Neuro- Critical Care

The primary functions of which lobe are hearing, speech, behavior, and memory? a. Frontal lobe b. Temporal lobe c. Occipital lobe d. Parietal lobe

ANS: B The temporal lobe lies beneath the temporal bone in the lateral portion of the cranium. Separated from the frontal and parietal lobes by the lateral fissure, this lobe has the primary functions of hearing, speech, behavior, and memory.

A patient has been admitted post craniotomy for a brain tumor. The nursing management plan should include monitoring the patient for what complication? a. Diabetes mellitus b. Fluid retention c. Intracranial hypotension d. Surgical hemorrhage

ANS: D Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, and deep venous thrombosis.

Herniation syndromes

medial temporal lobe (uncus) hernias down to the midbrain (compression on posterior cerebral artery and CN III)

Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)? a. Mannitol b. Furosemide c. Urea d. Glycerol

ANS: A The most widely used diuretic is mannitol, a large-molecule agent that is retained almost entirely in the extracellular compartment and has little of the rebound effect observed with other osmotic diuretics. Administration of mannitol increases cerebral blood flow and thus induces cerebral vasoconstriction as part of the brain's autoregulatory response to keep blood flow constant.

A person with a cerebellar lesion will have difficulty with which physiologic mechanism? a. Breathing b. Equilibrium c. Memory d. Speech

ANS: B Cerebellar impulses are communicated to descending motor pathways to integrate spatial orientation and equilibrium with posture and muscle tone, ensuring synchronized adjustments in movement that maintain overall balance and motor coordination. Cerebellar monitoring and adjustment of motor activity occurs simultaneously with movement, enabling significant control of fine motor function.

Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)? a. Occurrence is greater in men than women younger than the age of 40 years old. b. Occurrence is greater in men than women older than the age of 40 years old. c. 90% of SAHs are caused by traumatic injury. d. Patients with SAHs have a better survival rate than patients with arteriovenous malformations.

ANS: A Among people younger than 40 years, more men than women are likely to have subarachnoid hemorrhages (SAHs); among those older than 40 years, more women have SAHs. Hemorrhage from arteriovenous malformation rupture has a better chance of survival and is associated with an overall mortality rate of 10% to 15%. Ninety percent of aneurysms are congenital, the cause of which is unknown. The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial vessel) or infectious material.

Which areas of the spinal cord have tenuous blood supply and are especially vulnerable to circulatory embarrassment? a. C2 to C3 b. C5 to C6 c. T8 to T10 d. L4 to L5

ANS: A Arterial supply to the spinal cord is segmented at best, making portions of the spinal cord that receive blood supply from two separate sources vulnerable to low flow states. The most vulnerable of these areas are C2 to C3, T1 to T4, and L1 to L2.

A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and symptoms might the patient exhibit? a. Right-sided hemiplegia and receptive aphasia b. Left-sided hemiplegia and tactile agnosia c. Decorticate posturing and unequal pupils d. Unilateral neglect and dressing apraxia

ANS: A Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills.

2. Which neurologic structure carries nerve impulses from the central nervous system (CNS) to the periphery to produce a response such as contraction of the skeletal muscles? a. Efferent fibers b. Afferent fibers c. Sensory fibers d. Neurotransmitters

ANS: A Efferent fibers (motor fibers) transmit the central nervous system (CNS) response to the periphery to produce a motor response such as contraction of skeletal muscles, contraction of the smooth muscles of organs, or secretion by endocrine glands. This sensory information is transmitted to the CNS by afferent fibers (sensory fibers). Fibers enclosed in the sheath are called myelinated fibers. Neurotransmitters help with nerve transmission from one neuron to the next.

