Exam 3: Intracranial Problems NCLEX Questions
c
A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patients bed to 60 degrees. b. Document the BP and ICP in the patients record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patients vital signs and ICP.
c d
A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temp. 99, pulse 100, respirations 18, and BP 140/70. The nurse should report which changes should they occur to the HCP? Select all that apply a. decreasing urinary output b. decreasing systolic BP c. bradycardia d. widened pulse pressure e. tachycardia
d
When assessing the bodily functions of a patient with increased ICP, what should the nurse assess first? a. corneal reflex testing b. pupillary reaction to light c. extremity strength testing d. circulatory and respiratory status
a
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.
c
An unconscious patient with increased ICP is on ventilatory support. Which ABG measurement should prompt the nurse to notify the HCP? a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 70 mm Hg d. PaCO2 of 35 mm Hg
c
A client has an increased ICP of 20 mm Hg. The nurse should a. give the client a warming blanket b. administer low-dose barbituates c. encourage the client to take deep breaths to hyperventilate d. restrict fluids
d
A client is recovering from a head injury and is participating in care. The nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? a. blowing the nose b. isometric exercises c. coughing vigorously d. exhaling during repositioning
b d
A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply a. suction the endotracheal tube frequently b. decrease the noise level in the client's room c. elevate the client's head on two pillows d. administer a stool softener e. keep the client well hydrated
b
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a. hyperglycemia b. hyponatremia c. hypervolemia d. oliguria
c
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a. Glascow Coma Scale b. cranial nerve function c. oxygen saturation d. pupillary response
b
After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patients neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.
c
An early sign of increased ICP that the nurse should assess for is a. Cushing's triad b. unexpected vomiting c. decreasing LOC d. dilated pupil with sluggish response to light
a
An unconscious client with multiple injuries to the head and neck arrives in the ED. What should the nurse do first? a. establish an airway b. determine the identity of the client c. stop bleeding from open wounds d. check for a neck fracture
a
During admission of a patient with a severe head injury to the ED, the nurse places the highest priority on assessment for a. patency of airway b. presence of a neck injury c. neurologic status with the GCS d. cerebrospinal fluid leakage from the ears or nose
c
The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? a. Document the ICP reading in the chart. b. Determine if the patient has a headache. c. Assess the patient's level of consciousness. d. Position the patient with head elevated 60 degrees.
a c e
Which factors decrease cerebral blood flow? Select all that apply a. increased ICP b. PaO2 of 45 c. PaCO2 of 30 d. arterial blood pH of 7.3 e. decreased MAP
a
Which respiratory pattern indicates increased ICP in the brain stem? a. slow, irregular respirations b. rapid, shallow respirations c. asymmetric chest expansion d. nasal flaring
b
The nurse administers mannitol to the client with increased ICP. Which parameters requires close monitoring? a. muscle relaxation b. intake and output c. widening of the pulse pressure d. pupil dilation
c
Which activity should the nurse encourage the client to avoid when there is a risk for increased ICP? a. deep breathing b. turning c. coughing d. passive ROM exercises
b c d
The nurse has established a goal to maintain ICP within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply a. encourage client to cough to expectorate secretions b. elevate the head of bed 15-20 degrees c. contact the HCP if ICP is >15 d. monitor neurologic status using the GCS e. stimulate the client with active ROM exercises
b
Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated intracranial pressure (ICP), causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below?
d
The nurse is assessing a client for decerebrate posturing. The nurse should assess the client for a. internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b. back hunched over and rigid flexion of all 4 extremities with supination of arms and plantar flexion of feet c. supination of arms and dorsiflexion of the feet d. back arched and rigid extension of all 4 extremities
d
How are the metabolic and nutritional needs of the patient with increased ICP best met? a. enteral feedings that are low in sodium b. simple glucose available in D5W IV solutions c. fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate
c
How is cranial nerve III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brainstem? a. assess for nystagmus b. test the corneal reflex c. test pupillary reaction to light d. test for oculocephalic (doll's eyes) reflex
d
The nurse is assessing a client with increasing ICP. The nurse should notify the HCP about which early change in the client's condition? a. widening pulse pressure b. decrease in the pulse rate c. dilated, fixed pupils d. decrease in LOC
b d e
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 a. Judgment b. Eye opening c. Abstract reasoning d. Best verbal response e. Best motor response
d
The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? a. Monitor cerebrospinal fluid color hourly. b. Document intracranial pressure every hour. c. Turn and reposition the patient every 2 hours. d. Check capillary blood glucose level every 6 hours.
a
The client has sustained increased ICP of 20 mm Hg. Which client position would be most appropriate? a. the HOB elevated 15-20 degrees b. trendelenburg position c. left Sims' position d. the head elevated on two pillows
b
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? a. Test the drainage for the presence of glucose. b. Apply a loose gauze pad under the patient's nose. c. Place the patient in a modified Trendelenburg position. d. Ask the patient to gently blow the nose to clear the drainage.
