ICP EXAM 6

. A patient with a cerebral injury is experiencing increased intracranial pressure (ICP). Which intervention should the nurse use to help prevent further increasing intracranial pressure? a. Avoid touching the patient as much as possible. b. Provide stimulation such as radio and television for 12 hours each day. c. Provide as much nursing care at one time as possible to allow the patient to rest. d. Space nursing care at intervals so that necessary care is distributed evenly throughout a shift.

. ANS: DThe nurse should space care activities to provide rest between each disturbance. C. Clustering care may raise ICP. B. Stimulation can also raise ICP. A. Avoiding touch is not necessary.

which positioning technique is not appropriate when the nurse changes a clients position in bed if the client has hemiparalysis? a. rolling the client onto the side b. sliding the client to move up in bed c. lifting the client when moving the client up in bed d. having the client help lift off the bed using a trapeze

2 sliding a cient on a sheet causes friction and is to be avoided. friction injures skin and predisposes to pressure ulcer formation. rolling the client is acceptable method to use when changing position as long as the client is maintained in an anatomically neutral position and the limbs are properly supported.

The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the carbon dioxide (CO2)should be maintained at what level? a. 10 to 15 mm Hg b. 15 to 20 mm Hg c. 20 to 25 mm Hg d. 25 to 30 mm Hg

ANS: D The CO2 level is set to be maintained at 25 to 30 mm Hg to create vascular constriction, raise blood pressure, and perfuse the cerebrum.

The nurse suspects that a patient is experiencing increasing intracranial pressure. What observations did the nurse make to come to this conclusion? (Select all that apply.) a. Headache b. Rising temperature c. Decreasing systolic pressure d. Dilated pupil on affected side e. Decreasing level of consciousness (LOC)

ANS: A, B, D, EHeadache, increasing systolic pressure, decreasing LOC, dilated pupil on affected side, and rising temperature are all signs of increased ICP. C. Decreasing systolic blood pressure is not associated with increased intracranial pressure.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

The nurse is caring for a patient with a neurologic injury who is awake. On assessment, the patient displays mild disorientation to surroundings and time and needs additional verbal cues to stimulate response to commands. The nurse correctly documents the patient's level of consciousness (LOC) by using which term? a. alert b. confused c. lethargic d, obtunded

ANS: B The confused patient is awake, but slightly confused and needs coaching to respond to commands. Alert indicates appropriate response to questions and commands with little stimulation. Lethargic is described as the patient being drowsy, but easily aroused. Obtunded patients are more difficult to arouse and respond slowly to stimulation.

when assessing a pt with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting b. headache c. change in LOC d. sluggish pupil response to light

Correct Answer: C Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

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

Correct Answer: C Rationale: 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. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

Following a craniotomy to relieve increased intracranial pressure (ICP), which implementation should the nurse implement? a. elevate the head of the bed 20 to 30 degrees b. place drip pad or cotton to absorb cerbrospinal fluid drainage from the nose or ears c. stimulate the patient to better assess changing level of consciousness (LOC) d. reposition the patient frequently for comfort

a a patent airway must be secured, and head raised to 20 to 30 degrees with the body in correct alignment, elevation helps reduce ICP. neurologic signs are monitored closely

8. a client is at risk for increased intracranial pressure. which finding is the priority for the nurse to monitor a. unequal pupil size b. decreasing systolic blood pressure c. tachycardia d. decreasing body temperature

a increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain

1.A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.) a. minor ischemic stroke within 30 days b. flucose level 120 c. blood pressure 190/120 d. lumbar puncture 2 days ago e. stroke onset 5 hours ago f. INR 1.o

a c d e

14. the nurse administers mannitol to the client with increased intracranial pressure. which parameter requires close monitoring a. muscle relaxation b. intake and output c. widening of pulse pressure d. pupil dilation

b after administering mannitol, the nurse closely monitors intake and output

The patient with a suspected subdural hematoma is on an intravenous (IV) drip of mannitol infusing at 50 mL/hr. The nurse explains that the slow infusion rate is essential for what purpose? a. To ensure effectiveness of the drug. b. To avoid fluid overload. c. To maintain electrolyte balance. d. To maintain adequate blood pressure (BP).

b the slow infusion rate will not cause fluid overload, which would add to the possibility of increased intracranial pressure

A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. Which action should the nurse make a priority at this time? a. Find out how the accident happened. b. Ensure the patient is bathed before surgery. c. Have the patients next of kin sign a consent form. d. Send the patients belongings home with a family member.

