Med Surg Ch 56 Acute Intracranial Problems

A patient is admitted to the ED following a head injury. Number the nurse's actions in order of priority in management of the patient. Use 1 for the first action and 6 for the last action

1-Confirm patent airway. 2-Maintain cervical spine precautions. 3-Establish IV access with a large-bore catheter. 4- Determine the presence of increased ICP. 5-Monitor for changes in neurologic status. 6-Anticipate cerebral surgery

42. When teaching children about rabies, which statement tells the school nurse that the child understands the teaching? a. "Only dogs spread rabies." b. "It is okay to play with wild raccoons." c. "Any warm-blooded mammal can carry rabies." d. "It is easier to treat rabies than it is to prevent it."

42. c. Any warm-blooded mammal, including livestock, can carry rabies. Worldwide, dogs are the most common carrier of rabies; however, in developed countries raccoons, skunks, bats, and foxes are the primary animal carriers. Because rabies is usually fatal, it is much better to prevent its spread.

21. 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, b, d, e. The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased SBP with widened pulse pressure and bradycardia.

Which events cause increased ICP (select all that apply)? a. Vasodilation b. Necrotic tissue edema d. Edema from initial brain insult c. Blood vessel compression e. Brainstem compression and herniation

a, b, d. Increased ICP is caused by vasodilation and edema from the initial brain insult or necrotic tissue. Blood vessel compression and brainstem compression and herniation occur as a result of increased ICP.

1. Which components are able to change to adapt to small increases in intracranial pressure (ICP) (select all that apply)? a. Blood b. Skull bone c. Brain tissue d. Scalp tissue e. Cerebrospinal fluid (CSF)

a, c, e. Blood adapts with increased venous outflow, decreased cerebral blood flow (CBF), and collapse of veins and dural sinuses. Brain tissue adapts with distention of the dura, slight compression of tissue, or herniation. Cerebrospinal fluid (CSF) adapts with increased absorption, decreased production, and displacement into the spinal canal. Skull bone and scalp tissue do not adapt to changes in intracranial pressure (ICP).

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. An intraventricular catheter is a fluid-coupled system that can provide direct access for microorganisms to enter the ventricles of the brain and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

When a patient is admitted to the ED following a head injury, what should be the nurse's first priority in management of the patient once a patent airway is confirmed? a. Maintain cervical spine precautions. b. Monitor for changes in neurologic status. c. Determine the presence of increased ICP. d. Establish IV access with a large-bore catheter.

a. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

19. 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 to 20 mm Hg. c. Cluster nursing activities to provide periods of uninterrupted rest. d. Routinely suction to prevent accumulation of respiratory secretions.

a. Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli. They should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP.

30. A 54-year-old man is recovering from a skull fracture with a subacute subdural hematoma that caused unconsciousness. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge of the patient, what should the nurse explain to the patient and the family? a. The patient is likely to have long-term emotional and mental changes that may require professional help. b. Continuous improvement in the patient's condition should occur until he has returned to pretrauma status. c. The patient's complete recovery may take years and the family should plan for his long-term dependent care. d. Role changes in family members will be necessary because the patient will be dependent on his family for care and support.

a. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose for longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning and professional assistance may be required. There is no indication the patient will be dependent on others for care but he likely will not return to pretrauma status.

35. For the patient undergoing a craniotomy, when should the nurse provide information about the use of wigs and hairpieces or other methods to disguise hair loss? a. During preoperative teaching b. If the patient asks about their use c. In the immediate postoperative period d. When the patient expresses negative feelings about his or her appearance

a. To prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed preoperatively that the head is usually shaved in surgery while the patient is anesthetized and that a turban, scarf, or cap may be used after the dressings are removed postoperatively and a wig also may be used after the incision has healed to disguise the hair loss. In the immediate postoperative period the patient is very ill and the focus is on maintaining neurologic function but preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

15. Why is the Glasgow Coma Scale (GCS) used? a. To quickly assess the LOC b. To assess the patient's ability to communicate c. To assess the patient's ability to respond to commands d. To assess the patient's coordination with motor responses

a. . The Glasgow Coma Scale (GCS) is used to quickly assess the LOC with a standardized system. The three areas assessed are the patient's ability to speak, obey commands, and open eyes to verbal or painful stimulus. Although best motor response is an indicator, it is not used to assess coordination.

