Neuro Therapeutic Management

1 (Lorazepam (Ativan) is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached.)

A fast acting, short duration agent used for breakthrough seizures is: 1. Lorazepam (Ativan). 2. Phenytoin (Dilantin). 3. Phenobarbital. 4. Midazolam (Versed).

3 (The patient is showing signs of subarachnoid bleed and poor cerebral perfusion. Although pain is an important diagnosis, the patient needs the tissue perfusion addressed first. The history does not reflect that a breathing problem or infection is the primary problem.)

A patient arrives complaining of nausea and vomiting for 1 week and with a stiff neck and "the worst headache of my life." What is the priority nursing diagnosis? 1. Pain 2. Ineffective breathing pattern 3. Inadequate cerebral tissue perfusion 4. High risk for infection

1 (The patient is displaying signs of Guillain-Barré syndrome and requires intubation and ventilatory support. A bronchodilator does not help the respiratory muscles. Pulmonary function tests track the progression of the paralysis, but this patient requires support. Increasing oxygen will not help the patient breathe because the muscles of ventilation have been affected.)

A patient was admitted complaining of an abrupt onset of weakness that started in both legs and is now causing flaccidity of the arms after an episode of the flu. Which intervention does the nurse anticipate when the patient complains of difficulty breathing? 1. Prepare for immediate intubation. 2. Order a respiratory treatment. 3. Order a pulmonary function test. 4. Start oxygen via non-rebreather mask.

1 (These effects are indicative of central herniation, due to an expanding mass lesion of the midline, frontal, parietal, or occipital lobes.)

Downward displacement of the hemispheres, basal ganglia, and diencephalon through the tentorial notch, is indicative of: 1. central herniation. 2. uncal herniation. 3. cingulate herniation. 4. infratentorial herniation.

4 (Advantages of a ventriculostomy include access for CSF drainage and sampling, access for determination of volume-pressure curve, direct measurement of pressure, and access for medication instillation.)

Mr. P. is admitted to the critical care unit with an acute head injury following a motor vehicle accident. He has a Glasgow coma scale score of 6. He is intubated and ventilated, and a ventriculostomy is placed with physician orders to keep the intracranial pressure less than 15 mm Hg. Mr. P.'s intracranial pressure continues to rise despite aggressive intervention. Which of the following is an advantage of a ventriculostomy intracranial pressure monitoring system? 1. Lower risk of infection 2. Ease of insertion 3. No penetration of brain 4. Access for CSF drainage and sampling

2 (Mr. P. has herniated. Signs and symptoms of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The ICP drops as the pressure is relieved by shifting the intracranial components downward.)

Mr. P. is admitted to the critical care unit with an acute head injury following a motor vehicle accident. He has a Glasgow coma scale score of 6. He is intubated and ventilated, and a ventriculostomy is placed with physician orders to keep the intracranial pressure less than 15 mm Hg. Mr. P.'s intracranial pressure continues to rise despite aggressive intervention. Mr. P. becomes flaccid with fixed and dilated pupils. His intracranial pressure falls from 65 mm Hg to 12 mm Hg. What should the nurse suspect is happening? 1. Mr. P. is having a seizure. 2. Mr. P.'s brain has herniated. 3. Mr. P.'s cerebral edema is resolving. 4. Mr. P. is excessively dehydrated from the mannitol.

3 (One of the earliest and most important signs of increased ICP is a decrease in the level of consciousness.)

One of the earliest and most important signs of increased ICP is: 1. Cushing's triad. 2. decerebrate posturing (abnormal extension). 3. a decrease in the level of consciousness. 4. an increase in pupillary size.

1 (Normal ICP waveforms have three distinct peaks known as P1 (percussion wave), P2 (tidal wave), and P3 (dicrotic wave).)

The normal intracranial pressure waveforms can best be described as: 1. having three distinct peaks known as the percussion wave, tidal wave, and dicrotic wave. 2. elevated plateau-shaped waves. 3. sharp, rhythmic oscillations with a sawtooth appearance. 4. small rhythmic waves that fluctuate with respiration.