ANS: CThe patient is unlikely to be able to sign a consent form, and it must be signed for surgery to begin. B. Bathing is not a priority. A. D. Belongings and further questioning can be taken care of after the patient is in surgery.

14. The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102 F (38.9 C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness. The nurse most carefully monitors the patient for which change? a. Increasing respiratory rate b. Decreasing heart rate c. Decreasing pulse pressure d. Decreasing level of consciousness (LOC)

ANS: D Assessment of LOC provides the greatest amount of information about neurologic condition. A reduction in LOC may signal the onset of complications in the patient who has had a head injury.

A patient is diagnosed with increased intracranial pressure. What pressure measurement should the nurse expect to be associated with this diagnosis? a. 3 b. 5 c. 8 d. 17

ANS: D Normal ICP is 0 to 15 mm Hg. This pressure fluctuates with normal physiological changes, such as arterial pulsations, changes in position, and increases in intrathoracic pressure. A. B. C. These are considered normal intracranial pressure measurements.

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 of a 10-point scale. d. The patient's apical pulse is slightly irregular.

Correct Answer: B Rationale: 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. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed. c. Notify the health care provider about the assessments. d. Check the patient's pupillary response to light.

Correct Answer: C Rationale: 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. Documentation and monitoring are inadequate responses to the patient's problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information.

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.

Correct Answer: C Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective.

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

a nurse is teaching a client about ways to adapt to a visual disability following a stroke. which does the nurse identify as the primary safety precuation to use? a. wear a patch over one eye b. place personal items on the sighted side c. lie in bed with the unaffected side toward the door d. turn the head from side to side when walking

d

12. the nurse is assessing a client with increasing intracranial pressure. the nurse should notify the healthcare provider about which early change in the clients condition? a. widening pulse pressure b. decrease in the pulse rate c. dilated fixed pupils d. decrease in level of consciousness

d a decrease in the clients LOC is an early indicatory of deterioration of the clients neurologic status. changes in LOC such as restlessness and irritability may be subtle

10. which respiratory pattern indictes increasing intracranial pressure in the brain stem a. slow irregular respirations b. rapid shallow respirations c. asymmetric chest excursion d. nasal flaring

neural control of respiration takes place in the brain stem. deteroriation and pressure produce slow and irregular respirations.

which of the following should be avoided when caring for a client diagnosed with increased intracranial pressure a. starting an iv access line b. administering oxygen c. placing the bed in trendelenburg d. placing the client on bed rest

ANS: 3 Intravenous access and supplemental oxygen are common interventions in the treatment of increased intracranial pressure. Placing the client on bed rest is a proper safety measure. Placing the bed in Trendelenburg position will increase blood flow to the brain and increase ICP.

the nurse, caring for a client recovering from a traumatic brain injury, knows the client and the family are eligible for specific federal programs because of the: a. health brain act b. associated brain act c. traumatic brain injury act of 2008 d. brain protection act

ANS: 3 The Traumatic Brain Injury Act of 2008 is legislation that provides a framework for prevention of, education about, and research on traumatic brain injuries. The act also supports community living for people who have sustained a traumatic brain injury and their families. The other choices are not programs to assist clients who have sustained a traumatic brain injury or their families

The nurse is planning care for a client diagnosed with increased intracranial pressure after a head injury. Which of the following interventions can be used to reduce increased intracranial pressure a. administer antibiotics as prescribed b. keep the head of the bed in the flat position c. administer corticosteroids and osmotic diuretics as prescribed d. perform range of motion exercises every hour