What are causes of vasogenic cerebral edema (select all that apply)? a. Hydrocephalus b. Ingested toxins c. Destructive lesions or trauma d. Local disruption of cell membranes e. Fluid flowing from intravascular to extravascular space

b, e. A variety of insults, such as brain tumors, abscesses, and ingested toxins, lead to vasogenic cerebral edema. It is the most common type of cerebral edema and characterized by leakage of macromolecules from the capillaries into the surrounding extracellular space. This results in an osmotic gradient that favors the flow of fluid from the intravascular to the extravascular space. Hydrocephalus causes interstitial cerebral edema. Destructive lesions or trauma destroy cell membranes and cause cytotoxic cerebral edema.

34. What is the best explanation of stereotactic radiosurgery? a. Radioactive seeds are implanted in the brain. b. Very precisely focused radiation destroys tumor cells. c. Tubes are placed to redirect CSF from one area to another. d. The cranium is opened with removal of a bone flap to open the dura.

b. A stereotactic radiosurgery technique uses precisely focused radiation to destroy tumor cells. The radiation is computer and imagery guided. Radioactive seeds are used to deliver radiation. Ventricular shunts are used to redirect CSF from one area to another. A craniotomy is done by first making burr holes and then opening the cranium by connecting the holes to remove a flap of bone to expose the dura mater.

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 transducer of the ventriculostomy monitor is at the level of the upper ear. d. The drain of the CSF drainage device was closed for 6 minutes before taking the reading.

b. An inaccurate ICP reading can be caused by CSF leaks around the monitor device, obstruction of the intraventricular catheter, kinks or bubbles in the tubing, and incorrect height of the transducer or drainage system relative to the patient's reference point. The P2 wave being higher than the P1 wave indicates poor ventricular compliance. The transducer height should be at the tragus of the ear. The drain of the CSF drainage device should be closed for 6 minutes preceding the reading.

32. Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor in which part of the brain? a. Ventricles b. Frontal lobe c. Parietal lobe d. Occipital lobe

b. Frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, seizures, and personality and judgment changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, speech disturbances, or disturbances in sensation and perception that occur with other tumors, are more likely to be understood and accepted by the family.

40. What are the key manifestations of bacterial meningitis? a. Papilledema and psychomotor seizures b. High fever, nuchal rigidity, and severe headache c. Behavioral changes with memory loss and lethargy d. Jerky eye movements, loss of corneal reflex, and hemiparesis

b. High fever, severe headache, nuchal rigidity, nausea, and vomiting are key signs of meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, and cranial nerve dysfunction may occur as complications of increased ICP in meningitis.

22. Priority Decision: While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do first? a. Use restraints to protect the patient from injury. b. Perform the exercises less frequently because posturing can increase ICP. c. Administer central nervous system (CNS) depressants to lightly sedate the patient. d. Continue the exercises because they are necessary to maintain musculoskeletal function.

b. If reflex posturing occurs during range of motion (ROM) or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes because posturing can cause increases in ICP and may indicate herniation. Neither restraints nor central nervous system (CNS) depressants would be indicated.

41. Vigorous control of fever in the patient with meningitis is required to prevent complications of increased cerebral edema, seizure frequency, neurologic damage, and fluid loss. What nursing care should be included? a. Administer analgesics as ordered. b. Monitor LOC related to increased brain metabolism. c. Rapidly decrease temperature with a cooling blanket. d. Assess for peripheral edema from rapid fluid infusion.

b. LOC must be monitored because it will decrease with the increased brain metabolism that the fever causes. Analgesics will not aid in lowering the body temperature, although acetaminophen will be used as an antipyretic. Rapid cooling may lead to shivering that increases metabolism. Monitoring cerebral edema will be done. Peripheral edema is unrelated and there will not be a rapid fluid infusion for the fever. Fluid replacement will be calculated with 800 mL/day for respiratory losses and 100 mL for each degree of temperature above 100.4°F (38°C).

