56: Acute intercranial pressure

The nurse is caring for four patients in the intensive care unit (ICU). Which patient with an infection is at the highest risk for the development of cerebral edema? 1 A patient with encephalitis 2 A patient with cerebral thrombosis 3 A patient who sustained a contusion from a fall 4 A patient with hydrocephalus from a malfunctioning shunt

1 A patient with encephalitis Encephalitis is a cerebral infection that can cause cerebral edema. Hydrocephalus is the buildup itself of fluid in the brain. A contusion is bruising. A thrombosis is a blood clot in the circulatory system.

A patient is diagnosed with viral encephalitis and is hospitalized. What drug does the nurse anticipate administering? 1 Acyclovir 2 Ampicillin 3 Vidarabine 4 Vancomycin

1 Acyclovir Acyclovir is the drug of choice to treat viral encephalitis because it has fewer side effects. Ampicillin and vancomycin are used to treat bacterial meningitis. Vidarabine is used to treat encephalitis, but it has more side effects than acyclovir

A nurse is caring for a patient with a brain injury as a result of a car accident. On admission, the patient's vital signs are blood pressure (BP), 132/72; pulse 100 beats/minute; and respirations 24. Later, the nurse reassesses the patient's vital signs. Which set of vital signs should the nurse report to the physician immediately? 1 Blood pressure 172/54, pulse 58 beats/minute, respirations 10 2 Blood pressure 136/84, pulse 88 beats/minute, respirations 26 3 Blood pressure 112/56, pulse 98 beats/minute, respirations 28 4 Blood pressure 126/68, pulse 110 beats/minute, respirations 32

1 Blood pressure 172/54, pulse 58 beats/minute, respirations 10 1 Blood pressure 172/54, pulse 58 beats/minute, respirations 10

What is the appropriate action by the nurse if an assessment of a patient scheduled for a lumbar puncture reveals increased intracranial pressure (ICP)? 1 Cancel the lumber puncture. 2 Schedule the lumbar puncture for the next day. 3 Perform the lumbar puncture immediately. 4 Administer intravenous fluids before the lumber puncture.

1 Cancel the lumber puncture. Lumbar puncture may cause cerebral herniation due to the sudden release of pressure in the skull from the area above the punctured site and is contraindicated in a patient with increased ICP, so it should be cancelled. Scheduling the lumbar puncture for the next day may not reduce the risk of cerebral herniation. Performing the lumbar puncture immediately may cause cerebral herniation. Administering intravenous fluids does not reduce the risk of cerebral herniation.

The nurse determines that a patient's mean arterial pressure (MAP) is below 70 mm Hg. What outcome of this MAP should be of most concern to the nurse? 1 Decreased cerebral blood flow (CBF) 2 Increased intracranial pressure (ICP) 3 Increased cerebral perfusion pressure (CPP) 4 Normal intracranial pressure (ICP)

1 Decreased cerebral blood flow (CBF) A MAP below 70 mm Hg results in a decreased CBF. It will not result in an increased or normal ICP. The cerebral perfusion pressure will be decreased. A MAP below 70 mm Hg does not necessarily guarantee a normal ICP.

When evaluating level of consciousness on the basis of the Glasgow Coma Scale (GCS), which possible responses could be scored under best motor response? Select all that apply. 1 Flexion withdrawal 2 Localization of pain 3 Obedience of command 4 Disorganized use of words 5 Opening the eyes in response to sound

1 Flexion withdrawal 2 Localization of pain 3 Obedience of command Flexion withdrawal, localization of pain, and obedience of command can be recorded under best motor response. Opening of the eyes in response to stimuli and disorganized use of words are not recorded under motor response.

The nurse is caring for a patient with meningitis that has a fever. Which parameter should be monitored to prevent complications for this patient? 1 Fluid intake 2 Urine output 3 Blood pressure 4 Respiratory rate

1 Fluid intake A patient with a fever may develop dehydration, so the patient's fluid intake should be assessed. Urine output, blood pressure, and respiratory rate might be altered with fever, but monitoring these parameters would not help prevent any complications in a patient with meningitis

The nurse is caring for a patient with increased intracranial pressure (ICP). What seizure precautions should the nurse take to protect the patient? Select all that apply. 1 Keep suction equipment readily available. 2 Provide sufficient stimulation to the patient. 3 Use seizure treatment only after confirming the diagnosis. 4 Use padded side rails and maintain an airway at the bedside. 5 Use prophylactic antiseizure therapy during first seven days after injury.

