NCLEX-RN Intracranial Regulation
A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention?
Correct response: contacting the physician
An 8-month-old infant is brought to the emergency department following a fall from a high chair and a possible head injury. The parents are distressed because the infant is crying and irritable. The mother asks if she can try to breastfeed the infant. What is the nurse's best response?
"Until assessments are complete, we should not give your child anything by mouth."
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. Drag the assessment findings that require immediate treatment by the team to the box on the right.
Assessment Findings Requiring Immediate Treatment seizure time 6 minutes periods of apnea
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. Drag the assessment findings that require immediate treatment by the team to the box on the right.
Assessment Findings Requiring Immediate Treatment: seizure time 6 minutes periods of apnea
A 28-year-old male client is in the neurological intensive care unit following a right supratentorial craniotomy for excision of a brain tumor 2 days earlier. Drag the assessment findings from 1300 that require immediate attention.
Assessment findings that require immediate attention Intracranial pressure Orientation to time and place Upper extremity strength Vital signs
Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury?
Correct response: hyperactive reflexes
The intensive care unit (ICU) nurse is caring for a 33-year-old female client with an injury to left side of the forehead from hitting the steering wheel in a motor vehicle crash 1 day ago. Which assessment finding(s) requires immediate follow up? Select all that apply.
Glasgow Coma Scale score intracranial pressure
The intensive care unit (ICU) nurse is caring for a 33-year-old female client with an injury to left side of the forehead from hitting the steering wheel in a motor vehicle crash 1 day ago. For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.
Improved: eye opening pulse pressure best motor response oxygen saturation best verbal response No change: pupil assessment Declined: serum sodium
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. Which action should the nurse take? Complete the sentence(s) by choosing from the lists of options.
It is a priority for the nurse to insert an intravenous line. The next priority action by the nurse would be to ---
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. For each client finding below, click to specify if the finding is consistent with the process of status epilepticus, hypoglycemia, or Tourette syndrome. Each finding may support more than 1 disease process.
Status Epilepticus: prolonged tonic-clonic movements confusion respiratory arrest lethargy Hypoglycemia: confusion hunger nervousness lethargy Tourette Syndrome: facial tics throat clearing
The intensive care unit (ICU) nurse is caring for a 33-year-old female client with an injury to left side of the forehead from hitting the steering wheel in a motor vehicle crash 1 day ago. Complete the following sentence by choosing from the lists of options.
The client is at greatest risk for developing increased intracranial pressure (ICP) as evidenced by --- increasing systolic blood pressure, and --- Signs of increasing ICP include bradycardia, an increasing systolic blood pressure, and a widening pulse pressure (difference between systolic and diastolic blood pressures).
The nurse is assessing a client for potential subdural hematoma development after a head injury. Which manifestation does the nurse anticipate seeing first?
You Selected: alteration in level of consciousness
The nurse is evaluating a group of living clients for consideration for potential organ donation. What client(s) is at high risk for brain death and thus a potential organ donor? Select all that apply.
a client experiencing a drug overdose a client found after a recent hanging a client with a blunt head trauma
The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise?
padded tongue blade at the bedside
A 28-year-old male client is in the neurological intensive care unit following a right supratentorial craniotomy for excision of a brain tumor 2 days earlier. The nurse is developing a plan of care for this client who has undergone a craniotomy. Which complication is this client at risk for developing in the postoperative period? Select all that apply.
seizures cerebral edema intracerebral hematoma
A 5-year-old child has been placed on phenytoin for tonic-clonic seizures. The child weighs 42 lb (19.1 kg), and the maintenance dose prescribed for this child is 7.5 mg/kg/day. How many milligrams should the child receive each day? Record your answer using a whole number.
Correct response: 143
An adolescent sustains a head injury and develops diabetes insipidus. The healthcare provider orders desmopressin, 10 mcg subcutaneously. When does the nurse assess the client to determine the need for an additional dose?
Correct response: 4 to 7 hours
A toddler is admitted to the emergency department with a suspected seizure disorder. When informing the parents about necessary diagnostic procedures, which statement is most appropriate for the nurse?
Correct response: "An important initial test is a computed tomography (CT) scan."
A charge nurse is educating a new nurse on antipsychotic medications. The charge nurse knows teaching has been effective when the new nurse makes which statement?
Correct response: "Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine."
The intensive care unit (ICU) nurse is caring for a 33-year-old female client with an injury to left side of the forehead from hitting the steering wheel in a motor vehicle crash 1 day ago. The nurse has notified the health care provider (HCP) of the findings of the 0900 assessment and the HCP has written a prescription for mannitol 30 grams IV to be administered over 30 minutes. Which intervention(s) will the nurse perform?
Monitor serum electrolytes every 8 hours. Check the mannitol infusion for crystals. Use an in-line filter to administer mannitol. Infuse mannitol over 30 to 60 minutes.
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. Which finding would indicate to the nurse that the emergency response team's actions have been effective? Select all that apply.
The client is resting quietly on his side. The client is sleeping. The client's RR is 18 breaths/minute.