A patient has had an ischemic stroke and now having difficulty with speech. The nurse knows the patient is experiencing what problem? a. Expressive aphasia b. Global aphasia c. Receptive aphasia d. Apraxia

ANS: A Expressive aphasia, also known as motor, Broca, or nonfluent aphasia, is primarily a deficit in language output or speech production. Global aphasia results when a massive lesion affects the motor and sensory speech areas. The patient cannot transform sounds into words and cannot comprehend spoken words. Receptive aphasia, also referred to as sensory, Wernicke, or fluent aphasia, occurs when the connection between the primary auditory cortex in the temporal lobe and the angular gyrus in the parietal lobe is destroyed. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily.

How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown? a. 2 hours b. 4 hours c. 8 hours d. 12 hours

ANS: A Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist.

Which medication is a fast-acting, short-duration agent used for breakthrough seizures? a. Lorazepam b. Phenytoin c. Phenobarbital d. Midazolam

ANS: A Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.

A lack of which two substances can cause disruption in neuronal function and irreversible damage? a. Oxygen and glucose b. Protein and insulin c. Oxygen and protein d. Protein and glucose

ANS: A No reserve of either oxygen or glucose is found in the cerebral tissues. A lack or inadequate amount of either one rapidly disrupts cerebral function and produces irreversible damage.

Which patient has the best prognosis based on the cause of coma? a. A 36-year-old man with closed head injury b. A 50-year-old woman with hepatic encephalopathy c. A 46-year-old woman with subarachnoid hemorrhage d. A 72-year-old man with hypertensive intracerebral hemorrhage

ANS: A Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.

The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods? a. First 24 hours b. 4 to 12 days c. 3 to 4 weeks d. 3 to 6 months

ANS: A Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%.

Stimulation of what nerve will elicit the gag reflex? a. Glossopharyngeal b. Facial c. Spinal accessory d. Hypoglossal

ANS: A The glossopharyngeal nerve is a sensory nerve whose functions are taste in the posterior third of the tongue and sensation in the back of the throat; stimulation elicits the gag reflex.

A patient has neurologic damage to the limbic system. Which assessment finding is specific to this type of deficit? a. Flat affect with periods of emotional lability b. Unable to recall early events c. Disorientation to place and time d. Unable to interpret written words

ANS: A The limbic lobe's primary functions are related -to self-preservation and -recall of pleasurable as well as unpleasant -or potentially dangerous events modification of mood and emotional responses in relation to perceived events interpretation of smell -augmentation of visceral processes (eg, heart rate, respiration) associated with emotion.

Downward displacement of the hemispheres, basal ganglia, and diencephalon through the tentorial notch is indicative of what type of herniation? a. Central b. Uncal c. Cingulate d. Infratentorial

ANS: A These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri. The two infratentorial herniation syndromes are upward transtentorial herniation and downward cerebellar herniation.

The extrusion of cerebral tissue through the cranium is what type of herniation? a. Transcalvarial b. Uncal c. Cingulate d. Transtentorial

ANS: A Transcalvarial herniation is the extrusion of cerebral tissue through the cranium. In the presence of severe cerebral edema, transcalvarial herniation occurs through an opening from a skull fracture or craniotomy site. These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri.

Which area of the ventricular system is usually cannulated for intracranial pressure monitoring? a. Frontal horn of the lateral ventricle b. Aqueduct of Sylvius c. Foramen of Monro d. Fourth ventricle

ANS: A When cannulation of the ventricular system is required for intracranial pressure monitoring, cerebrospinal fluid (CSF) drainage, or placement of a CSF shunt, the frontal horn of the lateral ventricle on the nondominant side of the brain is most often selected.

If the right internal carotid artery is blocked, what happens to the blood flow to the right side of the brain? a. Blood flow is delivered via the circle of Willis b. Blood flow is diminished by 25% c. Blood flow is diminished by 50% d. Blood flow ceases

ANS: A When complete, the circle of Willis is capable of supporting some degree of collateral blood flow in the case of arterial occlusion, although a sufficient arterial supply in the face of arterial obstruction is not guaranteed.