1 Keep suction equipment readily available. 4 Use padded side rails and maintain an airway at the bedside. 5 Use prophylactic antiseizure therapy during first seven days after injury. Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Prophylactic antiseizure therapy can be used during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate his condition; therefore, the environment should be quiet. Seizure treatment should be used prophylactically; instead of waiting for the confirmation of diagnosis or the seizures to happen, the nurse should administer antiseizure treatment in such a situation.

The nurse is caring for a patient experiencing increased intracranial pressure (ICP). What is the priority nursing action in the care of this patient? 1 Monitor fluid and electrolyte status carefully. 2 Position the patient in a high Fowler's position. 3 Administer vasoconstrictors to maintain cerebral perfusion. 4 Maintain physical restraints to prevent episodes of agitation.

1 Monitor fluid and electrolyte status carefully. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors typically are not administered in the treatment of ICP.

A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment? Select all that apply. 1 Monitor fluid intake and sodium levels regularly. 2 Monitor patient's sleep and diet routine regularly. 3 Perform blood glucose monitoring at least every six hours. 4 Avoid taking any antacids along with corticosteroid treatment. 5 Start concurrent treatment with antacids or proton pump inhibitors.

1 Monitor fluid intake and sodium levels regularly. 3 Perform blood glucose monitoring at least every six hours. 5 Start concurrent treatment with antacids or proton pump inhibitors. Patients on corticosteroid treatment should be regularly monitored for fluid intake and sodium levels. Blood glucose monitoring should be performed at least every six hours until hyperglycemia is ruled out. Starting concurrent treatment with antacids or proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding, because complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal bleeding. Regularly monitoring the patient's sleep and diet routine does not contribute to avoiding complications related to corticosteroid therapy. Antacids should be given along with corticosteroids to prevent gastrointestinal complications. Test-Taking Tip: Try putting questions and answers in your own words to test your understanding.

The nurse is caring for a patient who sustained a head injury during a fall. Which factors influence intracranial pressure (ICP)? Select all that apply. 1 Posture 2 Swallowing 3 Drowsiness 4 Temperature 5 Carbon dioxide levels 6 Intraabdominal pressure

1 Posture 4 Temperature 5 Carbon dioxide levels 6 Intraabdominal pressure Posture, temperature, intraabdominal pressure, and carbon dioxide levels all influence ICP. Swallowing does not affect ICP. Drowsiness may be a sign of increased ICP, but it does not influence it.

When performing a neurologic assessment on a patient, the nurse notes fixed pupils that are unresponsive to a light stimulus. Which causes of fixed pupils should the nurse consider during this assessment? Select all that apply. 1 Previous eye surgery 2 Administration of diuretics 3 Increased intraocular pressure 4 Increased intracranial pressure (ICP) 5 Direct injury to the third cranial nerve (CN III)

1 Previous eye surgery 4 Increased intracranial pressure (ICP) 5 Direct injury to the third cranial nerve (CN III) A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eye drops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need to be prepared for which treatment modality? 1 Surgery 2 Chemotherapy 3 Radiation therapy 4 Biologic drug therapy

1 Surgery Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur

When performing an assessment on a patient with a head injury, which objective data does the nurse record? Select all that apply. 1 Headache 2 Battle's sign 3 Projectile vomiting 4 Past health history 5 Mechanism of injury 6 Cranial nerve deficits

2 Battle's sign 3 Projectile vomiting 6 Cranial nerve deficits Battle's sign, projectile vomiting, and cranial nerve deficits are objective data the nurse will record when assessing a patient with a head injury. A headache is considered subjective data. While the mechanism of injury may be helpful information, it is not part of the assessment itself. Past health history is considered subjective data.

The nurse is caring for a patient with increased intracranial pressure (ICP). What actions should the nurse perform as a part of nutritional therapy? Select all that apply. 1 Keep the patient in a hypovolemic fluid state. 2 Begin parenteral nutrition if oral intake is not adequate. 3 Begin nutritional replacement within three days after injury. 4 Wait for at least seven days to begin nutritional replacement. 5 Evaluate the patient's urine output, fluid loss, and electrolyte balance.

