Lippincott NCLEX Review -The Client With A Head Injury -

2. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. 1. Systolic blood pressure. 2. Urine output. 3. Breath sounds. 4. Cerebral perfusion pressure. 5. Level of pain.

1, 4 1. Systolic blood pressure. 4. Cerebral perfusion pressure. The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

22. When evaluating an arterial blood gas report from a client with a subdural hematoma who had surgery and is now on a ventilator, the nurse notes the PaCO2 is 35 mm Hg (4.7 kPa). The ventilator settings are: TV 400, respiration rate 24, FIO2 100%. What should the nurse do first? 1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. 2. Position the client with the head of bed elevated. 3. Continue to monitor the client. 4. Inform the charge nurse of the results of the report.

1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Since the client's PaCO2 level is normal (35 to 45 mm Hg or 4.7 to 6.0 kPa), paging the respiratory technician to change the respiration rate is an appropriate action. Elevating the head of the client's bed is contradicted with this client's condition: that would lower blood pressure and care of these patients involves maintenance of a flat position in bed for 24 hours after surgery. Continuing to monitor the client is inappropriate because the PaCO2 level is normal and the respiratory technician needs to adjust the hyperventtilation setting to normal on the ventilator since the lab indicates that PaCo2 is normal. Informing the charge nurse about the change in ventilator settings is not necessary at this time because this is expected care for this client.

6. An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? 1. Establishing an airway. 2. Replacing blood loss. 3. Stopping bleeding from open wounds. 4. Checking for a neck fracture.

1. Establishing an airway. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.

10. Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? 1. Slow, irregular respirations. 2. Rapid, shallow respirations. 3. Asymmetric chest excursion. 4. Nasal flaring.

1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

13. The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1. The head of the bed elevated 30 to 45 degrees. 2. Trendelenburg's position. 3. Left Sims' position. 4. The head elevated on two pillows.

1. The head of the bed elevated 30 to 45 degrees. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.

8. A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? 1. Unequal pupil size. 2. Decreasing systolic blood pressure. 3. Tachycardia. 4. Decreasing body temperature.

1. Unequal pupil size. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

4. A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply. 1. Find a television so the client can view the football game. 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. 4. Arrange for the client to be with his wife and baby. 5. Administer a sedative.

2, 3 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.

1. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of- motion exercises.

2, 3, 4 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

21. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other. 2. Elevating the head of the bed to 30 degrees. 3. Logrolling or turning as a unit when turning. 4. Keeping the neck in a neutral position.

2. Elevating the head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies.

14. The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? 1. Muscle relaxation. 2. Intake and output. 3. Widening of the pulse pressure. 4. Pupil dilation

2. Intake and output. After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

20. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: 1. Count the rate to be sure that ventilations are deep enough to be suffcient. 2. Notify the physician of the client's breathing pattern. 3. Increase the rate of ventilations. 4. Increase the tidal volume on the ventilator.

2. Notify the physician of the client's breathing pattern. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings

16. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? 1. Place in a jacket restraint. 2. Wrap the hands in soft "mitten" restraints. 3. Tuck the arms and hands under the drawsheet. 4. Apply a wrist restraint to each arm.

2. Wrap the hands in soft "mitten" restraints. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

18. A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: 1. Exhibit no further episodes of short-term memory loss. 2. Be able to return to his construction job in 3 weeks. 3. Actively participate in the rehabilitation process as appropriate. 4. Be emotionally stable and display pre-injury personality traits.

3. Actively participate in the rehabilitation process as appropriate. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.

17. Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1. Deep breathing. 2. Turning. 3. Coughing. 4. Passive range-of-motion (ROM) exercises.

3. Coughing. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

11. Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? 1. Give the client a warming blanket. 2. Administer low-dose barbiturates. 3. Encourage the client to hyperventilate. 4. Restrict fluids.

3. Encourage the client to hyperventilate. Normal ICP is 15 mm Hg or less or 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

9. What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client tissues to collect the fluid. 4. Administer an antihistamine for postnasal drip.

3. Give the client tissues to collect the fluid. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

7. A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse do the following as a part of a plan to care for this client? 1. Request a prescription for haloperidol (Haldol) 2. Maintain a quiet environment. 3. Assure client's safety. 4. Approach the client using short sentences.

4,3,2,1 4. Approach the client using short sentences. 3. Assure client's safety. 2. Maintain a quiet environment. 1. Request a prescription for haloperidol (Haldol) The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining the care given. The nurse should also assure the client's safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective. When the underlying problems related to the head injury are resolved, the delirium likely will improve.

23. A client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? 1. "I'll get your family." 2. "Can you tell me your name and where you live?" 3. "I'll bet you're a little confused right now." 4. "You are in the hospital. You were in an accident and unconscious."

4. "You are in the hospital. You were in an accident and unconscious." It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" is not helpful and may cause anxiety.

19. Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet. 3. Supination of arms, dorsifexion of the feet. 4. Back arched, rigid extension of all four extremities.

4. Back arched, rigid extension of all four extremities. Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

12. The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? 1. Widening pulse pressure. 2. Decrease in the pulse rate. 3. Dilated, fixed pupils. 4. Decrease in level of consciousness (LOC)

4. Decrease in level of consciousness (LOC) A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

15. The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? 1. The client's shoulders shrug against downward pressure of the examiner's hands. 2. The client's arm pulls up from a resting position against resistance. 3. The client's arm straightens out from a flexed position against resistance. 4. The client's hand-grasp strength is equal.

4. The client's hand-grasp strength is equal. The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a flexed position against resistance.

3. A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? _______________mm Hg.

80mm Hg To obtain the MAP, use this formula: MAP = [systolic BP + (2 x diastolic BP)] ÷ 3 MAP = [120 + (2 x 60)] ÷ 3 MAP= 240 ÷ 3 = 80