The patient has sustained an ischemic stroke involving the left cerebral hemisphere. Which of the following neurologic abnormalities would you expect to see? (Select all that apply.) a. Aphasia b. Left visual field defect c. Difficulty balancing his checkbook d. Ataxic gait e. Somnolence

ANS: A, C With strokes in the left (dominant) hemisphere, patients may have aphasia; right hemiparesis; right-sided sensory loss; right visual field defect; poor right conjugate gaze; dysarthria; and difficulty in reading, writing, or calculating. With strokes in the right (nondominant) hemisphere, patients may have neglect of the left visual space, left visual field defect, left hemiparesis, left-sided sensory loss, poor left conjugate gaze, extinction of left-sided stimuli, dysarthria, and spatial disorientation. With strokes in the brainstem, cerebellum, and posterior hemisphere, patients may have motor or sensory loss in all four limbs, crossed signs, limb or gait ataxia, dysarthria, disconjugate gaze, nystagmus, amnesia, and bilateral visual field defects.

Which of these substances are examples of small-molecule transmitters? (Select all that apply.) a. Acetylcholine b. Glucose c. Norepinephrine d. Dopamine e. Epinephrine f. GABA receptors

ANS: A, C, D, E Examples of small-molecule transmitters include acetylcholine, dopamine, norepinephrine, epinephrine, serotonin, histamine, -aminobutyric acid, glycine, and glutamate.

A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse checks the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.) a. Aspirin b. Sodium nitroprusside c. Warfarin d. Labetalol e. Any antiplatelet drugs

ANS: A, C, E The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.

Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study? a. Magnetic resonance imaging b. Noncontrast computed tomography c. Contrast computed tomography d. Lumbar puncture

ANS: B Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. In addition to excluding intracranial hemorrhage, CT can assist in identifying early neurologic complications and the cause of the insult. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)? a. Decreasing the ventilator rate b. Decreasing noxious stimuli c. Frequent orientation checks d. Administration of loop diuretics

ANS: B A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing intracranial pressure.

A male patient post right-sided stroke is experiencing hemiagnosia. This is evidenced by which finding? a. The patient only reads the right side of the newspaper. b. The patient refuses to acknowledge the left side of his body. c. The patient is hyperresponsive when approached on the right side. d. The patient attempts to comb his hair with a toothbrush.

ANS: B Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. This denial may range from inattention to refusing to acknowledge a paralysis by neglecting the involved side of the body or by denying ownership of the side, attributing the paralyzed arm or leg to someone else. The neglect also may extend to extrapersonal space. This defect most often results from right hemispheric brain damage that causes left hemiplegia.

A patient becomes flaccid with fixed and dilated pupils. The patient's intracranial pressure (ICP) falls from 65 to 12 mm Hg. What should the nurse suspect is happening? a. The patient is having a seizure. b. The patient's brain has herniated. c. The patient's cerebral edema is resolving. d. The patient is excessively dehydrated from the mannitol.

ANS: B Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs and symptoms of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.

The patient has uncontrolled intracranial pressure and now is receiving high-dose barbiturate therapy. The nursing management plan for this patient should include monitoring the patient for what complication? a. Hypothermia b. Hypotension c. Myocardial depression d. Dehydration

ANS: B Hypotension, the most common complication in barbiturate therapy, results from peripheral vasodilation and can be compounded in an already dehydrated patient who has received large doses of an osmotic diuretic in an attempt to control intracranial pressure. Myocardial depression results from cardiac muscle suppression and can be avoided by frequent monitoring of fluid status, cardiac output, and serum drug levels.

A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract computed tomography (CT) findings are negative. The patient is being prepared for a lumbar puncture. What appearance does the nurse anticipate that the cerebrospinal fluid (CSF) would look? a. Cloudy b. Bloody c. Xanthochromic d. Clear

ANS: B If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH

A female right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. While assisting with personal care, the nurse notes that the patient is unable to comb her hair with her left hand. The nurse suspects the patient may be experiencing which complication? a. Agnosia b. Apraxia c. Broca aphasia d. Wernicke aphasia

ANS: B Lesions in the parietal lobe, as well as in other cortical structures, can result in apraxia, an inability to perform a learned movement voluntarily.