2 Begin parenteral nutrition if oral intake is not adequate. 3 Begin nutritional replacement within three days after injury. 5 Evaluate the patient's urine output, fluid loss, and electrolyte balance. For a patient with increased ICP, parenteral nutrition should be started if oral intake is not adequate. Nutritional replacement should begin within three days after injury. The patient's urine output, fluid loss, and electrolyte balance should be monitored to evaluate the effectiveness of nutritional therapy. The patient should not be kept in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, full nutritional replacement should be reached within seven days after injury.

A patient sustained head trauma during a skiing accident and lost consciousness but was then awake and alert. What complication of a head trauma might this patient have developed that results in bleeding between the dura and the inner surface of the skull? 1 Contusion 2 Epidural hematoma 3 Subdural hematoma 4 Intracerebral hematoma

2 Epidural hematoma An epidural hematoma is bleeding between the dura and the inner surface of the skull. The patient may lose consciousness followed by a period of being awake and alert. A subdural hematoma is bleeding between the dura and the arachnoid layer of the meninges. An intracerebral hematoma is bleeding into the brain tissue. A contusion is bruising of the brain tissue within a focal area

When a patient's systemic arterial pressure is altered, how does the brain respond? 1 It decreases intracranial pressure. 2 It autoregulates. 3 It increases intracranial pressure. 4 It increases brain compliance.

2 It autoregulates. Autoregulation is a normal response that occurs in the brain when systemic arterial pressure is altered. Intracranial pressure alterations, decreasing or increasing, are not an initial response to systemic pressure changes. Compliance is the expandability of the brain and is not an initial response to systemic arterial pressure change

The nurse is planning to administer pharmacologic therapy for a patient with increased intracranial pressure (ICP). Which factors should the nurse consider? Select all that apply. 1 Use benzodiazepines as a standalone treatment for sedation. 2 Monitor for hypotension when using opioids to manage anxiety. 3 Monitor for hypotension when using continuous intravenous sedatives. 4 Use nondepolarizing neuromuscular blocking agents alone for better outcomes. 5 Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

2 Monitor for hypotension when using opioids to manage anxiety. 3 Monitor for hypotension when using continuous intravenous sedatives. 5 Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents. The appropriate factors to evaluate include monitoring for hypotension when using opioids to manage anxiety and monitoring for hypotension when using continuous intravenous sedatives, because hypotension is a side effect. Using sedatives or analgesics with nondepolarizing neuromuscular blocking agents is important because these agents paralyze muscles without blocking pain or noxious stimuli. Using benzodiazepines as a standalone treatment for sedation is not advisable due to their hypotensive effects and long half-life. Nondepolarizing neuromuscular blocking agents paralyze muscles without blocking pain or noxious stimuli; they are used in combination with sedatives, analgesics, or benzodiazepines.

A patient was ejected from a car during a motor vehicle crash and has a diagnosis of subdural hematoma. Which type of brain injury does this represent? 1 Anoxia 2 Primary 3 Cerebral 4 Secondary

2 Primary Primary injuries are those that occur at the time of the injury (blunt force trauma, car accident); the subdural hematoma is itself an example of this. Secondary injuries are those injuries resulting from the primary injury; for instance, increased intracranial pressure may result from the hematoma. A cerebral injury is damage to the cerebrum, and an anoxia injury results from a lack of oxygen to the brain.

When considering the use of hypertonic saline treatment in a patient with increased intracranial pressure (ICP), which factors should the nurse consider? Select all that apply. 1 The nurse should closely monitor blood sugar levels in the patient. 2 The nurse should frequently monitor the blood pressure and sodium levels. 3 Hypertonic saline treatment works similarly to mannitol in treating increased ICP. 4 Hypertonic saline treatment provides massive movement of water out of swollen brain cells. 5 The nurse should ensure that antacid is given to prevent gastrointestinal complications.

2 The nurse should frequently monitor the blood pressure and sodium levels. 3 Hypertonic saline treatment works similarly to mannitol in treating increased ICP. 4 Hypertonic saline treatment provides massive movement of water out of swollen brain cells. Hypertonic saline provides massive movement of water out of swollen brain cells and into blood vessels. When the patient is on this treatment, frequent monitoring of blood pressure and sodium levels is required because intravascular fluid volume excess can occur. Hypertonic saline is as effective as mannitol in treating increased ICP. The treatment does not require monitoring of blood sugar levels, and antacids are not required to be given.

