Med/Surg ch 66

Cerebral edema peaks at which time frame after intracranial surgery?

24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.

Which phase of a migraine headache usually lasts less than an hour?

AURA Explanation: The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurologic symptoms. The prodrome phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the post headache phase, patients may sleep for extended periods.

Which of the following is a late sign of increased ICP?

Altered respiratory patterns Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache is an early sign of increased ICP. Irritability and any change in LOC are early signs of increased ICP. Speech changes, such as slowing or slurring, are early signs of increased ICP.

Which of the following medication classifications is utilized preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the patient with increased ICP

Which of the following is the earliest sign of increasing ICP?

Change in level of consciousness (LOC) Explanation: The earliest sign of increasing ICP is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate Explanation: Decerebrate posturing, the result of lesions at the midbrain, is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and plantar flexion of the feet?

Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper extremities and plantar flexion of the feet. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone.

Which of the following should be avoided in patients with increased ICP?

Enemas Explanation: Enemas should be avoided in patients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the patient raises ICP, rotating beds, turning sheets, and holding the patient's head during turning may minimize the stimuli that cause increased ICP.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

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

The nurse is caring for a patient with a ventriculostomy. Which assessment finding documented demonstrates effectiveness of the ventriculostomy?

IICP is 12 mm Hg. Explanation: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid (CSF) to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so an ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading of less than 50 is consistent with irreversible neurologic damage.

Which is the priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter?

Ineffective cerebral tissue perfusion Explanation: The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The patient is at risk for injury, but this is not first priority. The patient is at risk for fluid volume deficit due to a possible fluid restriction to maintain normovolemia, but this is not first priority. The patient is at risk for infection due to the placement of the intraventricular catheter, but again this is not first priority.

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate?

Place patient in supine position with head slightly elevated. Explanation: After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg position, and the prone position can increase intracranial pressure.

A patient experiences a seizure while hospitalized for appendicitis. During the postictal phase, the patient is yelling and swings with a closed fist at the nurse. Which of the following is the appropriate action for the nurse to take?

Reorient the patient while gently holding the arms. Explanation: Some patients during the postictal phase will become confused and agitated. This reaction is not intentional and most patients do not remember becoming agitated. The nurse should attempt to calm and reorient the patient, but also should gently hold the arms to prevent the patient from hitting. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the patient before applying wrist restraints. Lorazepam (Ativan) is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this patient.

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?

Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients. A patient with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratory distress.

A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?

Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

A patient with increased ICP has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP?

The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects?

To dehydrate the brain and reduce cerebral edema Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the patient with IICP. Although mannitol is a type of diuretic, it is not used to increase urine output. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

A female patient with meningitis has a history of seizures. Which of the following actions by the nurse is appropriate while the patient is actively seizing?

Turn the patient to the side Explanation: When a patient is in a seizure, the nurse should turn the patient to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway should not be inserted while the patient is actively seizing. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the patient is actively seizing could cause harm to the patient and is not indicated for seizure activity.

Which of the following are used to help reduce ICP?

Using a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

The nurse is caring for an 82-year-old patient diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered. Explanation: Cranial arteritis is caused by inflammation. The inflammation can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The patient should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Documentation of signs and symptoms of inflammation should be done by the nurse after measures have been taken to decrease complications.

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?

Assess for a patent airway. Explanation: A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.

The Monro-Kellie hypothesis refers to which of the following statements?

The dynamic equilibrium of cranial contents Explanation: The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. Cushing's response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.

Which interventions are appropriate for a patient with increased ICP? Select all that apply.

b) Frequent oral care c) Administering prescribed antipyretics d) Maintaining aseptic technique with the intraventricular catheter Explanation: Controlling a fever is an important intervention for a patient with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate for control of fevers. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the patient is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a patient with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated at 30 to 45 degrees and in a neutral position to allow for venous drainage.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply.

d) Maintain a headache diary. e) Keep a food diary. Explanation: The patients should be encouraged to keep a food and headache diary to identify triggers, and to track frequency and characteristics of the migraines. The patients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but the exercise may worsen the headache and associated symptoms. Patients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.

The nurse is caring for a patient involved in a motorcycle accident 7 days ago. Since admission the patient has been unresponsive to painful stimuli. The patient had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F rectal, urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which of the following is the priority nursing action?

Administer acetaminophen (Tylenol) per orders. Explanation: The nurse needs to control the fever by administering the ordered acetaminophen (Tylenol) as the priority action. An increase in the patient's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the patient has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.