 50 and BP 140/60 B. Pulse 56 and BP 130/110 C. Pulse 60 and BP 126/96 D. Pulse 120 and BP 80/60

Correct Answer: A Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate.

44. A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe: A. Hyperextension of both the upper and lower extremities B. Spastic paralysis of both the upper and lower extremities C. Hyperflexion of the upper extremities and hyperextension of the lower extremities D. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities

Correct Answer: A Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign.

3. The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern? A.Marked irritability B.Complaints of pain C. Pulse of 100 beats/min D. Temperature of 99.4° F (37.4° F)

Correct Answer: A Marked irritability may be a sign of malfunction of the shunt or infection and should be reported immediately.

32. A child with meningitis suddenly assumes an opisthotonic position. In what position should the nurse position the child? A. Side-lying B. Knee-chest C. High Fowler D. Trendelenburg

Correct Answer: A Maximal safety and comfort are ensured with the side-lying position because the child's neck and back are hyperextended. The knee-chest position is impossible because the child is in a rigid opisthotonic position, with the neck and back hyperextended. The high Fowler is impossible because the child is in a rigid position with the neck and back hyperextended. The Trendelenburg position increases intracranial pressure and is contraindicated in meningitis.

39. A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. The nurse explains to the parents that the primary reason this procedure is performed is to: A. Determine the causative agent. B. Identify the presence of blood. C. Reduce the intracranial pressure. D. Measure the spinal fluid glucose level.

Correct Answer: A Organisms that cause meningitis are often harbored in the spinal fluid. The lumbar puncture helps determine whether meningitis is present and whether the causative agent is bacterial or viral. Although some blood may be found in the spinal fluid, its presence is not a confirmation of the diagnosis of meningitis.

4. A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs? A. Lubricating the skin with baby oil B. Suctioning the oropharynx routinely C. Elevating the head of the bed 20 degrees D. Cleansing the eyes every four hours with normal saline

Correct Answer: B Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure.