N476 FINAL CH17
26. When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the: a.corneal reflexes are absent. b.patient develops nystagmus. c.right pupil does not react to light. d.left pupil is 10 mm in size.
ANS: C A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation.
13. The patient's respiratory pattern is characterized by rhythmic crescendo and decrescendo in the rate and depth of respiration and brief periods of apnea. The nurse recognizes that this is usually a sign of: a.deep cerebral lesions. b.cortical lesions. c.brainstem injury. d.subarachnoid hemorrhage.
ANS: A Cheyne-Stokes respirations are characterized by rhythmic crescendo and decrescendo in the rate and depth of respiration, including brief periods of apnea. This pattern is usually seen with bilateral deep cerebral lesions and some cerebellar lesions.
5. The nurse reads in the progress notes that the patient has decerebrate posturing. Which of the following actions will the nurse expect to see? a.The patient extends both arms downward and outward in response to sternal rub. b.The patient flexes both arms and extends both legs in response to painful stimuli. c.The patient's head, neck, and torso spontaneously arch back in a severe spasm. d.The patient reacts to painful stimuli by reaching over with the opposite hand to the side where the pain is occurring.
ANS: A Decerebration is characterized by abnormal extension response, which may occur spontaneously or in response to noxious stimuli.
3. The patient flexes both arms upward in response to sternal rub. The nurse recognizes that this response is due to a lesion: a.above the midbrain, in the region of the thalamus or cerebral hemispheres. b.in the sympathetic pathways of the brainstem. c.in the vestibular system. d.in the cerebellum.
ANS: A Decortication is manifested by an abnormal flexion response that may occur spontaneously or in response to noxious stimuli. Abnormal flexion occurs with lesions above the midbrain, in the region of the thalamus or cerebral hemispheres.
15. The patient's husband is alarmed at the sight of a technician applying electrodes to his wife's head. The nurse explains to him: a."This is done to take an EEG or electroencephalogram. The results will help us identify the place in your wife's brain where the seizures are coming from." b."We are looking at how electricity is conducted through the tissue of her brain. This will help us determine whether she has a brain infection." c."This procedure will help us determine whether your wife is in a coma or simply in a very deep state of sleep." d."We can find out how her brain is responding to stimuli by sending electrical signals to the tissue."
ANS: A Electroencephalography differentiates epilepsy from mass lesion and identifies the focus of seizure activity.
4. The patient fails to respond to either nail bed pressure or sternal rub. The nurse notes this in the patient's chart as a _____ response. a.flaccid b.decorticate c.decerebrate d.localized
ANS: A Flaccidity is manifested by lack of response to painful stimuli.
22. When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider? a.Oral temperature 101.6° F b.Intracranial pressure 15 mm Hg c.Mean arterial pressure 70 mm Hg d.Apical pulse 106 beats/min
ANS: A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; the temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.
27. When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as: a.decorticate posturing. b.decerebrate posturing. c.localization of pain. d.flexion withdrawal.
ANS: A Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.
2. The patient has localized motor function. Which of the following actions would the nurse observe? a.The patient reaches with the left hand to stop nail bed pressure on the right index finger. b.The patient attempts to withdraw the left foot as it is being subjected to pressure on the left great toe. c.The patient has no response to pressure from a sternal rub. d.The patient has spontaneous extension responses to pressure on the right index finger.
ANS: A Localization of motor function occurs when the extremity opposite the one receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.
11. While assisting with a lumbar puncture, the nurse notes that the cerebrospinal fluid returning is cloudy. This is a symptom of: a.infection. b.traumatic tap. c.subdural hematoma. d.cerebral edema.
ANS: A The cerebrospinal fluid should be clear and colorless. Cloudiness results from the accumulation of white blood cells in response to the presence of microorganisms.
12. The patient's responses to environmental stimuli are minimal, and verbal responses are limited. The nurse will document the patient's consciousness level by describing the patient as: a.stuporous. b.delirious. c.lethargic. d.obtunded.
ANS: A The patient is obtunded as the patient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response.
21. Calculate the cerebral perfusion pressure (CPP) for a patient with a mean arterial pressure (MAP) = 95 mm Hg and an intracranial pressure (ICP) = 15 mm Hg. a.65 mm Hg b.80 mm Hg c.95 mm Hg d.110 mm Hg
ANS: B 80 mm Hg CPP = MAP - ICP (95 - 15 = 80)
10. The nurse observes that the patient with an intracranial injury has bradycardia, systolic hypertension, and widening pulse pressure. These signs may signal: a.deep coma. b.herniation syndrome. c.intracranial hypotension. d.improvement in the patient's condition.
ANS: B Cushing's triad is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem. These signs often occur in response to intracranial hypertension or a herniation syndrome.
8. The nurse observes that when the head is turned briskly the patient's eyes do not deviate in the opposite direction to the head turn. The nurse knows that this is a symptom of: a.cerebellar lesion. b.brainstem injury. c.cortical lesion. d.subarachnoid hemorrhage.
ANS: B If the oculocephalic reflex arc is not intact, the reflex is absent. This lack of response, in which the eyes remain midline and move with the head, indicates significant brainstem injury.
28. When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a.The blood pressure increases from 120/54 to 136/62. b.The patient is more difficult to arouse. c.The patient complains of a headache at pain level 5 on a 10-point scale. d.The patient's apical pulse is slightly irregular.
ANS: B The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications.
9. Injury to the medulla can result in interrupted transmission of impulses through the vagus nerve and cause: a.gastrointestinal dysfunction. b.respiratory dysfunction. c.altered mental status. d.peripheral motor paralysis.