The nurse suspects a patient has increased intracranial pressure. Which assessment findings may indicate this condition? Select all that apply. 1 The patient is alert and oriented. 2 The patient is experiencing hemiplegia. 3 The patient has unilateral pupil dilation. 4 The patient has a regular respiratory rate of 14. 5 The patient is vomiting without preceding nausea.

2 The patient is experiencing hemiplegia. 3 The patient has unilateral pupil dilation. 5 The patient is vomiting without preceding nausea. Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. A patient with increased intracranial pressure would likely have an impaired level of consciousness rather than being alert and oriented. He or she would also have an irregular, not regular, respiratory rate

patient with a head injury has a score of five on the Glasgow Coma Scale. How should the nurse interpret the score? 1 The patient is alert and oriented. 2 The patient is unresponsive and comatose. 3 The patient is awake but lethargic and drowsy. 4 The patient responds appropriately to commands.

2 The patient is unresponsive and comatose. The Glasgow Coma Scale ranges from 3 to 14. A score of seven or less indicates that a patient is in a coma. The lower the score, the more serious the patient's condition. A patient who is alert and orient, awake but lethargic, or responding appropriately to commands has a Glasgow Coma Scale score higher than seven.

How many meningococcal polysaccharide vaccine doses are recommended for the vaccination of bacterial meningitis? 1 One 2 Two 3 Three 4 Four

2 Two The meningococcal polysaccharide vaccine is given in two doses to prevent bacterial meningitis.

A nurse is caring for a patient with a traumatic brain injury and increased intracranial pressure (ICP). Which symptom would the nurse report to the physician immediately? 1 ICP of 20 mm Hg 2 Urine output of 1000 mL in 1 hr 3 Respiratory rate of 24 4 Pulse of 100 beats/minute

2 Urine output of 1000 mL in 1 hr An increased urine output of 1000 mL in one hour could cause critical fluid and electrolyte imbalance issues and needs prompt attention; this indicates a decline in the patient's condition. An ICP of 20 mm Hg, respiratory rate of 24, and pulse of 100 beats/minute do not indicate a need for the nurse to call the physician.

Which type of cerebral edema occurs mainly in the white matter and is characterized by leakage of large molecules from the capillaries into the surrounding space? 1 Interstitial cerebral edema 2 Vasogenic cerebral edema 3 Hypoxic cerebral edema 4 Cytotoxic cerebral edema

2 Vasogenic cerebral edema Vasogenic cerebral edema occurs mainly in the white matter and is the most common type characterized by leakage of large molecules from the capillaries into the surrounding space. Interstitial cerebral edema is usually a result of hydrocephalus. Hypoxia is a lack of oxygen to the brain and does not cause cerebral edema, though the edema may cause the hypoxia. Cytotoxic cerebral edema results from disruption of the integrity of the cell membranes from lesions or trauma.

patient with increased intracranial pressure (ICP) will undergo lumbar puncture for cerebrospinal fluid (CSF) drainage. In which order are the necessary actions performed for intermittent CSF drainage? 1. Allow CSF to drain for two to three minutes. 2. Determine that the ICP is above the indicated level. 3. Close the stopcock to return the ventriculostomy to a closed system. 4. Open the ventriculostomy system at the indicated ICP.

2, 4, 1, 3 Reading that the ICP is above the indicated level is the first step. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. Once the stopcock is opened, allowing CSF to drain for two to three minutes helps to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step.

A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above how many mm Hg to preserve cerebral perfusion? 1 20 2 40 3 60 4 80

3 60 Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained above 60 mm Hg to preserve cerebral perfusion.

The nurse is caring for a group of patients on the acute care unit. Which patient is at greatest risk for the development of bacterial meningitis? 1 A patient with a skull fracture 2 A patient with prior brain trauma 3 A patient with a pulmonary infection 4 A patient with bacterial endocarditis

3 A patient with a pulmonary infection A patient with a pulmonary infection is at a risk of developing bacterial meningitis. A skull fracture, bacterial endocarditis, and prior brain trauma or surgery places the patient at risk of developing brain abscess.