ANS: 3 The administration of corticosteroids will decrease the swelling of the brain, and osmotic diuretics will decrease the fluid that is building up. This intervention will decrease the intracranial pressure. Antibiotics do not reduce intracranial pressure. Keeping the head of the bed in the flat position can increase intracranial pressure and not decrease it. Performing range-of-motion exercises every hour will not reduce intracranial pressure.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

In assessing the patient with a significant right-sided closed head injury, the nurse would anticipate the patient to demonstrate which sign? a. left sided motor deficit with sluggish right pupil response b. right sided motor deficit with brisk right pupil response c. bilateral motor deficit with bilaterally sluggish pupil response d. left sided motor deficit and bilateral PERRLA

ANS: A A right-sided injury will cause contralateral (opposite side) motor deficit and ipsilateral (same side) pupillary response.

In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs? a. Left-sided hemiplegia with dilated right pupil b. Right-sided hemiplegia with brisk right pupil response c. Bilateral motor hemiplegia with bilaterally dilated pupils d. Left-sided hemiplegia and bilateral PERRLA

ANS: A An acute intracerebral bleed causing hematoma formation is accompanied by unconsciousness, hemiplegia on the contralateral (opposite) side, and a dilated pupil on the ipsilateral (same) side. However, the symptoms indicating a slow buildup of pressure within the skull are more subtle and less easily detected.

the nurse is aware that the older adult is more at risk for a cranial bleed following ahead injury because the older adult has a. a smaller brain, which allows for more movement inside the cranium b. fragile vessels more likely to rupture c. less crebrospinal fluid to cushion the brain d. less flexibility of the meninges to absorb impact

ANS: A Atrophy of the brain leaves increased intracranial space, allowing increased movement of the brain in the event of head trauma.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. Increased pressure from the abscess can cause seizures. b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. ask the client why he or she is acting out and behaving differently c. refer the client and spouse to a head injury support group d. tell the spouse this is expected and he or she will have to learn to cope

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isnt useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. prepare to give iv pain medication

ANS: A These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

the nurse is caring for a patient with an acute brain injury. Which interventions should the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.) a. Avoid hip flexion. b. Administer stool softeners. c. Keep head of bed elevated 30 degrees. d. Encourage deep breathing and coughing. e. Administer opioid analgesics for headache.

ANS: A, B, C Elevation of the head of the bed may help reduce intracranial pressure (ICP). Stool softeners prevent straining, which can increase ICP. Hip flexion may also increase ICP. D. E. Coughing can increase ICP, and opioid analgesics make neurological assessment difficult.

A patient recovering from a brain injury is having difficulty completing activities of daily living. What should the nurse suggest to help this patient recover independence with self-care? a. Occupational therapy consultation b. Transfer to a rehabilitation facility c. Hire long-term private care assistance d. Cognitive stimulation to keep on track

ANS: AFor the patient having difficulty completing self-care actions, an occupational therapy consultation might be needed. An occupational therapist is trained to assist patients to manage ADLs within health limitations. B. The patient does not need to be transferred to a rehabilitation facility. C. Long-term private care assistance is not needed while the patient is still hospitalized. This might need to be an option once discharged to home. D. Cognitive stimulation is not an option for this type of health problem.

the vital signs for a client with a possible head injury were on admission. Blood pressure 128/72 mmHg pulse 90 beats per min, and respirations 66 breaths / min. which vital sign assessment conducted four hours later most likely indicates the presence of increased ICP? a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/minb. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/minc. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/mind. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

ANS: AVital sign changes are a late indication of increasing ICP. Cushings response is a classic late sign of increased ICP. Cushings response (or Cushings triad) is characterized by bradycardia, bradypnea, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure. B. These vital signs indicate tachycardia. C. These vital signs indicate tachypnea. C. These vital signs indicate both tachycardia and tachypnea.

a clients mean arterial pressure is 60 mmHg and intracranial pressure is 20 mmHg. based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client? a. impending brain hemiation b. poor prognosis and cognitive function c. probable complete recovery d. unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. the client has very low CPP, which will lead to a poorer prognosis with significant cognitive dysfunction should the client survive

a client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

The nurse documents which sign(s) of epidural hematoma in a patient with a closed head injury? (Select all that apply.) a. Mottling of extremities b. Periorbital ecchymosis c. Battle sign d. Nausea and vomiting e. PERRLA

ANS: B, C, D Raccoon eyes (periorbital ecchymosis), bruising behind the ears (Battle sign), and nausea and vomiting are some of the typical signs of epidural hematoma.

