Chapter 10

A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which physiologic process will occur in this patient?

1. Cerebral blood vessels will constrict. 2. Cerebral blood vessels will dilate. 3. Blood flow to the cerebral cortex will slow. 4. Blood will be shunted from the cerebral cortex. Correct Answer: 2

The nurse, evaluating the tracing made from a patient's intracranial pressure monitor, notes the presence of many C waves. This finding would be indicative of:

1. Decreased cerebral compliance 2. Pending brain herniation 3. No evidence of pathology 4. Impaired cerebral spinal fluid flow Correct Answer: 3

A patient is admitted with a fracture to the base of the skull. What might the nurse assess in this patient?

1. Depressed respiratory rate 2. Ecchymoses of the neck 3. Increased intracranial pressure 4. Cerebral spinal fluid leak from the nose Correct Answer: 4

The nurse is caring for a patient with status epilepticus. The first goal of care for this patient would be to:

1. Determine the patient's medical history. 2. Obtain an EEG. 3. Maintain an airway. 4. Identify the cause of the seizure. Correct Answer: 3

The nurse is preparing to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment?

1. ECG 2. Brainstem functioning 3. Reflexes 4. Level of consciousness Correct Answer: 4

The nurse is planning care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient?

1. Encourage family and physician to discuss patient's care and prognosis in the patient's room. 2. Assess for daily bowel movement and provide intervention as appropriate. 3. Maintain head of bed at a 15-degree angle with knee elevation. 4. Cluster care activities. Correct Answer: 2

The nurse is going to assist with the assessment of a patient's oculovestibular reflex. What should be done before this reflex is assessed?

1. Ensure that the patient's spinal cord has been found intact. 2. Ensure that the patient has an intact gag reflex. 3. Determine that the patient can tolerate being in the supine position. 4. Determine that the patient has an intact tympanic membrane. Correct Answer: 4

When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), the nurse would:

1. Expect that any reduction in ICP will begin approximately an hour after the dose is administered. 2. Assess the patient carefully for the development of hypertension. 3. Review lab data to identify the presence of hypernatremia and hyperkalemia. 4. Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered. Correct Answer: 4

A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to:

1. Increased intracranial pressure 2. Hypoxic cerebral tissue 3. Increased urine output 4. Bradycardia Correct Answer: 2

A ventilated patient with a head injury needs to be suctioned. What will the nurse do to limit problems related to suctioning?

1. Limit the duration of each suctioning pass to less than 20 seconds. 2. Medicate with opiates after suctioning. 3. Reduce the flow of oxygen prior to suctioning. 4. Preoxygenate before suctioning. Correct Answer: 4

The nurse is providing care to a patient with an intracranial pressure monitoring device. What is a priority when providing care to this patient?

1. Monitor intracranial pressure every 4 hours. 2. Perform neurologic assessment checks every 2 hours. 3. Use clean technique when working with the system. 4. Use strict aseptic technique when working with the system. Correct Answer: 4

A patient comes into the emergency department with a fever, stiff neck, and change in mental status. On assessment it is learned that this patient also has a positive Kernig's sign. These findings suggest the patient:

1. Needs surgery to reduce intracranial pressure 2. Needs to be intubated 3. Should receive 100% oxygen via face mask 4. Has meningeal irritation Correct Answer: 4

The nurse is assessing a patient's corneal reflex. The cranial nerve that is being assessed with this reflex is:

1. Oculomotor 2. Optic 3. Trigeminal 4. Vagus Correct Answer: 3

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that what will most likely be implemented for this patient?

1. Prophylactic hypothermia treatment 2. High-dose barbiturate therapy 3. Intubation 4. Prophylactic anticonvulsant therapy Correct Answer: 4

A patient with a traumatic brain injury is showing signs of having pain. What would be the medication of choice for this patient?

1. Propofol 2. Meperidine 3. Morphine sulfate 4. Fentanyl Correct Answer: 3

A patient is being admitted after sustaining a head injury from an acceleration/deceleration motor vehicle accident. The type of injury that this patient most likely sustained would be:

1. Skull fracture 2. Penetrating 3. Concussion 4. Coup-countercoup Correct Answer: 4

When providing care to a patient with increased intracranial pressure, the nurse would be concerned about which clinical finding because it can result in an additional increase in intracranial pressure?

1. Temperature of 99°F (37.2°C) 2. Respiratory rate of 24 3. Serum sodium of 110 mEq/L 4. Blood pressure of 150/65 Correct Answer: 3

A patient who has suffered a traumatic brain injury has his blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by:

1. Weighing the patient to determine if the patient is fluid overloaded 2. Documenting the blood pressure and completing a neurologic assessment 3. Alerting the physician and preparing to administer an antihypertensive agent 4. Providing the patient with immediate pain and/or antianxiety medication Correct Answer: 2

A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is:

1. An anticonvulsant 2. A steroid 3. A barbiturate 4. A pain medication Correct Answer: 2

What would be appropriate for the nurse to do when assessing a patient's motor function?