A patient's ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Given that the practitioner has left appropriate orders, which action should the nurse take next? a. No action is required. b. Administer mannitol 1 to 2 g/kg IV. c. Place the patient supine and flat in bed. d. Suction the patient.

ANS: B Mannitol is an osmotic diuretic and will pull swelling out of edematous brain tissue, thereby decreasing intracranial pressure (ICP). Having the patient lie flat in bed will impair venous drainage from the head and worsen ICP. Suctioning will cause increased intrathoracic pressure, which will also worsen the already elevated ICP.

Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival? a. Decorticate posturing b. Absent pupillary light reflexes c. Decerebrate posturing d. Central hyperventilation

ANS: B Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy.

Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms? a. 1 b. 3 c. 6 d. 10

ANS: B National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and Stroke rtPA Stroke Study. This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours of onset of the stroke was an effective and safe therapy for ischemic stroke. This time frame has now been expanded from 3 to 4.5 hours with additional excursion criteria.

Substances most likely to pass across the blood-brain barrier have what characteristics? a. Low pH compared with body fluids b. Lipid solubility c. Large particle size d. A close relation to toxic metabolites

ANS: B Passage of substances across the blood-brain barrier is a function of particle size, lipid solubility, and protein-binding potential. Most drugs or compounds that are lipid soluble and stable at body pH rapidly cross the blood-brain barrier. The blood-brain barrier is also very permeable to water, oxygen, carbon dioxide, and glucose.

ANS: C After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery, patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema.

ANS: B Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP) in the postoperative neurosurgical patient. Antiemetics are administered as soon as nausea is apparent. Fluid restriction may be ordered as a routine measure to lessen the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of inappropriate antidiuretic hormone secretion. Most craniotomy patients can be turned from side to side within these restrictions, using pillows for support, except in some cases of extensive tumor removal, cranioplasty, and when the bone flap is not replaced. Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications. To prevent dangerous elevations in ICP, this care measure must be performed using proper technique and at time intervals that are adequately spaced from other patient care activities.

Which type of hematoma results from traumatic injury involving the middle meningeal artery? a. Subdural b. Epidural c. Subarachnoid d. Intercerebral

ANS: B The main blood supply for the dura mater is the middle meningeal artery. This artery lies on the surface of the dura in the epidural space within grooves formed on the inside of the parietal bone. Traumatic disruption of the parietal bone may result in tearing of the middle meningeal artery and development of an epidural hematoma.

Which statement best describes the role of neuroglial cells? a. They are fewer in number than neurons. b. They provide support to the neuron in nutrients and structural formation. c. They protect the central nervous system (CNS) from nonmetabolic primary neoplasms. d. They produce a steady supply of neurotransmitters.

ANS: B These cells provide the neuron with structural support, nourishment, and protection (Table 26-1). They also retain their ability to replicate but can replicate abnormally and hence are the primary source of central nervous system neoplasms.

Control of the rate of respirations occurs in the in which brain center? a. Apneustic center b. Pneumotaxic center c. Reticular activating system d. Midbrain

ANS: B Two respiratory control centers are located in the pons, namely the apneustic and pneumotaxic centers. Whereas the apneustic center controls the length of inspiration and expiration, the pneumotaxic center controls respiratory rate.

Which cranial nerves are responsible for motor functions of the eye? (Select all that apply.) a. Optic nerve b. Oculomotor c. Trochlear d. Trigeminal e. Abducens f. Acoustic

ANS: B, C, E The oculomotor nerve is the motor nerve whose function is raising the eyelids and extraocular movement of the eyes. The trochlear nerve is the motor nerve whose function is the extraocular movement of the eyes. The abducens nerve is the motor nerve that functions with extraocular eye movement and rotates the eyeball outward. The optic nerve is the sensory nerve whose function is vision. The trigeminal nerve is the sensory nerve that gives sensation to the cornea, ciliary body, iris, and lacrimal gland. The acoustic nerve is the sensory nerve whose function is hearing.

