Intracranial Issues

At which timeframe would an acute subdural hematoma occur after an injury? Weeks to months 48 hours - 2 weeks 5 hours 24-48 hours

24-48 hours

The nurse would raise the head of the bed _________ degrees when caring for a patient with increased intracranial pressure (ICP).

30

A patient presents with abnormal extension, does not open their eyes to stimulus, and does not give a sound as reaction to pain. The patient exhibiting these signs would be given a score of _________ using the Glasgow Coma Scale.

4

A Glasgow Come Scale (GCS) score of ______ or less could indicate a coma.

8 The highest GCS score is 15 for a fully alert person. The lowest possible score is 3. A GCS score of 8 or less generally indicates coma.

Match the type of subdural hematoma with its progression of symptoms. Immediate deterioration Progressive alteration in LOC with a nonspecific progression Alteration in mental status progresses as hematoma develops

Acute Chronic Subacute

Which medication may be prescribed after a head injury? Antiseizure medication Advil Aspirin Metoclopramide

Antiseizure medication

Which action would the nurse take first when caring for a patient with increased intracranial pressure (ICP) with the nursing assessment denoting one pupil is 3mm and the other is 7mm? Assess the patient's lung sounds. Notify the health care provider. Assess the cranial nerves for abnormalities. Document findings in the patient's medical record.

Assess the cranial nerves for abnormalities.

Which health promotion activity would the nurse recommend to reduce the risk of head injuries? Select all that apply. Taking medication as prescribed Avoiding texting and driving Wearing helmet Smoking cessation Wearing seat belts

Avoiding texting and driving Wearing helmet Wearing seat belts

Which component can affect a patient's increased intracranial pressure (ICP)? Select all that apply. Blood Brain tissue Hematoma Synovial fluid Cerebrospinal fluid (CSF)

Blood Brain tissue Hematoma Cerebrospinal fluid (CSF)

Which physiologic event can lead to increased intracranial pressure (ICP) and hypercapnia? Select all that apply. Brain abscess Occipital tumor Hyperventilation Subdural hematoma Bacterial meningitis

Brain abscess Occipital tumor Subdural hematoma Bacterial meningitis

Which clinical manifestation is common in primary brain injuries? Bruising Hypoxia Increased intracranial pressure (ICP) Hypotension

Bruising

Which diagnostic test would the nurse anticipate when caring for a patient with recent head trauma who presented to the emergency department? Computed tomography (CT) Electroencephalogram (EEG) X-ray Blood work

Computed tomography (CT)

Which intervention would be implemented initially after a head injury? Prepare the patient for EEG. Control bleeding. Give IV fluids. Maintain normothermia.

Control bleeding.

Which surgical procedure would the nurse anticipate for a patient who has suffered a depressed skull fracture? Craniotomy Cranioplasty Craniectomy Ventricular shunt

Cranioplasty

Which surgical procedure would the collaborative care team perform for a patient who has suffered an epidural hematoma and is experiencing increased intracranial pressure (ICP)? Craniotomy Cranioplasty Stereotactic biopsy Ventricular shunt

Craniotomy

Which treatment would the nurse anticipate when caring for a patient with an acute subdural hematoma and a decline in mental status? IV hydration Craniectomy Antiseizure medications Craniotomy

Craniotomy

Which result occurs in brain tissue when cerebrovascular resistance is high? Neuron death Ischemia Decreased blood flow Compression

Decreased blood flow

Which physiologic event leads to decreased oxygen and death of the brain cells? Tissue edema Excessive hydration Decreased cerebral blood flow (CBF) Accumulation of carbon dioxide

Decreased cerebral blood flow (CBF)

Match the types of skull fractures with their description. Inward indentation of the skull Linear or depressed fracture without fragmentation Multiple fractures with bone fragmentation Depressed fracture with scalp laceration

Depressed Simple Comminuted Compound

Which type of skull fracture would the nurse suspect when admitting a patient to the ED who sustained a powerful blow to the head? Comminuted Compound Simple Depressed linear

Depressed linear This is a skull fracture described as an inward indentation of the skull secondary to a powerful blow to the head.

Which factor is a common cause of head injury? Falls Meningitis Assaults War-related

Falls

Which incident is among the leading causes of head injury? Select all that apply. Falls Assaults Car accidents Gunshot wounds Sports-related trauma

Falls Car accidents

Which physical symptom is associated with vasogenic cerebral edema? Select all that apply. Focal neurological deficits Syndrome of inappropriate antidiuretic hormone (SIADH) Hydrocephalus Headache Decreased level of consciousness

Focal neurological deficits Headache Decreased level of consciousness

Which component does the brain require to maintain blood flow? Select all that apply. Sodium Potassium Calcium Glucose Oxygen

Glucose Oxygen

Which assessment finding is consistent with a diagnosis of Cushing triad following a head trauma? Select all that apply. Heart rate of 52 beats per minute Pulses that seem thready in nature Irregular breathing pattern Systolic blood pressure reading of 178 mm Initial blood pressure reading of 160/45 mm/Hg with later reading of 189/32 mm/Hg