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

ANS: BAfter the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such.

The nurse is preparing to assess a patient with a head injury. Which data should the nurse include in this routine neurological nursing assessment? a. Vital signs, lung sounds, and pedal pulses b. Glasgow Coma Scale, pupil response, and vital signs c. Range of motion, deep tendon reflexes, and capillary refill d. Romberg test, Babinski reflex, and cranial nerve assessment

ANS: BAssessment of neurological status minimally includes Glasgow Coma Scale score, pupil responses, muscle strength, and vital signs. A. C. Additional assessment of body systems are important but are not part of a neurological assessment. D. Romberg, Babinski, and cranial nerve assessment is more advanced and not routine.

the emergency room nurse is assessing a newly admitted pt with a head injury. the nurse observes clear drainage from the nose. which action should the nurse perform first? a. document the presence of rhinorrhea b. inform the physician of the assessment c. test the fluid with dextrostix d. tape a drip pad under the nsoe

ANS: C Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there is a cerebrospinal fluid (CSF) leak. Testing with a Dextrostix will determine whether glucose is present; the presence of glucose indicates CSF. Documentation, informing the physician, and applying a drip pad under the nose are actions that should occur after confirmation of the fluid type.

The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention? a. Document the presence of rhinorrhea. b. Inform the physician of the assessment. c. Test fluid with a glucose Accu-Chek or Dextrostix. d. Tape a drip pad under the nose

ANS: C The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid. Documentation and informing the physician should occur after confirmation of the character of the fluid.

The nurse notes that a patient with a head injury has a widening pulse pressure. Which action should the nurse take at this time? a. Give an extra dose of diuretic. b. Lay the bed flat and check pupil response. c. Raise the head of the bed and notify the registered nurse (RN). d. None; this is an expected finding after a head injury.

ANS: C Widening pulse pressure or falling blood pressure are signs of increased intracranial pressure (ICP) and should be reported promptly. B. Raising the head of the bed 30 degrees may help reduce ICP. D. Increased ICP is not unexpected, but it is not normal and must be reported. A. A diuretic would only be given with a physicians order.

A teen is experiencing a headache and dizziness after falling of a bicycle and hitting the head. The physician diagnoses a concussion. What explanation should the nurse provide to the patients mother? a. The patient may lose consciousness before beginning to recover .b. The patient has had some intracranial bleeding but should recover in time. c. The patient has had a minor head trauma and should recover spontaneously. d. The patient may need to have surgery to relieve increased intracranial pressure.

ANS: C Cerebral concussion is considered a mild brain injury. If there is a loss of consciousness, it is for 5 minutes or less. Concussion is characterized by headache, dizziness, or nausea and vomiting. The patient may complain of amnesia of events before or after the trauma. On clinical examination, there is no skull or dura injury and no abnormality detected by computed tomography (CT) or magnetic resonance imaging (MRI). A. B. D. These statements explain more serious head injuries.

the physician prescribes intravenous mannitol for a patient who has a head injury and increased intracranial pressure (ICP). Which assessment finding indicates to the nurse that the patient is having a therapeutic response to the mannitol? a. Return of the gag reflex b. Increased blood glucose c. Increased urinary output d. Decreased Glasgow Coma Scale (GCS) score

ANS: C if ICP remains elevated despite drainage of cerebrospinal fluid, the next step is use of an osmotic diuretic. The most commonly used drug is intravenous mannitol (Osmitrol). Mannitol utilizes osmosis to pull fluid into the intravascular space and eliminate it via the renal system. D. The GCS score should increase, not decrease. A. B. Blood glucose and gag reflex are not affected by mannitol.