A patient with meningitis has seizures, cranial nerve (CN) III palsy, and bradycardia. What is the most likely cause for the development of these symptoms? 1 Cerebral abscess 2 Subdural effusion 3 Acute cerebral edema 4 Increased intracranial pressure

3 Acute cerebral edema Acute cerebral edema is a complication of meningitis that causes seizures, cranial nerve (CN) III palsy, and bradycardia. Cerebral abscess, subdural effusion, and increased intracranial pressure are complications of meningitis, but they do not cause the aforementioned symptoms.

A nurse is educating a patient's family about intracranial pressure (ICP). The nurse explains that normal ICP is a balance of which three components? 1 Blood pressure, brain tissue, body mass index 2 Glucose level, blood pressure, and brain tissue 3 Blood pressure, brain tissue, and cerebrospinal fluid 4 Blood pressure, brain tissue, and ventricles of the brain

3 Blood pressure, brain tissue, and cerebrospinal fluid Normal ICP involves a balance of blood pressure, brain tissue, and cerebrospinal fluid. The ventricles of the brain, glucose level, and body mass index do not contribute to maintaining normal ICP.

The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is suspected to have encephalitis. What type of encephalitis does the nurse anticipate the patient is at risk for? 1 La Crosse encephalitis 2 West Nile encephalitis 3 Cytomegalovirus encephalitis 4 Herpes simplex virus encephalitis

3 Cytomegalovirus encephalitis Cytomegalovirus encephalitis is commonly found in patients with acquired immunodeficiency syndrome (AIDS). La Crosse encephalitis and West Nile encephalitis are epidemic diseases transmitted by ticks and mites. Herpes simplex virus encephalitis is a nonepidemic encephalitis.

The nurse assesses a comatose head-injured patient and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. How can the findings be described? 1 Stroke 2 Epileptic seizure 3 Decorticate posturing 4 Decerebrate posturing

3 Decorticate posturing Decorticate posturing, described as flexion of the arms, wrists, and fingers and adduction of the upper extremities, indicates damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The assessment findings described are not specifically related to a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. Decerebrate posturing is described as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing, which may indicate more serious damage, results from disruption of motor fibers in the midbrain and brainstem.

A patient has a systemic blood pressure of 120/60 and an intracranial pressure (ICP) of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? 1 High blood flow to the brain 2 Normal intracranial pressure 3 Impaired blood flow to the brain 4 Adequate autoregulation of blood flow

3 Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = systolic blood pressure (SBP) + 2 (diastolic blood pressure [DBP])/3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP-ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.

The nurse is preparing to change the body position of a patient with increased intracranial pressure (ICP). Which factors should the nurse consider prior to changing the position? Select all that apply. 1 Placing the patient in side-lying position 2 Raising the head of bed above 30 degrees 3 Maintaining a head-up position for the patient 4 Taking care to prevent extreme neck flexion of patient 5 Adjusting the patient's body position to decrease intracranial pressure (ICP)

3 Maintaining a head-up position for the patient 4 Taking care to prevent extreme neck flexion of patient 5 Adjusting the patient's body position to decrease intracranial pressure (ICP) Maintaining a head-up position for the patient is important because elevation of the head of the bed promotes drainage and decreases the vascular congestion that can produce cerebral edema. The nurse should take care to prevent extreme neck flexion of the patient because it can cause venous obstruction and contribute to elevated ICP. The patient's body position should be adjusted to decrease ICP and improve the cerebral perfusion pressure (CPP). Raising the head of the bed above 30 degrees is not advisable because it may decrease the CPP by lowering systemic blood pressure (BP). Maintaining a side-lying position may further increase the ICP.

Following an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which behavior of the patient supports the nurse's conclusion? 1 Movement of the eye in the opposite direction to the turning head 2 Movement of the eye in the upward direction when the neck is flexed 3 Movement of the eye in the sideward direction when the neck is extended 4 Movement of the eye in the downward direction when the neck is extended

3 Movement of the eye in the sideward direction when the neck is extended The oculocephalic reflex is tested by having the patient turn his or her head briskly to the left or right while holding the eyelids open. The eye movement should be in the opposite direction and not in the sideward direction if the neck is extended. The sideward eye movement indicates an intracranial lesion. Movement of the eye in the opposite direction to the turning head is a normal response. Movement of eye in the upward direction if the neck is flexed is normal and does not indicate any abnormality. Movement of the eye in the downward direction if the neck is extended indicates a normal finding.