After neurosurgery, the patient is at risk of developing what problem? a. Aspiration b. Diabetes mellitus c. Seizures d. Corneal abrasions

ANS: C After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery, patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema.

When an object is placed in the hand of a patient with neurologic impairment during assessment, the patient is unable to recognize the placement. What is this complication called? a. Homonymous hemianopsia b. Aphasia c. Agnosia d. Apraxia

ANS: C Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. Tactile agnosia is a perceptual disorder in which a patient is unable to recognize an object that has been placed in his or her hand by touch alone. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily. Optic radiations extend back to the occipital lobes. Visual defects restricted to a single field, right or left, are called homonymous hemianopsia. Aphasia is a loss of language abilities caused by brain injury, usually to the dominant hemisphere.

Which intervention should be considered LAST in treating uncontrolled intracranial hypertension? a. Sedatives b. Analgesics c. Barbiturates d. Hyperventilation

ANS: C Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not responded to the conventional treatments previously described. The two most commonly used drugs in high-dose barbiturate therapy are pentobarbital and thiopental. The goal with either of these drugs is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.

13. Obstructive hydrocephalus can occur in the presence of what abnormality? a. Blockage in the arachnoid villi b. Malformation of the falx cerebelli c. Blockage of cerebrospinal fluid (CSF) flow in the ventricular system d. Increased production of CSF

ANS: C Blockage of cerebrospinal fluid (CSF) flow occurring within the ventricular system obstructs the normal circulation of CSF, causing dilation of the ventricles, a condition called obstructive hydrocephalus.

What is one cause of metabolic coma? a. Trauma b. Ischemic stroke c. Drug overdose d. Intracerebral hemorrhage

ANS: C Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.

Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention? a. Administering osmotic diuretics and vasodilator agents b. Providing the patient with a quiet environment c. Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg d. Keeping the patient's central venous pressure at 5 to 8 mm Hg

ANS: C Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures.

Which medication is prescribed to decrease cerebral vasospasm? a. Phenytoin b. Phenobarbital c. Nimodipine d. Vecuronium

ANS: C Nimodipine is used to decrease cerebral vasospasm.

What is one of the earliest signs of increased intracranial pressure (ICP)? a. Cushing triad b. Decerebrate posturing (abnormal extension) c. Change in level of consciousness d. Increase in pupillary size

ANS: C One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness.

A patient has coherent speech but the words are illogical. Which part of the brain has been affected? a. The cerebellum b. The Broca area c. The Wernicke area d. The hypothalamus

ANS: C The Wernicke area (Brodmann area 22) is partially located within the parietal lobe and partially in the temporal lobe, most commonly on the left side of the cerebral cortex. This area is concerned with reception of written and verbal language and includes many intricate connections to other parts of the brain associated with auditory and visual functions, cognitive appraisal, and expressive language. Injury to this area of the brain may result in disability ranging from minor receptive language dysfunction to receptive or fluent aphasia, in which expressive language function remains but is illogical in content or a "word salad."

A patient is admitted after a stroke. The patient has an altered level of consciousness and garbled speech. A computed tomography scan is performed to determine the cause of the stroke, and a lumbar puncture is performed for analysis of cerebrospinal fluid (CSF). Because the patient's speech is garbled, the nurse documents the occurrence of which type of aphasia? a. Fluent b. Receptive c. Expressive d. Global

ANS: C The area involved in the formulation of verbal speech is the Broca area. Damage to this area results in an expressive or nonfluent aphasia.