1. Assess all four extremities together. 2. Assess the right leg and the right arm together. 3. Assess the arms together and then assess the legs separately. 4. Assess the left leg and the left arm together. Correct Answer: 3

A patient with a severe head injury has a pO2 of 88 and a pCO2 of 48. What should be done to support this patient?

1. Assess oxygen saturation and plan for intubation if saturation is below 86%. 2. Provide 100% oxygen via face mask. 3. Plan for a rapid sequence intubation. 4. Plan for a routine intubation. Correct Answer: 3

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response?

1. 1 2. 4 3. 2 4. 3 Correct Answer: 1

The nurse is providing medication to a patient with status epilepticus. The medication of choice for this patient would be:

1. A barbiturate 2. A steroid 3. An opioid 4. A benzodiazepine Correct Answer: 4

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of:

1. A cerebral spinal fluid leak 2. A subdural hematoma 3. An epidural hematoma 4. A subarachnoid hemorrhage Correct Answer: 3

What might a patient develop if intravenous phenytoin (Dilantin) was administered faster than 50 mg/minute?

1. A severe rash 2. Hypotension 3. Hematologic abnormalities such as agranulocytosis 4. A pronounced increase in heart rate Correct Answer: 2

A patient is demonstrating neurologic changes consistent with increasing intracranial pressure. For which primary causes of this pressure increase will the nurse assess at this time?

Select all that apply. 1. Cerebral hemorrhage 2. Ischemic stroke 3. Airway obstruction 4. Drop in blood pressure 5. Electrolyte imbalance Correct Answer: 1,2

The nurse is concerned that a patient's intracranial pressure monitor readings are incorrect. What can the nurse do to ensure that the monitor is measuring accurately?

Select all that apply. 1. Check the location of the stopcocks. 2. Check the position of the transducer. 3. Check the monitoring line for air. 4. Ensure the catheter is not obstructed. 5. Check to make sure the dressing is dry. Correct Answer: 1,2,3,4

A patient, diagnosed with a subdural hematoma, has an intracranial pressure of 14 mm Hg. The nurse realizes that if this pressure increases, the body may respond by:

Select all that apply. 1. Displacing cerebrospinal fluid into the lumbar cistern 2. Reabsorbing more cerebrospinal fluid 3. Shunting blood out of venous sinuses 4. Raising the body temperature 5. Increasing the carbon dioxide level Correct Answer: 1,2,3

A patient is diagnosed with meningitis that developed after experiencing otitis media. What will the nurse most likely assess in this patient?

Select all that apply. 1. Fever 2. Stiff neck 3. Confusion 4. Photophobia 5. Palpitations Correct Answer: 1,2,3,4

The nurse is teaching a patient, recovering from a mild brain injury, about manifestations to expect during the recovery process. What will the nurse instruct this patient to expect while recuperating from this injury?

Select all that apply. 1. Headache 2. Dizziness 3. Fatigue 4. Memory loss 5. Nausea Correct Answer: 1,2,3,4

The nurse is caring for a patient who sustained head and abdominal injuries from a motor vehicle crash. While the nurse is inserting a nasogastric tube to decompress the stomach, the patient begins to cough and gag. What cranial nerves did the nurse inadvertently assess when inserting the nasogastric tube into the patient?

Select all that apply. 1. IX (glossopharyngeal) 2. X (vagus) 3. V (trigeminal) 4. VII (facial) 5. III (oculomotor) Correct Answer: 1,2

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What would the nurse be more likely to assess in this patient than in one who had experienced a chronic subdural hematoma?

Select all that apply. 1. Loss of consciousness 2. Hemiparesis 3. Dysphagia 4. Confusion 5. Headache Correct Answer: 1,2,3

When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse would:

Select all that apply. 1. Monitor the patient for renal failure and pulmonary edema. 2. Administer any concentrations greater than 2% through a central line. 3. Monitor serum sodium levels frequently during administration. 4. Expect the patient's neurologic status and ICP will begin to improve within 15 minutes following administration. 5. Monitor the patient's serum osmolarity every 24 hours. Correct Answer: 1,2,3,4

A patient has been receiving treatment for status epilepticus for the last 20 minutes. What will the nurse prepare to implement to help the patient at this time?

Select all that apply. 1. Prepare for emergency intubation. 2. Insert an indwelling urinary catheter. 3. Monitor body temperature. 4. Obtain an order for a bedside electroencephalogram. 5. Insert an intravenous access line. Correct Answer: 1,2,3,4