A patient with a brain tumor presents with symptoms of visual disturbances and seizures. When evaluating the patient, the nurse knows that this tumor is most likely located in which area of the brain? 1 Subcortical 2 Parietal lobe 3 Occipital lobe 4 Temporal lobe

3 Occipital lobe Manifestations of tumors in the occipital lobe include vision disturbances and seizures. Manifestations of tumors in the subcortical region include hemiplegia; other symptoms may depend on area of infiltration. Tumors in the parietal lobe present with speech disturbance (if the tumor is in the dominant hemisphere), dyscopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures, and dysphagia.

The nurse is assessing a comatose patient. Which findings does the nurse anticipate observing? Select all that apply. 1 Patient can cough and swallow. 2 Patient has bowel and bladder control. 3 Patient does not respond to painful stimuli. 4 Patient has incontinence of urine and feces. 5 Patient's corneal and pupillary reflexes are absent.

3 Patient does not respond to painful stimuli. 4 Patient has incontinence of urine and feces. 5 Patient's corneal and pupillary reflexes are absent. A coma is the deepest state of unconsciousness in which the corneal and pupillary reflexes are absent. A comatose patient is also incontinent of urine and feces and does not respond to painful stimuli. The comatose patient is not able to cough and swallow and does not have any bowel and bladder control.

At which stage of increased intracranial pressure (ICP) does a loss of autoregulation occur? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

3 Stage III In Stage III, there is a loss of autoregulation, and Cushing's triad will develop as decompensation increases. In Stage I, there is total compensation. In Stage II, compliance begins to decrease, and an increase in volume places the patient at risk for increased ICP. In Stage IV, the ICP rises to lethal levels, and brain herniation occurs.

The nurse preceptor is working with the newly licensed registered nurse in caring for a patient with a newly placed ventricular shunt. What statement made by the new nurse requires immediate intervention by the preceptor? 1 "I need to wear sterile gloves whenever I palpate the incision site." 2 "I should be concerned if my patient begins to vomit and has a headache." 3 "I need to compare my assessment findings now with preoperative assessments." 4 "I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches."

4 "I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches." Rapid decompression of intracranial pressure (ICP) can cause total body collapse, weakness, and headache by rapid position change. To prevent this, the patient should be gradually moved into an upright position. Infection of shunts can occur, so the nurse should use sterile precautions when assessing incision sites. To recognize changes in neurologic status, the nurse should compare postoperative findings with baseline to quickly recognize complications or establish improvement from the surgical intervention. Headache, vomiting, change in level of consciousness (LOC), restlessness, and visual disturbances are all indications of increased ICP from malfunction of the shunt.

The family of a patient who was admitted 12 hours ago with suspected meningitis approaches the charge nurse stating "We do not understand. We were told the spinal tap looks good. Why is everyone still wearing gowns and masks"? What is the best response by the nurse? 1 "I apologize. The isolation should have been discontinued." 2 "These precautions need to be continued as long as the patient is in the hospital." 3 "I will check with the health care provider and see if we can get the isolation discontinued." 4 "The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."

4 "The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available." Patients who are suspected of having meningitis should be placed in respiratory isolation until the spinal fluid cultures are negative or effective antibiotic therapy has been in place for 24 to 48 hours. The earliest culture reports can be released is 24 hours. Standard precautions are still essential when the patient is removed from isolation. There is no need to contact the health care provider because infection control policies dictate the necessity of isolation. Even if the patient is diagnosed with meningitis, respiratory isolation will be discontinued once effective antibiotic therapy has been in place for a specified period.

A patient sustained a concussion after a motor vehicle crash and is fully alert when arriving at the emergency department. What does the nurse document that the Glasgow Coma Scale score is? 1 3 2 6 3 8 4 15

4 15 The Glasgow Coma Scale is a quick, practical, and standardized system for assessing the level of consciousness in a patient. According to the Glasgow Coma Scale, the score of a fully alert patient will be 15. This includes 4 for spontaneous response of the patient when approached to bedside, 5 for appropriate response during verbal questioning, and 6 for obedience of commands. The lowest possible score according to the Glasgow Coma Scale is 3, which indicates severe coma conditions. A score of 6 or 8 indicates coma.