b
A nurse plans care for the patient with increased ICP with the knowledge that the best way to position the patient is to a. keep the head of bed flat b. elevate the head of bed to 30 degrees c. maintain the patient on the left side with the head supported on a pillow d. use a continuous-rotation bed to continuously change patient position
d
Skull x-rays and a CT scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the ED following an automobile accident. In planning care for the patient, what should the nurse anticipate? a. the patient will receive life support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial cavity c. the patient will be treated conservatively with close monitoring for changes in neurologic status d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium
a
A client is at risk for increased ICP. Which finding is the priority for the nurse to monitor? a. unequal pupil size b. decreasing systolic BP c. tachycardia d. decreasing body temperature
b
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head.
d
The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient? a. deafness, lost of taste, and CSF ottorhea b. CSF otorrhea, vertigo, and Battle's sign with a dural tear c. boggy temporal muscle because of extravasation of blood d. headache, retrograde amnesia, and transient reduction in LOC
d
The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24-48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC
a
A patient has ICP monitoring with an intraventricular catheter. What is a priority nursing intervention for the patient? a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities
a
A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient? a. avoid positioning the patient with neck and hip flexion b. maintain hyperventilation to a PaCO2 of 15-20 mm Hg c. cluster nursing activities to provide periods of uninterrupted rest d. routinely suction to prevent accumulation of respiratory secretions
c
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? a. High blood flow to the brain b. Normal intracranial pressure c. Impaired blood flow to the brain d. Adequate autoregulation of blood flow
a
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).
d
A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be better avoided with feedings. d. Malnutrition promotes continued cerebral edema.
b
A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain. d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.
b
After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.
c
The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury c. develops decreased LOC and a headache within 48 hours of a head injury d. has an immediate loss of consciousness with a brief lucid interval followed by a decreasing LOC
b
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)? a. Tachypnea b. Bradycardia c. Hypotension d. Narrowing pulse pressure
a d
The nurse is monitoring a client with increased ICP. What indicators are the most critical for the nurse to monitor? Select all that apply a. systolic BP b. urine output c. breath sounds d. cerebral perfusion pressure e. level of pain
a b d e
The nurse is monitoring a patient for increased ICP following a head injury. What are manifestations of increased ICP? Select all that apply a. fever b. oriented to name only c. narrowing pulse pressure d. right pupil dilated greater than left pupil e. decorticate posturing to painful stimulus
a
The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg
c
The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes? a. increased pulse, irregular respiration, increased BP b. decreased pulse, increased respiration, decreased systolic BP c. decreased pulse, irregular respiration, widened pulse pressure d. increased pulse, decreased respiration, widened pulse pressure
a
What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status carefully. b. Position the patient in a high Fowler's position. c. Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation.
c
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? a. compress the nares b. tilt the head back c. collect the drainage d. administer an antihistamine for postnasal drip
a
When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patients pulse is slightly irregular. c. The patients blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.
b
When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. This type of monitoring system is complex and highly skilled staff are needed. b. The monitoring system helps show whether blood flow to the brain is adequate. c. The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure. d. This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.
c
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. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.
b
When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings? a. the P2 wave is higher than the P1 wave b. CSF is leaking around the monitoring device c. the stopcock of the drainage device is open to drain the CSF fluid d. the transducer of the ventriculostomy monitor is at the level of the upper ear
c
Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min
d
Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure
b
Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. I will return if I feel dizzy or nauseated. b. I am going to drive home and go to bed. c. I do not even remember being in an accident. d. I can take acetaminophen (Tylenol) for my headache.
a
While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patients nose. Which of these admission orders should the nurse question? a. Insert nasogastric tube. b. Turn patient every 2 hours. c. Keep the head of bed elevated. d. Apply cold packs for facial bruising.
a b d
Which events cause increased ICP? Select all that apply a. vasodilation b. necrotic cerebral tissue c. blood vessel compression d. edema from initial brain insult e. brainstem compression and herniation
d
A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.
b
A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage? a. examine the tympanic membrane for a tear b. test the fluid for a halo sign on a white dressing c. test the fluid with a glucose-identifying strip d. collect 5 mL of fluid in a test tube and send it to the laboratory for analysis
c
The patient comes to the ED with cortical blindness and visual field defects. Which type of head injury does the nurse expect? a. cerebral contusion b. orbital skull fracture c. posterior fossa fracture d. frontal lobe skull fracture
a
When a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6 F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg
a
When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patients blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.
d
Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? a. Bruising under both eyes b. Complaint of severe headache c. Large ecchymosis behind one ear d. Temperature of 101.5 F (38.6 C)
b
Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light