1. Which structure(s) form(s) the blood-brain barrier? a. Postsynaptic terminals b. Pia mater c. Vascular endothelial cells d. Myelin sheath

ANS: C The blood-brain barrier operates on the concept of tight junctions between adjacent cells and actually consists of three separate barriers: the endothelial cells of cerebral blood vessels, the epithelial cells of the choroid plexus, and the cells that form the outermost layer of the arachnoid.

What percentage of the body's total resting cardiac output is used by the brain? a. 5% b. 10% c. 20% d. 40%

ANS: C The brain constitutes 2% of the body's weight but uses 20% of the body's total resting cardiac output. It requires approximately 750 mL of blood flow per minute and can extract as much as 45% of arterial oxygen to meet normal metabolic needs.

What is the large opening at the base of the cranium called? a. Cisterna magna b. Median foramen c. Foramen magnum d. Lateral foramen

ANS: C The cranium is a solid, nonexpanding bony vault with only one large opening at the base called the foramen magnum, through which the brainstem projects and connects to the spinal cord.

Cranial nerves IX, X, XI, and XII are located in which section of the brainstem? a. Midbrain b. Pons c. Medulla oblongata d. Reticular formation

ANS: C The medulla oblongata forms the last section of the brainstem, situated between the pons and the spinal cord. The cell bodies of cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory), and XII (hypoglossal) are located in the medulla oblongata.

What is the tissue that adheres directly to the brain called? a. Dura mater b. Arachnoid mater c. Pia mater d. Blood-brain barrier

ANS: C The outermost layer of meninges directly beneath the skull is the dura mater. The arachnoid membrane is a delicate, fragile membrane that loosely surrounds the brain. Cerebrospinal fluid (CSF) circulates freely in the subarachnoid space fragile membrane that loosely surrounds the brain. The pia mater adheres directly to brain tissue. Rich in small blood vessels that supply a large volume of arterial blood to the central nervous system, this membrane closely follows all folds and convolutions of the brain's surface.

Which patient position is optimal to prevent elevated intracranial (ICP) pressures? a. The head of the bed elevated 30 to 40 degrees b. Supine with the patient's neck in a neutral alignment c. Individualized head position to minimize ICP measurements d. The head of the bed elevated with flexion of the hips

ANS: C The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements.

What is the region of the brain that acts as a relay station for both motor and sensory activity called? a. Cerebrum b. Cerebellum c. Thalamus d. Hypothalamus

ANS: C The thalamus consists of two connected ovoid masses of gray matter and forms the lateral walls of the third ventricle. The two thalami serve as a relay station and gatekeeper for motor and sensory stimuli, preventing or enhancing transmission of impulses based on the behavioral needs of the person.

A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) of the patient's head reveals a large left parietal area bleed. Patient assessment includes temperature (T), 98.7° F; pulse (P), 98 beats/min and thready; respirations (R), 8 breaths/min; and blood pressure (BP), 168/100 mm Hg. Initial management of the patient includes which intervention? a. Placing the patient in the Trendelenburg position b. Administering an antihypertensive agent c. Initiating induced hypertensive therapy d. Intubating and ventilating the patient

ANS: D Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg.

A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy? a. Instillation of mannitol b. Drainage of subdural hematoma c. Brain tissue sampling d. Cerebrospinal fluid drainage

ANS: D Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.

What is a pathologic consequence of an unruptured cerebral aneurysm? a. It shunts blood away from the surrounding tissues. b. It leaks blood into the subarachnoid space. c. It causes damage the middle layer of the arterial wall. d. It places pressure on the surrounding tissues

ANS: D An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.

A patient with neurologic damage continues with extremely high core body temperature despite interventions to lower temperature. The nurse suspects the patient has sustained damage to which area of the brain? a. Cerebrum b. Cerebellum c. Thalamus d. Hypothalamus

ANS: D Areas of the internal environment regulated and maintained by the hypothalamus include temperature regulation, autonomic nervous system responses, food and water intake, hormonal secretions, and behavioral responses.