The nurse is caring for a patient with a traumatic brain injury. Which assessment finding alerts the nurse to possible diabetes insipidus? a. Headache b. Confusion c. Frequent urination d. Elevated blood glucose

ANS: CEdema or direct injury affects the posterior portion of the pituitary gland or hypothalamus. Inadequate release of antidiuretic hormone results in polyuria and, if the patient is awake, polydipsia. Fluid replacement and intravenous vasopressin are used to maintain fluid and electrolyte balance. A. B. Headache and confusion are symptoms of intracranial pressure (ICP). D. Elevated glucose is a sign of diabetes mellitus, not insipidus

A client is diagnosed with a mild brain injury. Which of the following is an example of a mild injury? a. coma b. locked in syndrome c. vegetative state d. concussion

ANS: d A concussion is a mild form of brain trauma, and it accounts for 75% of all brain injuries. A moderate brain injury would result in the loss of consciousness ranging from a few minutes to hours and days or weeks of confusion. Coma, locked-in syndrome, and a vegetative state are all examples of severe brain injury.

the nurse caring for a client with a traumatic brain injury, realizes that the major cause of these types of injuries is a. guns b. sports c. falls d. motor vehicle crashes

ANS: d Although all are major causes of traumatic brain injury, motor vehicle crashes account for 20% of all traumatic brain injuries. Reasons for motor vehicle accidents causing the most traumatic brain injuries include not wearing seat belts and driving while intoxicated.

A patient is admitted to the hospital with a severe headache and photophobia. A lumbar puncture confirms a bleeding aneurysm. What nursing interventions should the nurse anticipate assisting with to prevent increased intracranial pressure (ICP) during the acute phase of illness? a. morphine, dark glasses, and expectorants b. quiet room, head of bed up and stool softeners c. coughing and deep breathing exercises and tranquillizers d. range of motion exercises, bedside commode and suctioning as needed

ANS:B A quiet room with minimal stressors, elevated head, and stool softeners can help reduce ICP. A. C. Morphine and tranquilizers are not usually recommended because they can make neurological assessment difficult. A. C. Expectorants can promote coughing, which can raise ICP. C. D. Exercises, moving, and suctioning can also raise ICP.

why is the older adult more at risk for cranial bleed following a head injury? a. The older adults brain is smaller, which allows for more movement inside the cranium b. the older adults brain features fragile vessels more likely to rupture c. the older adults brain contains less cerebrospinal fluid to cushion the brain d. the older adults brain has less flexible meninges to absorb impact

a the brain atrophies with age and does not take up as much space in the cranial vault. this change allows for more movement and more potential for torn vessels and confusions on the brain when an accident occurs that involves a head injury

13. the client has sustained increased intracranial pressure of 20 mm Hg. which client position would be most appropriate? a. the head of bed elevated to 15-20 degrees b. trendelburgs position c.left sims position d. the head elevated on two pillows

a the clients ICP is elevated and the client should be positioned to avoid extreme neck flexion or extension

After an older adult falls, the nurse suspects the development of a subdural hematoma based on which finding(s)? (Select all that apply.) a. Increasing irritability b. Complaint of a dull headache c. Frequent "nodding off" in chair during the day d. Focal seizures e. Staggering gait

a b c increasing irritability and complaint of headache as well as changing level of consciousness are signs of increasing intracranial regulation

the nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. which position is appropriate? SATA a. placing a pillow in the axilla so the arm is away from the body b. inserting a pillow under the slightly flexed arm so the hand is higher than the elbow c. immobilizing the extremity in a sling d. positioning a hand cone in the hand so the fingers are barely flexed e. keeping the arm at the side using a pillow

a b d placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. placing a pillow under the arm so the hand is higher than the elbow prevents edema, placing a rolled washcloth or cone in the hand prevents hand contractures

the nurse is teaching the family of a client with dysphagia about decreasing risk of aspiration while eating. which strategies should the nurse include in the teaching plan? SATA a. maintaining an upright position while eating b. restricting the diets to liquids until swallowing improves c. introducing foods on the unaffected side of the mouth d. keeping distractions to a minimum e. cutting food into large pieces of finger food