16. A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. What should the nurse record as the patient's GCS score? a. 6 b. 7 c. 9 d. 11

b. No opening of eyes = 1; incomprehensible words = 2; flexion withdrawal = 4. Total = 7

26. 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 or stick. d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis.

b. Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip but if blood is present, the glucose in the blood will produce an unreliable result. To test bloody drainage, the nurse should test the fluid for a "halo" or "ring" that occurs when a yellowish ring encircles blood dripped onto a white pad or towel within a few minutes.

12. The patient is being monitored long-term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2) will maintain cerebral oxygen supply and demand? a. 55% to 75% b. 20 to 40 mm Hg c. 70 to 150 mm Hg d. 80 to 100 mm Hg

b. 20 to 40 mm Hg The normal pressure of oxygen in brain tissue (PbtO2) is 20 to 40 mm Hg. The normal jugular venous oxygen saturation (SjvO2) is 55% to 75% and indicates total venous brain tissue extraction of oxygen; this is used for short-term monitoring. The MAP of 70 to 150 mm Hg is needed for effective autoregulation of CBF. The normal range for PaO2 is 80 to 100 mm Hg.

Which descriptions are characteristic of encephalitis (select all that apply)? a. Increased CSF production b. Most often caused by bacteria c. Is an inflammation of the brain d. Almost always has a viral cause e. May be transmitted by insect vectors f. Involves inflammation of tissues surrounding the brain and spinal cord

c, d, e. Encephalitis is usually caused by a virus that inflames the brain and can be transmitted by ticks and mosquitoes. The other options are characteristics of meningitis.

Which factors decrease cerebral blood flow (select all that apply)? a. Increased ICP b. PaO2 of 45 mm Hg c. PaCO2 of 30 mm Hg d. Arterial blood pH of 7.3 e. Decreased mean arterial pressure (MAP)

c, e. Cerebral blood flow is decreased when the MAP and the PaCO2 are decreased. The other options increase cerebral blood flow.

20. An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal what? a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 70 mm Hg d. PaCO2 of 35 mm Hg

c. A PaO2 of 70 mm Hg reflects hypoxemia that may lead to further decreased cerebral perfusion. PaO2 should be maintained at greater than or equal to 100 mm Hg. The pH and SaO2 are within normal range and a PaCO2 of 35 mm Hg reflects a normal value.

8. 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

c. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, hypothalamus, pons, and thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing SBP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

18. How is cranial nerve (CN) 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

c. One of the functions of cranial nerve (CN) III, the oculomotor nerve, is pupillary constriction and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associated with specific lesions or chemical toxicities and is not a definitive sign of ICP.

25. The patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. Which type of injury should the nurse record? a. Linear skull fracture b. Depressed skull fracture c. Compound skull fracture d. Comminuted skull fracture

c. The compound skull fracture is a depressed skull fracture and scalp lacerations with communicating pathway(s) to the intracranial cavity. A linear skull fracture is a straight break in the bone without alteration in the fragments. A depressed skull fracture is an inward indentation of the skull that may cause pressure on the brain. A comminuted skull fracture has multiple linear fractures with bone fragmented into many pieces.

Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as what? a. Uncal herniation b. Tentorial herniation c. Cingulate herniation d. Temporal lobe herniation

c. The dural structures that separate the two hemispheres and the cerebral hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulate herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri. Uncal herniation occurs when there is lateral and downward herniation. Tentorial herniation occurs when the brain herniates down through the opening created by the brainstem. The temporal lobe can be involved in central herniation.

24. The patient comes to the emergency department (ED) with cortical blindness and visual field defects. Which type of head injury does the nurse suspect? a. Cerebral contusion b. Orbital skull fracture c. Posterior fossa fracture d. Frontal lobe skull fracture

c. The posterior fossa fracture causes occipital bruising resulting in cortical blindness or visual field defects. A cerebral contusion is bruising of brain tissue within a focal area. An orbital skull fracture would cause periorbital ecchymosis (raccoon eyes) and possible optic nerve injury. A frontal lobe skull fracture would expose the brain to contaminants through the frontal air sinus and the patient would have CSF rhinorrhea or pneumocranium.