The ability to access cerebrospinal fluid (CSF) by a lumbar puncture is attributable to the flow of CSF in which space? a. Subdural b. Subpia c. Epidural d. Subarachnoid

ANS: D Cerebrospinal fluid fills the ventricular system and surrounds the brain and spinal cord in the subarachnoid space.

A patient has been told he has a nonencapsulated tumor that has infiltrated the brain tissue. Why type of tumor does the nurse suspect the patient has? a. Angioma b. Pituitary adenoma c. Meningioma d. Glioma

ANS: D Gliomas are nonencapsulated; tend to infiltrate brain tissue; arise in any part of brain connective tissue; infiltrate primarily cerebral hemisphere tissue; are not well outlined, so they are difficult to excise completely; and grow rapidly. Angiomas arise from vascular structures and are usually difficult to resect. Pituitary adenomas arise from various tissues. Meningiomas arise from meningeal coverings of brain and are usually encapsulated.

A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a. Hemorrhagic stroke b. Intracerebral hemorrhages c. Subarachnoid hemorrhages d. Ischemic stroke

ANS: D Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.

Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit? a. The demyelination process of the peripheral nerves is irreversible. b. The demyelination process is limited to the peripheral nervous system only. c. The paralysis associated with the syndrome occurs in a descending pattern. d. The most common cause of death is respiratory arrest.

ANS: D Most patients with Guillain-Barré syndrome (GBS) do not require admission to the critical care unit. However, the prototype of GBS, known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), involves a rapidly progressive, ascending peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure. Because of the need for ventilatory support, AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment.

What is the target range for PaCO2 in the patient with intracranial hypertension? a. 25 to 30 mm Hg b. 25 to 35 mm Hg c. 35 to 40 mm Hg d. 33 to 37 mm Hg

ANS: D The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings.

Which afferent pathway carries sensory impulses from the body into the spinal cord? a. Subarachnoid b. Spinal nerves c. Ventral root d. Dorsal root

ANS: D The dorsal root is an afferent pathway that carries sensory impulses from the body into the spinal cord. The ventral root is an efferent pathway that carries motor information from the spinal cord to the body.

Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents? a. Epinephrine, hydrocortisone, and Benadryl b. Dopamine, 10% dextrose in distilled water, and calcium chloride c. Mannitol, dexamethasone, and sodium bicarbonate d. Thiamine, glucose, and opioid antagonist

ANS: D The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.

What are the most common medications used in high-dose barbiturate therapy? a. Phenytoin and fosphenytoin b. Mannitol and nimodipine c. Lidocaine and phenobarbital d. Pentobarbital and thiopental

ANS: D The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained. Phenytoin and fosphenytoin are anticonvulsants. Mannitol is an osmotic diuretic, lidocaine is a local anesthetic, and nimodipine is a calcium channel blocker.

Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome? a. Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients or increased metabolic demand b. Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c. Risk for aspiration d. Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment

ANS: D The most common cause of death of patients with Guillain-Barré syndrome (GBS) is respiratory arrest; thus, the highest nursing priority for a patient with GBS is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.

The sensory, motor, and cognitive functions are the primary functions of which area of the brain? a. Diencephalon b. Basal ganglia c. Cerebellum d. Cerebrum

ANS: D The outermost aspect of the cerebrum is called the cerebral cortex. The primary functions of the cerebral cortex include sensory, motor, and intellectual (cognitive) functions, making this area of the brain vital to normal human functioning and providing capabilities that make humans unique as a species.

Which lobe of the brain deals primarily with sensory function? a. Frontal lobe b. Temporal lobe c. Occipital lobe d. Parietal lobe

ANS: D The parietal lobe is primarily concerned with sensory functions, including integration of sensory information; awareness of body parts; interpretation of touch, pressure, and pain; and recognition of object size, shape, and texture. Injury to these areas may result in tactile sensory loss on the opposite side of the body.