a c d a client with dysphagia commonly has the most difficulty ingesting thin liquids, liquids should be thickened to avoid aspiration. positioning should be upright and food should be introduced into unaffected side of mouth. distractions should be avoided

which outcomes indicate effective management of a conscious client who is being treated with a recombinant tissue plasminogen therapy during the initial phase of an ischemic CVA? SATA a. headache reduced b. dysphagia improved c. visual disturbances improved d. responds to comfort measures e. no signs/ symptoms of bleeding

a d e a headache is commonly associated with an ischemic CNA. a conscious client responds to comfort measures. bleeding is a side effect of TPA therapy. reduction of visual and dysphagia is an unpredictable outcome

The nurse, planning care for a client recovering from a traumatic brain injury, is including interventions to prevent sympathetic storming. Which of the following should be included in this clients plan of care? (Select all that apply.) a. medicate for pain prior to conducting a painful procedure b. elevated blood pressure indicates a sympathetic storm is ending c. continue suctioning until the clients heart rate is greater than 100 beats per minute d. cardiac arrhythmias indicate a drop in intracranial pressure e. provide beta blockers as prescribed with symptoms of sympathetic storm f. if symptoms of sympathetic storm do not appear within 24 hours, the client will develop this health problem

a e The nurse should medicate the client for pain prior to conducting a painful procedure and provide beta-blockers as prescribed with symptoms of a sympathetic storm. An elevated blood pressure is a symptom of sympathetic storm. An elevated heart rate is a symptom of sympathetic storming. Cardiac arrhythmias are also a symptom of a sympathetic storm and do not indicate a drop in intracranial pressure. Symptoms of sympathetic storming can occur within 24 hours after a traumatic brain injury and can reoccur periodically during the recovery process.

A client is being evaluated for a stroke. The nurse knows that one of the easiest and most common diagnostic tests used to differentiate between strokes is: a. computed tomography CT b. MRI c. EEG d. PET

aThe CT scan is widely available in most hospitals and is an important tool to differentiate between ischemic strokes and hemorrhagic stroke. It is the most common tool used to diagnose a stroke. An MRI is contraindicated in clients with metal implants or pacemakers, and it can exacerbate claustrophobia. An EEG will determine the presence of brain waves, and it is not a diagnostic test for a stroke. A PET scan determines brain tissue functioning but, it will not be able to differentiate between the types of strokes.

for the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? a. speaking loudly and slowly b. using a picture board for the client to point to pictures c. writing directions so the client can read them d. speaking in short sentences

b expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. a picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires. receptive aphasia is when the client does not comprehend what is being said

the nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will a. have a preference for foods high in salt b. eat food on only half of the plate c. forget the names of foods d. not be able to swallow liquids

b homonymous hemianopia is blindness of half of the visual field, therefore the client would see only half of the plate

what is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke a. cholesterol level b. pupil size c. bowel sounds d. echocardiogram

b it is crucial to monitor pupil size and response to indicate changes around the cranial nerves

the nurse has established a goal to maintain intracranial pressure within the normal range for a client who had a craniotomy 12 hours ago. what should the nurse doSATA a. encourage the client to cough to expectorate secretions b. elevate the head to 15 to 20 degrees c. contact the HCP if ICP is > 15 mm Hg d. monitor neurologic status using the glasgow coma scale e. stimulate the client with active range of motion exercises

b c d the nurse should elevate the head of the bed between 15 to 20 degrees and monitor neurologic status. AN ICP > 15 indicates ICP. coughing and range of motion will increase ICP

The nurse is providing discharge instructions to a client recovering from a traumatic brain injury. Which of the following should be included in these instructions? (Select all that apply.) a. return to a full schedule of work as soon as possible b. acquire medical clearance prior to returning to work that uses heavy equipment c. avoid use of helmets d. limit amount of alcoholic beverages e. avoid all illicit drug use f. eat a well balanced diet

b e f Discharge instructions for a client recovering from a traumatic brain injury should include: medical clearance is needed prior to returning to work that uses heavy equipment; avoid all illicit drug use; and eat a well-balanced diet. The client should be cautioned to avoid returning to a full schedule of work as soon as possible. The client should be encouraged to use helmets or other safety equipment to protect the head. The clients should be instructed to avoid all alcoholic beverages.