Heart rate of 52 beats per minute Irregular breathing pattern Systolic blood pressure reading of 178 mm Initial blood pressure reading of 160/45 mm/Hg with later reading of 189/32 mm/Hg

Which next step in a patient's treatment is anticipated when the medical team reports a score of 7 on the Glasgow Coma Scale (GCS) during initial assessment of a patient with a head trauma? Intubation Burr hole procedure Computerized tomography (CT) scan Positron emission tomography (PET) scan

Intubation

Which manifestation is the classic sign of an epidural hematoma? Loss of consciousness Leakage of cerebrospinal fluid (CSF) Loss of sensation in the extremities Periorbital bruising

Loss of consciousness

Which diagnostic study would be performed in order to determine whether internal bleeding is present in a patient with increased intracranial pressure (ICP)? Select all that apply. MRI Burr hole Craniotomy Infrascanner Toxicology screen

MRI Infrascanner

Which medication would the nurse anticipate administering for increased intracranial pressure (ICP)? Mannitol Corticosteroids Nitroglycerin Nitroprusside

Mannitol

Which medication can be given simultaneously in order to decrease the patient's increased intracranial pressure (ICP)? Select all that apply. Morphine Mannitol Protonix Acetaminophen Hypertonic saline

Mannitol Hypertonic saline

Which finding would the nurse report when assisting the provider with a neurological assessment on an unconscious adult patient with increased intracranial pressure (ICP), and the eyes move to the left side when moving the patient's head moves to the right side? Ipsilateral damage Normal Moro reflex Negative oculovestibular reflex Normal oculocephalic reflex

Normal oculocephalic reflex Oculocephalic reflex, or the dolls eye reflex, is tested by turning the patient's head briskly to the left or right while holding the eyelids open. A normal response is movement of the eyes across the midline in the direction opposite that of the turning.

The nurse would suspect a fracture in which location if the patient is exhibiting raccoon eyes upon assessment? Posterior fossa Parietal Orbital Basilar

Orbital

Which provider order would the nurse anticipate when caring for a patient who presents with an actively bleeding head wound, is obtunded, has one fixed pupil, with a thready pulse and increased respiratory effort? Select all that apply. Insert urinary catheter. Prepare for intubation. Insert nasogastric tube. Administer intravenous (IV) dextrose 5%. Administer intravenous (IV) 0.9% saline.

Prepare for intubation. Administer intravenous (IV) 0.9% saline.

Which order would the nurse anticipate when monitoring a patient with increased intracranial pressure (ICP) using a ventriculostomy and notes the P2 wave is higher than the other wave? Provide an IV fluid bolus. Administer IV mannitol. Prepare for surgery. Maintain patient supine.

Prepare for surgery. When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. The nurse would expect to prepare the patient for surgery to assess/reposition the ventriculostomy tube.

Which manifestation can occur with unrelieved brainstem compression? Respiratory arrest Increased intracranial pressure (ICP) Brain inflammation Encephalitis

Respiratory arrest

Which characteristic of the pupil would the nurse compare during a neurologic assessment? Select all that apply. Size Pain Reactivity Color Movement

Size Reactivity Movement

Which sign or symptom would be included in the teaching education about signs of head injury complications that should be reported to the health care provider? Select all that apply. Slurred speech Severe headache Difficulty waking up New onset irritability Development of hearing problems

Slurred speech Severe headache Difficulty waking up New onset irritability

Which physical assessment finding would be a late sign of herniation into the brainstem? Syncopal episodes Nausea and vomiting Sustained periods of apnea Severe pain in the occipital area

Sustained periods of apnea

Which action would the care team perform on the patient exhibiting signs of increasing intracranial pressure (ICP) after a head injury? Cranioplasty Initiate IV access Ventricular shunt Transport to CT scan

Transport to CT scan

Which condition can cause increased intracranial pressure (ICP)? Select all that apply. Traumatic brain injury Brain mass Sinus infection Headache Hematoma

Traumatic brain injury Brain mass Hematoma

Which central nervous system (CNS) assessment finding is indicative of neurologic injury? Symmetric facial movements Unequal pupils Hypoventilation Glasgow Coma Scale (GCS) score >12

Unequal pupils

Which measurement would the nurse monitor in patients with increased intracranial pressure who are at risk for diabetes insipidus? Weight Pain Temperature Urine output

Urine output

Which procedure is considered the gold standard for monitoring intracranial pressure (ICP)? Electroencephalogram (EEG) Ventriculostomy Lumbar puncture (LP) Infrascanner

Ventriculostomy

The nurse would instruct a patient with a head injury and their caregiver to monitor for which parameter? Select all that apply. Worsening headache Seizures Blood pressure Motor changes Behavioral changes

Worsening headache Seizures Motor changes Behavioral changes