The nurse is performing an assessment of a patient with a closed head injury from a blunt object. What is the most reliable clinical manifestation to determine the patient may be developing increased intracranial pressure (ICP)? 1 Steady vital signs 2 Reports of a headache 3 Increased motor function 4 An altered level of consciousness (LOC)

4 An altered level of consciousness (LOC) Changes in the LOC are a result of impaired cerebral blood flow, which causes oxygen deprivation to the cerebral cortex and reticular activating system, so this is the most sensitive and reliable manifestation of ICP. A decrease, not increase, in motor function occurs as the ICP increases. A headache could indicate compression but could also be attributed to other causes. Changes in vital signs can be caused by increased ICP; they will not necessarily remain steady.

A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute. Two hours later the nurse assesses the patient. Which finding indicates deterioration in the patient's condition? 1 The patient does not remember what happened. 2 The patient is sleeping but awakens in response to painful stimuli. 3 Blood pressure is 110/80 mm Hg, pulse is 78 beats/minute, and respirations are 20 breaths/minute. 4 Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.

4 Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute. Late signs of increased intracranial pressure include an increased systolic blood pressure and decreasing diastolic blood pressure (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a blood pressure of 110/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute do not necessarily indicate deterioration in the patient's condition.

What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces? 1 Linear 2 Depressed 3 Compound 4 Comminuted

4 Comminuted A comminuted skull fracture has multiple linear fractures with fragmentation of bone into many pieces. A depressed fracture is an inward dentation of the skull. A linear fracture is a break in continuity of the bone, and a compound skull fracture involves a depressed skull fracture and scalp lacerations.

After assessing the patient, the nurse declines to administer mannitol to the patient. Which condition supports this nursing intervention? 1 Cerebral edema 2 Cerebral tissue swelling 3 Increased serum osmolality 4 Increased intracranial pressure (ICP)

4 Increased intracranial pressure (ICP) Mannitol increases osmotic effect and may cause neurologic complications; it is contraindicated in a patient with increased serum osmolality. Mannitol is used to treat cerebral edema, cerebral tissue swelling, and increased ICP because of its diuretic effect.

A patient who sustained a head injury in a motorcycle crash has a baseline Glasgow Coma Scale (GCS) score of 14. The nurse recognizes signs of increasing intracranial pressure on the basis of what assessment findings? 1 Increased systolic blood pressure, increased pulse, GCS score of 12 2 Decreased diastolic blood pressure, decreased pulse, and GCS score of 13 3 Increased systolic and diastolic blood pressure, increased pulse, GCS score of 9 4 Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4

4 Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4 One classic sign of increasing intracranial pressure and neurologic deterioration is increased systolic blood pressure and decreased diastolic blood pressure (resulting in a widening pulse pressure) accompanied by bradycardia. Hypertension, bradycardia, and bradypnea together are known as the Cushing's triad. Increased systolic blood pressure, increased pulse, and GCS of 12 and decreased diastolic blood pressure, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic blood pressure, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the blood pressure and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score, reflecting a fully awake, alert, and oriented patient. Anything less than 8 is considered a coma.

A patient is brought to the emergency room with a head injury and is at risk of developing increased intracranial pressure. Which is the most reliable indicator that the nurse should use for assessing the patient's neurologic status? 1 Dim vision 2 Papilledema 3 Body temperature 4 Level of consciousness

4 Level of consciousness The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Dim vision can occur due to dysfunction of cranial nerves. Papilledema, which is an edematous optic disc seen on retinal examination, can be noted and is a nonspecific sign associated with persistent increases in intracranial pressure (ICP). A change in body temperature may also occur because increased ICP affects the hypothalamus.

patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). The patient has been maintained on intravenous (IV) fluids for two days. The nurse seeks enteral feeding for this patient based on what rationale? 1 Free water should be avoided. 2 Sodium restrictions can be managed. 3 Dehydration can be avoided better with feedings. 4 Malnutrition promotes continued cerebral edema.

4 Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious, and with increased ICP is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within three days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.