the nurse describes a concussion as a closed head injury in which a. no brain tissue is bruised b. no loss of consciousness occurs c. there is amnesia related to the incident d. there are no subsequent symptoms

c a concussion is a closed head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks

The nurse is caring for a patient with a closed head injury. Which finding causes the nurse to suspect that the patient has developed diabetes insipidus (DI)? a. Increased lethargy b. Widening pulse pressure c. Copious pale urine output d. Increasing blood glucose levels

c a large incease in urinary output of pale urine with low specific gravity is the clue to the development of DI related to edema of the posterior pituitary. Antidiuretic hormone is released in inadequate amounts resulting in polyuria and the awake pt may complain of excessive thirst

9. 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

c clear drainage must be analyzed to determine whether it is nasal drainage or cerbrospinal fluid

during the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the clients a. pulse b. respirations c. blood pressure d. temperature

c control of blood pressure is critical after treatment because of intracerebral hemorrhage

following a stroke, a client has dysphagia and left sided facial paralysis. which feeding technique will be most helpful at this time? a. encourage sipping diluted liquid meal supplements from a straw b. position the client with the bed at 30 degrees angle c. offer solid foods from the unaffected side of the mouth d. feed the client a soft diet from a spoon into the left side of the mouth

c following a stroke it is easiest for clients with dysphagia to swallow solid foods: introduce on unaffected side

11. a client has an increased intracranial pressure of 20 mmHg. The nurse should: a. give the client a warming blanket b. administer low dose barbiturates c. encourage the client to take deep breaths to hyperventilate d. restrict fluids

c normal icp is 15mmHg or less. hyperventilation causes vasoconstriction. which reduces cerbrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg

which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? a. place the clients feet against a firm footboard b. reposition the client every 2 hours c. have the client wear ankle high tennis shoes at intervals throughout the day d. massage the clients feet and ankles regularly

c the use of ankle high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anotomical position

what is the expected outcome of thrombolytic drug therapy for stroke a. increased vascular permeability b. vasoconstriction c. dissolved emboli d. prevention of hemorrhage

c thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion

while instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. the following medications are effective in preventing a stroke except a. anticoagulants b. antiplatelets c. anticholinergics d. neuroprotective agents

c Although anticholinergic drugs have a variety of uses, stroke prevention is not one of them. All the other medications are used in a variety of ways to help with stroke prevention.

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.

correct Answer: C Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg.

the nurse is caring for a patient brought to the emergency dept after an automobile acident. the patient is fully conscious. for what early signs of increased intracranial pressure should the nurse be alert a. bradycardia b. hypothermia c. pinpoint pupils d. decreased level of consciousness

d Initial symptoms of increased ICP include restlessness, irritability, and decreased level of consciousness, because cerebral cortex function is impaired. If not intubated, the patient may hyperventilate, causing vasoconstriction as the body attempts to compensate. As the pressure increases, the oculomotor nerve may be compressed on the side of the impairment. C. Compression of the outermost fibers of the oculomotor nerve results in diminished reactivity and dilation of the pupil. As the fibers become increasingly compressed, the pupil stops reacting to light. If the compression continues, and the brain tissue exerts pressure on the opposite side of the brain from the injury, both pupils become fixed and dilated. B. Hypothermia is not a sign of IICP. A. Vital sign changes are a late indication of increasing ICP.

which position is best for an unconscious patient with a right sided closed head injury a. high fowler b. right sided slying c. flat with small pillow under head d. head of bed 20 to 30 degrees

d keeping the head of the bed 20 to 30 degrees with the body in good alignment will help reduce intracranial pressure and keep the airway patent

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the clients lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair. d. Rotate the clients meal tray when the client stops eating.

d This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

6. an unconscious client with multiple injuries to the head and neck arrives in the emergency department. 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

the highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway other measures will he futile. determining the clients identity, blood loss, and stopping bleeding from open wounds, and checking for fracture are important but airway should be established first