37. On physical examination of a patient with headache and fever, the nurse should suspect a brain abscess when the patient has a. seizures. b. nuchal rigidity. c. focal symptoms. d. signs of increased ICP.

c. The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including fever, headache, nausea, vomiting, and increased ICP, except that the patient also may have some focal symptoms that reflect the local area of the abscess.

13. Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? a. Oxygen administration b. Pentobarbital (Nembutal) c. Mannitol (Osmitrol) (25%) d. Dexamethasone (Decadron)

c. Mannitol (Osmitrol) (25%) Mannitol (Osmitrol) (25%) is an osmotic diuretic that expands plasma and causes fluid to move from tissues into the blood vessels. Hypertonic saline reduces brain swelling by moving water out of brain tissue. The corticosteroid dexamethasone is used to treat vasogenic edema to stabilize cell membranes and improve neuronal function by improving CBF and restoring autoregulation. Oxygen administration is done to maintain brain function. Pentobarbital (Nembutal) and other barbiturates are used to reduce cerebral metabolism.

An early sign of increased ICP that the nurse should assess for is a. Cushing's triad. c. decreasing level of consciousness (LOC). b. unexpected vomiting. d. dilated pupil with sluggish response to light.

c. decreasing level of consciousness (LOC). One of the most sensitive signs of increased ICP is a decreasing level of consciousness (LOC). A decrease in LOC will occur before changes in vital signs, ocular signs, or projectile vomiting occur.

23. The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient? a. Deafness, loss of taste, and CSF otorrhea 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. A cerebral concussion may include a brief disruption in LOC, retrograde amnesia, and a headache, all of short duration. A basilar skull fracture may have a dural tear with CSF or brain otorrhea, rhinorrhea, hearing difficulty, vertigo, and Battle's sign. A temporal fracture would have a boggy temporal muscle because of extravasation of blood, Battle's sign, or CSF otorrhea.

33. Which cranial surgery would require the patient to learn how to protect the surgical area from trauma? a. Burr holes b. Craniotomy c. Cranioplasty d. Craniectomy

d. A craniectomy is excision of cranial bone without replacement, so the patient will need to protect the brain from trauma in this surgical area. Burr holes are opened into the cranium with a drill to remove blood and fluid. A craniotomy is opening the cranium with removal of a bone flap to open the dura. The replaced bone flap is wired or sutured after surgery. A cranioplasty replaces part of the cranium with an artificial plate.

27. 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 to 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.

d. An arterial epidural hematoma is the most acute neurologic emergency and typical symptoms include unconsciousness at the scene with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury. A chronic subdural hematoma develops over weeks or months.

39. A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of what? a. Mosquito or tick bites b. Chickenpox or measles c. Cold sores or fever blisters d. An upper respiratory infection

d. Meningitis is often a result of an upper respiratory infection or a penetrating wound of the skull, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes and nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate.

17. Priority Decision: When assessing the body 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

d. Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation).

36. Successful achievement of patient outcomes for the patient with cranial surgery would best be indicated by what? a. Ability to return home in 6 days b. Ability to meet all self-care needs c. Acceptance of residual neurologic deficits d. Absence of signs and symptoms of increased ICP

d. The primary goal after cranial surgery is prevention of increased ICP and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health.

28. Skull x-rays and a computed tomography (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.

d. When there is a depressed fracture or a fracture 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 or to aid in removing a bone flap but with a depressed fracture, surgery would be the treatment of choice.

14. 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

d. A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

31. The patient is suspected of having a new brain tumor. Which test will the nurse expect to be ordered to detect a small tumor? a. CT scan b. Angiography c. Electroencephalography (EEG) d. Positron emission tomography (PET) scan

d. The positron emission tomography (PET) scan or magnetic resonance imaging (MRI) are used to reliably detect very small tumors. The computed tomography (CT) and brain scans are used to identify the location of a lesion. Angiography could be used to determine blood flow to the tumor and further localize it. Electroencephalography (EEG) would be used to rule out seizures.