The nurse is teaching a client with seizures to recognize an aura. What should the nurse instruct the client to notice as an onset of an aura?
a symptom that occurs just before a seizure
A 28-year-old male client is in the neurological intensive care unit following a right supratentorial craniotomy for excision of a brain tumor 2 days earlier. The nurse administered dexamethasone at 1315, per the neurosurgeon's prescription. On the 1400 assessment, which finding indicates an effective outcome? Select all that apply.
orientation ICP vital signs
An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority?
Correct response: Monitor intracranial pressure.
Which finding would indicate to the nurse that the emergency response team's actions have been effective? Select all that apply.
Correct response: Monitor intracranial pressure.
A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first?
Correct response: Move the family to an area where an assessment can be completed and call for a physician.
After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction?
Correct response: "Brain damage may occur if the molding does not resolve quickly."
A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond?
Correct response: "The client's ICP remains elevated."
A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The parent questions pain medication for home. Which response by the nurse is most appropriate?
Correct response: "Your child has a mild concussion; acetaminophen can be given."
A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition?
Correct response: meningitis
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?
Correct response: occipital
Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?
Correct response: seizures
A 28-year-old male client is in the neurological intensive care unit following a right supratentorial craniotomy for excision of a brain tumor 2 days earlier. For each assessment finding below, click to specify if the finding is consistent with the disease process of increased ICP, neurogenic diabetes insipidus, or syndrome of inappropriate antidiuretic syndrome (SIADH). Each finding may support more than one disease process.
Increased intracranial pressure: Widening pulse pressure Increased systolic blood pressure Bradycardia Neurogenic diabetes insipidus: Polyuria Polydipsia SIADH: Concentrated urine Reduced urine output
Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?
Correct response: loss of consciousness, body stiffening, and violent muscle contractions
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back (see figure). What action should the nurse take first?
Correct response: Notify the health care provider (HCP).
Which respiratory pattern indicates increasing intracranial pressure in the brain stem?
Correct response: slow, irregular respirations
While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication?
Correct response: intracranial hemorrhage
A client is receiving intravenous mannitol for treatment of a brain tumor. The client's intracranial pressure before administration of the mannitol was 14 mm Hg. Which assessment finding indicates that the medication is attaining a therapeutic effect?
Correct response: intracranial pressure of 10 mm Hg
A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is which factor?
Correct response: level of consciousness
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective if the client does not develop which complication?
Correct response: seizures
A client is requesting the medication bupropion to treat depression. The nurse alerts the healthcare provider if the client has a history of which conditions? Select all that apply.
Correct response: seizures eating disorders
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?
Correct response: unequal pupil size
Which finding would be most indicative of hydrocephalus in an infant?
Correct response: sunset eyes
The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply.
Correct response: systolic blood pressure cerebral perfusion pressure
A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.
Correct response: Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. Based on the most likely diagnosis, the client is at risk for which outcome? Select all that apply.
brain damage death aspiration pneumonia
The nurse starts an infusion of tissue plasminogen alteplase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication?
Correct response: Conduct frequent neurologic assessments to determine whether the stroke is evolving or acute complications are developing.
A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about:
Correct response: 12 to 18 months.
A nurse is preparing to administer phenytoin to a 99-lb (45-kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.
Correct response: 75
The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.
Correct response: 90
A school-age child with a severe head injury is unconscious and has coarse breath sounds, a temperature of 39° C (102.2° F), a heart rate of 70 bpm, a blood pressure of 130/60 mm Hg, and an intracranial pressure (ICP) of 36 mm Hg. Which action should the nurse perform first?
Correct response: Administer prescribed IV mannitol.
The nurse assesses an 8-month-old infant for a possible head injury after a fall of about 3 feet. The child is awake, alert, and crying. Vital signs are within normal limits. What action should the nurse take next?
Correct response: Assess the infant's pupillary responses.
A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating?
Correct response: Assist the client in learning to eat with the left hand.
The intensive care unit (ICU) nurse is caring for a 33-year-old female client with an injury to left side of the forehead from hitting the steering wheel in a motor vehicle crash 1 day ago. For each client finding, click to specify if the finding is consistent with the disease process of traumatic brain injury (TBI), concussion, or diabetes insipidus. Each finding may support more than 1 disease process.
traumatic Brain Injury (TBI): altered level of consciousness nausea and vomiting, seizures, intracranial pressure (ICP) of 22 mm Hg Concussion: altered level of consciousness nausea and vomiting Diabetes Insipidus: diuresis serum sodium 147 mEq/l (147 mmol/l)
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?
Correct response: infection
The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?
Correct response: Reduced serum ammonia levels.
To assess a client's cranial nerve function, a nurse should assess
Correct response: gag reflex.
A nurse has a four-patient assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology?
Correct response: the client with diabetes insipidus
The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client?
Correct response: elevating the head of the bed to 30 degrees
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
Correct response: increased intracranial pressure (ICP)
While in the emergency department, an adolescent who was in a motorcycle accident less than 1 hour earlier remains conscious but is agitated and anxious. The nurse observes that his pulse and respirations are increasing and his blood pressure is decreasing. The nurse should initiate interventions to manage which complication?