Damage to the upper portion of the reticular activating system results in which condition? a. Seizures b. Diabetes insipidus c. Apnea d. Impaired consciousness

ANS: D The reticular activating system (RAS) works through activation of the hypothalamus, which results in diffuse cortical stimulation and autonomic stimulation. Damage to the thalamic or hypothalamic RAS pathways results in impaired consciousness.

The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The provider requests the drainage be tested for the presence of glucose. Why did the physician order this test? a. To assess for an infection b. To check for a shift in osmolality c. To check for occult blood d. To assess for a cerebrospinal fluid leak

ANS: D To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater.

A ventriculoperitoneal shunt may be placed in a post-stroke patient to treat which complication? a. Hyponatremia b. Intracerebral hemorrhage c. Spontaneous intracerebral hemorrhage d. Hydrocephalus

ANS: D Treatment for hydrocephalus consists of placing a drain to remove cerebrospinal fluid. This can be accomplished temporarily by inserting a ventriculostomy or permanently by placing a ventriculoperitoneal shunt. Treatment for hyponatremia is sodium replenishment with isotonic fluids.

Cerebral Perfusion Pressure

CPP = MAP - ICP. If CPP = 0, there is no cerebral perfusion and brain death would occur.

Basilar Skull Fracture Signs/Symptoms

Characterized by "battlesigns", bruising behind the ear, CSF drainage from ears, Raccoon eyes

rhinorrhea

Clear nasal discharge, "runny nose"

coup-contrecoup injury

Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds.

Glascow Coma Scale

EYE OPENING 4 - spontaneous 3 - open to speech 2 - open to pain 1 - no response VERBAL 5 - alert and oriented 4 - disoriented conversation 3 - inappropriate words 2 - nonsensical sounds 1 - no response MOTOR 6 - spontaneous 5 - localizes pain 4 - withdraws to pain 3 - decorticate posturing 2 - decerebrate posturing 1 - no movement

Intracranial Pressure (ICP)

Intracranial pressure (ICP) monitoring is a diagnostic test that helps your doctors determine if high or low cerebrospinal fluid (CSF) pressure is causing your symptoms. The test measures the pressure in your head directly using a small pressure-sensitive probe that is inserted through the skull.

Monroe - Kellie Hypothesis

The Monro-Kellie doctrine or hypothesis states that the sum of volumes of brain, cerebrospinal fluid (CSF) and intracerebral blood is constant. An increase in one should cause a reciprocal decrease in either one or both of the remaining two.

cerebral autoregulation

The ability of the brain to maintain constant cerebral blood flow despite changes in systemic arterial pressure over a range of 50 to 150 mm Hg

intraparynchemal

This type of hematoma, also known as intraparenchymal hematoma, occurs when blood pools in the tissues of the brain. There are many causes, including trauma, rupture of a bulging blood vessel (aneurysm), poorly connected arteries and veins from birth, high blood pressure, and tumors.

Cushing's Triad

What are the symptoms of Cushing's triad? set of signs that are indicative of increased intracranial pressure (ICP) Cushing's triad = hypertension, bradycardia, and irregular respirations (Cheyne-Stokes breathing). Some sources describe widened pulse pressure (increasing difference between systolic and diastolic BP) as the 3rd component of the triad, rather than irregular respirations.

Diffuse Axonal Injury (DAI)

Widespread disruption of axons due to acceleration or deceleration injury. Small, petechial hemorrhages at gray-white junction of cerebral hemispheres and or corpus callosum.

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid

Decorticate

arms flexed, legs extended

epidural hematoma

collection of blood above the dura mater

otorrhea

discharge from the ear

Decerebrate

extension away from body, pronation of arms/legs

basilar skull fracture

fracture at the base of the skull

cerebral edema

swelling from the inflammatory response, may compress and kill brain tissue

intracranial pressure

the amount of pressure inside the skull

sub-arachnoid space

the cerebrospinal fluid circulates between the pia mater and the arachnoid

brain death

total and irreversible cessation of brain function as indicated by a flat EEG reading