A patient with meningitis has adhesions that prevent the normal flow of cerebrospinal fluid from the ventricles. Which complication might be observed first? 1 Cerebral abscess 2 Acute cerebral edema 3 Cranial nerve irritation 4 Noncommunicating hydrocephalus

4 Noncommunicating hydrocephalus Adhesions preventing the normal flow of cerebrospinal fluid lead to an obstruction of the foramen magnum, which causes noncommunicating hydrocephalus. Cerebral abscess is an accumulation of pus within the brain tissue. An acute cerebral edema is an abnormal increase in water content within the extracellular fluid of the brain. The condition occurs due to hydrocephalus. Cranial nerve irritation is caused by neurologic dysfunctions, because of increased intracranial pressure

The nurse is reviewing the medical records of a patient with acquired immunodeficiency syndrome (AIDS) that has been diagnosed with a brain tumor. What tumor growth is associated with AIDS? 1 Metastatic tumor 2 Acoustic neuroma 3 Pituitary adenoma 4 Primary central nervous system lymphoma

4 Primary central nervous system lymphoma Lymphocyte production is affected in patients with AIDS. Primary central nervous system lymphoma originates from lymphocytes and, therefore, is seen in patients with AIDS. Metastatic tumors are malignant types that originate in the lungs and breasts. Acoustic neuroma is a low-grade malignancy, which originates from cells that form myelin sheath. Pituitary adenoma is usually benign and originates from the pituitary gland.

A patient experienced head trauma in a motor vehicle crash. What steps in order of the pathophysiology of the progression from injury to severe increased intracranial pressure (ICP) and death does the nurse recognize is occurring? 1. Increased ICP from increased blood volume 2. Decreased cerebral blood flow 3. Increased ICP with brainstem compression 4. Increased ICP 5. Tissue edema from initial insult 6. Compression of ventricles and blood vessels

5 4 6 2 3 1 After initial insult to the brain, there is tissue edema, which causes an initial increase in ICP, then compression of ventricles and blood vessels, which decreases cerebral blood flow, thus decreasing O2 and causing death of brain cells. Edema occurs around this necrotic tissue, and ICP is increased with compression of the brainstem and respiratory center, leading to accumulation of CO2. ICP is increased further from increased blood volume, which leads to death.

What is the gold standard for measuring intracranial pressure (ICP)? 1 Ventriculosotomy 2 Fiberoptic catheter 3 Air pouch/pneumatic 4 Transcranial Doppler

A ventriculosotomy is the gold standard for measurement of ICP. A fiberoptic catheter and air pouch/pneumatic are other measures for monitoring ICP, but they are not considered the gold standard. A transcranial Doppler evaluates blood flow in the brain.

A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? Test the drainage for the presence of glucose. Apply a loose gauze pad under the patient's nose. Place the patient in a modified Trendelenburg position. Ask the patient to gently blow the nose to clear the drainage.

Apply a loose gauze pad under the patient's nose. Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

Bradycardia Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A 68-yr-old man with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? Codeine Phenytoin (Dilantin) Ceftriaxone (Rocephin) Acetaminophen (Tylenol)

Ceftriaxone (Rocephin) Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

Which conditions can lead to the development of a brain abscess h (select all that apply.)? Endocarditis Ear infection Tooth abscess Skull fracture Scalp laceration Sinus infection

Endocarditis Ear infection Tooth abscess Skull fracture Sinus infection Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? Judgment Eye opening Abstract reasoning Best verbal response Best motor response Cranial nerve function

Eye opening Best verbal response Best motor response The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

What inflammatory condition is the most common cause of acute nonepidemic encephalitis? 1 St. Louis encephalitis 2 Eastern equine encephalitis 3 Western equine encephalitis 4 Herpes simplex virus encephalitis

Herpes simplex virus encephalitis Herpes simplex virus encephalitis is the most common cause of acute nonepidemic viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western equine cause epidemic encephalitis.

A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? High blood flow to the brain Normal intracranial pressure Impaired blood flow to the brain Adequate autoregulation of blood flow

Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? Monitor fluid and electrolyte status carefully. Position the patient in a high Fowler's position. Administer vasoconstrictors to maintain cerebral perfusion. Maintain physical restraints to prevent episodes of agitation.

Monitor fluid and electrolyte status carefully. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? Tonic spasms of the legs Curling in a fetal position Arching of the neck and back Resistance to flexion of the neck

Resistance to flexion of the neck Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? Administer IV mannitol Ventilator use to hyperoxygenate the patient Use strict aseptic technique with dressing changes. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

Use strict aseptic technique with dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.