Correct response: spinal shock
The intensive care unit (ICU) nurse is caring for a 33-year-old female client with an injury to left side of the forehead from hitting the steering wheel in a motor vehicle crash 1 day ago. For each potential intervention, click to specify whether the intervention is indicated or contraindicated.
Indicated: Maintain seizure precautions. Check that the hospital gown and dressings are not constricting at the client's neck. Maintain the client's body temperature between 97°F and 100.4°F (36.1°C and 38°C). Administer acetaminophen 500 mg rectally every 4 to 6 hours for a temperature greater than 100.4°F (38°C). Contraindicated: Position the client flat in bed. Turn the client's head to the side. Infuse 0.45% sodium chloride for maintenance fluids.
When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness?
Correct response: can be roused with stimulation
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
Correct response: pupil size and pupillary response
A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication?
Correct response: clear yellowish fluid on the dressing
The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test?
Correct response: cortisol levels before and after the system is challenged with a synthetic steroid
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?
Correct response: decrease in level of consciousness (LOC)
The health care provider (HCP) has prescribed intravenous mannitol for a child with a head injury. The best indicator that the drug has been effective is which assessment finding?
Correct response: decreased intracranial pressure.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include
Correct response: diminished responsiveness.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates
Correct response: dysfunction in the brain stem.
A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?
Correct response: head of the bed elevated to 30 degrees
The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have?
Correct response: impulsive acts of aggression
A full-term neonate is suspected of having hydrocephalus. The nurse collects what assessment finding to best assist in confirming the diagnosis?
Correct response: increasing occipital frontal circumference
A 28-year-old male client is in the neurological intensive care unit following a right supratentorial craniotomy for excision of a brain tumor 2 days earlier. The nurse is carrying out the plan of care for this client after the craniotomy. Which action(s) should the nurse take? Select all that apply.
Maintain the head of the bed at 30 degrees. Pad the side rails of the bed. Monitor the level of consciousness. Administer dexamethasone as prescribed.
A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?
Correct response: Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal?
Correct response: Decrease intracranial pressure.
What is the function of cerebrospinal fluid (CSF)?
Correct response: It cushions the brain and spinal cord.
A 12-year-old child has had a traumatic head injury from playing in a football game. He is admitted to the emergency department and transferred to the pediatric intensive care unit. He has an IV of dextrose 5% in water at 21 mL/h and nasal oxygen at 2 L/min. The nurse is assessing the child at the beginning of the shift (2300 hours) and reviews the accompanying Glasgow Coma Scale flow sheet. The nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal flexion of the limbs. What should the nurse do first?
Correct response: Notify the health care provider (HCP).
An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which is the nurse's best action?
Correct response: Notify the healthcare provider.
The nurse is completing a neurologic assessment on a client admitted with a contusion to the brain. Which finding does the nurse prioritize as requiring immediate action?
Correct response: Pupils are equal with sluggish reaction to light.
An infant diagnosed with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. What should the nurse do next?
Correct response: Wait a few minutes, and then refeed the child.
The nurse is documenting assessment findings of the newborn. When assessing the neonate's head, the above is noted. Upon further examination, swelling is limited to below the scalp on the left side of the head. How does the nurse document this finding most accurately on the admission assessment to the nursery?
Correct response: a cephalohematoma contained on the left side
A 28-year-old male client is in the neurological intensive care unit following a right supratentorial craniotomy for excision of a brain tumor 2 days earlier. For each potential intervention, click to specify whether the intervention is indicated, nonessential, or contraindicated in maintaining ICP in this client.
Indicated: Position the client flat in bed. Monitor neurologic status. Nonessential: Monitor serum amylase and lipase levels. Contraindicated: Encourage the Valsalva maneuver. Maintain a state of hypercarbia.
The client is an 8-year-old boy with new-onset seizures who is being seen in the child neurology clinic for increasing frequency of seizures. Which action is a priority for the emergency response team to perform for this client in status epilepticus? Select all that apply.
Maintain an airway and provide oxygenation. Obtain intravenous access. Maintain circulation. Administer intravenous anticonvulsants. Monitor vital signs and neurologic status. Check the blood glucose level by finger stick.
When caring for an adolescent who is at risk for injury related to intracranial pathology, which action by the nurse would maintain stable intracranial pressure (ICP)?
Correct response: Maintain the adolescent's head in midline position.
A 4-year-old child with meningitis exhibits a decreased level of consciousness and has increasing intracranial pressure. The nurse should report which finding to the health care provider?
Correct response: blood pressure of 122/84 mm Hg
A client is admitted to the rehabilitation unit after a cerebrovascular accident (or brain attack). The client is bedridden and aphasic. When assessing the client's emotional response to the illness, what would the nurse most want to explore?
Correct response: past experiences and coping abilities
After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question?
Correct response: performing a lumbar puncture
A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?
Correct response: risk for injury
A client has sustained a head injury and is to receive mannitol by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find:
Correct response: decreased cerebral edema.