ANS: B The lowest center, the medullary respiratory center, sends impulses through the vagus nerve to innervate muscles of inspiration and expiration.
19. The purpose of the computerized tomography (CT) scan is to: a.visualize the cerebral vasculature. b.obtain noninvasive visualization of the cerebral structures. c.obtain information about electrical activity in the brain. d.determine the size and shape of the cranial and spinal bones.
ANS: B The purpose of the CT scan is to obtain rapid, noninvasive visualization of the cerebral structures.
14. Reading the physician's order to prepare the patient for angiography, the nurse explains to the family that the purpose of the procedure is to: a.look for foreign bodies in the brain tissue. b.examine for tumors in the brain. c.assess the brain's vascular system for defects. d.evaluate the brain for signs of infection.
ANS: C Angiography visualizes extracranial and intracranial vasculature to identify aneurysm, arteriovenous malformation, vasospasm, and vascular tumors.
7. To assess the three cranial nerves of the eye in the conscious patient, the nurse will do which of the following? a.Percuss the nerves over the ocular area of the patient's face. b.Ask the patient to count the number of fingers displayed. c.Ask the patient to follow a finger through the full range of eye motion. d.Ask the patient to blink rapidly.
ANS: C In the conscious patient, the function of the three cranial nerves of the eye and their medial longitudinal fasciculus innervation can be assessed by asking the patient to follow a finger through the full range of eye motion. If the eyes move together into all six fields, extraocular movements are intact.
25. A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a.Blood pressure 130/72, pulse 90, respirations 32 b.Blood pressure 148/78, pulse 112, respirations 28 c.Blood pressure 156/60, pulse 60, respirations 14 d.Blood pressure 110/70, pulse 120, respirations 30
ANS: C Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP.
1. The breathing pattern of the patient with damage of the mid to lower pons will be altered with respect to: a.depth of inspiration. b.rhythm of respiration. c.length of inspiration and expiration d.depth of expiration.
ANS: C The apneustic and pneumotaxic centers of the pons are responsible for the length of inspiration and expiration and the underlying respiratory rate.
23. A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates: a.high blood flow to the brain. b.normal intracranial pressure (ICP). c.impaired brain blood flow. d.adequate cerebral perfusion.
ANS: C The patient's CPP is 56, below the normal range of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion.
24. A patient with a head injury has an arterial blood pressure of 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a.Documenting and continuing to monitor the parameters b.Elevating the head of the patient's bed c.Notifying the health care provider about the assessments d.Checking the patient's pupillary response to light
ANS: C The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP.
20. What is the role of the nurse in assisting the patient with diagnostic testing? a.Injection of contrast media b.Staying with the patient for each of the examinations c.Patient/family education about the procedures d.Ordering diuretics after injection of contrast media
ANS: C The role of the nurse in neurological diagnostic testing always includes patient/family education, physical preparation, and awareness of potential complications.
6. The nurse reads on the chart that the patient's Glasgow Coma Scale score is 6. Which of the following patient responses will the nurse observe, based on this score? a.The patient spontaneously opens the eyes, is oriented and alert, and obeys commands. b.The patient spontaneously opens the eyes, is confused with inappropriate verbal responses, and withdraws from noxious stimuli. c.The patient opens the eyes to noxious stimuli, makes incomprehensible verbalizations, and shows extension in response to painful stimuli. d.The patient shows no eye-opening response, no verbalization to stimuli, and no motor response to noxious stimuli.
ANS: C The score on the Glasgow Coma Scale can be computed as follows: eyes open to noxious stimuli = 2; incomprehensible sounds = 2; extension to noxious stimuli = 2.
18. The most serious complication of lumbar puncture (LP) in the critically ill patient is: a.bacterial meningitis. b.dural tear. c.brainstem herniation. d.spinal cord trauma.
ANS: C Two life-threatening risks associated with LP include possible brainstem herniation, if intracranial pressure is elevated, and respiratory arrest associated with neurological deterioration.
1. To obtain accurate intracranial pressure measurements from an intraventricular catheter, the nurse must do which of the following before every reading? (Select all that apply) a.Sedate the patient. b.Change the tubing to the fluid source. c.Balance and calibrate the transducer if needed. d.Ensure that the transducer is at a consistent level relative to external landmarks.
ANS: C, D All intracranial pressure measurements should be made with the transducer at a consistent level relative to external landmarks. The transducer in the intraventricular catheter must be frequently balanced and recalibrated.
17. Which of the following choices is an acceptable and recommended method of noxious stimulation for evaluating arousal? a.Nipple pinch b.Nail bed pressure c.Supraorbital pressure d.Sternal rub
ANS: D Acceptable methods of noxious stimulation for assessing arousal include sternal rub and trapezius pinch.
16. The priority assessment for a neurological examination is: a.motor function. b.respiratory function. c.papillary function. d.level of consciousness.
ANS: D Assessment of the level of consciousness is the most important aspect of the neurological examination. In most situations, a patient's level of consciousness deteriorates before any other neurological changes are noted.
Match each patient description with correct assessment of level of consciousness. a.Alert b.Delirious c.Lethargic d.Comatose 1. Mr. K appears somewhat wide-eyed and keeps asking, "Why is the dog barking?" 2. Ms. B appears to be asleep. The nurse must vigorously shake her shoulder before eliciting a response. 3. Mrs. P immediately responds appropriately to the nurse's cheery "Hello." 4. Mr. Z does not respond to vigorous stimulation except to withdraw his arm.
B, C, A, D