1 (Mannitol is the osmotic diuretic of choice because it has little or no rebound effect and may improve perfusion to ischemic areas of the brain.)

The osmotic diuretic that has been most effective in the reduction of increased intracranial pressure is: 1. mannitol. 2. furosemide (Lasix). 3. urea. 4. glycerol.

3 (The recent trend is to individualize the head position to maximize CPP and minimize ICP measurements.)

The patient position optimal to prevent elevated ICP pressures is which of the following? 1. The head of the bed elevated 30-40 degrees 2. Supine with the patient's neck in a neutral alignment 3. Individualized head position to maximize CPP and minimize ICP measurements 4. The head of the bed elevated with flexion of the hips

3 (The ability of the normal brain to maintain a constant cerebral blood flow despite wide ranges in arterial pressure is known as autoregulation.)

The primary mechanism for physiologic control of cerebral blood flow is: 1. arterial pressure. 2. the osmotic gradient. 3. autoregulation. 4. cerebral perfusion pressure.

4 (The trend now 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.)

The target range for PaCO2 when employing hyperventilation to lower ICP is: 1. 25-30 mm Hg. 2. 30-35 mm Hg. 3. 35-40 mm Hg. 4. 35 mm Hg + 2.

4 (High-dose barbiturates increase cerebral vascular resistance and therefore decrease cerebral blood flow, resulting in a reduction in intracranial volume.)

The use of barbiturates in the patient with increased intracranial pressure is: 1. contraindicated because respiratory arrest may occur. 2. used primarily for pain control. 3. indicated in low doses to prevent complications. 4. helpful in decreasing cerebral blood flow.

4 (Lidocaine is used to blunt the effects of tracheal stimulation on intracranial pressure and must be administered no longer than 5 minutes before suctioning.)

Which of the following is administered before suctioning to prevent associated increases in ICP? 1. Lorazepam (Ativan) 2. Midazolam (Versed) 3. Oxygen 4. Lidocaine

2 (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 ICP.)

Which of the following is the most common complication following high dose barbiturate therapy? 1. Hypothermia 2. Hypotension 3. Myocardial depression 4. Decrease central venous pressure

3 (Nimodipine is used to decrease cerebral vasospasm.)

Which of the following medications is prescribed to decrease cerebral vasospasm? 1. Phenytoin (Dilantin) 2. Phenobarbital 3. Nimodipine (Nimotop) 4. Vecuronium (Norcuron)

1 (Cerebral perfusion pressure (CPP) is the blood pressure gradient across the brain and is calculated as the difference between the incoming mean arterial pressure (MAP) and the opposing ICP.)

Which of the following statements regarding cerebral perfusion pressure (CPP) is correct? 1. CPP is calculated as the difference between the mean arterial pressure (MAP) and the ICP. 2. The CPP in the average adult is approximately 150-160 mm Hg. 3. When the CPP equals the MAP, cerebral blood flow ceases. 4. Neuronal ischemia and death occurs with a CPP less than 60 mm Hg.

3 (Coma prognosis is based on length of time in the coma and the cause: metabolic versus structural and traumatic versus nontraumatic. A metabolic trauma—induced coma of short duration has the best prognosis. A structural coma for 1 week, metabolic coma for 4 days, and structural and metabolic coma with trauma for longer than 1 week have worse prognoses.)

Which patient should have the best prognosis after a coma? 1) Patient with a brain tumor who has been in a coma for 7 days 2) Patient with diabetic ketoacidosis who has been in a coma for 4 days 3) Patient with a drug overdose who has been in a coma for 2 days after a motor vehicle accident 4) Patient with an intracerebral bleed from a cocaine overdose who has been in a coma for 8 days

2 (A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing intracranial pressure.)

13. Which of the following independent nursing measures can assist in reducing increased intracranial pressure? 1. Decreasing the ventilator rate 2. Decreasing noxious stimuli 3. Frequent orientation checks 4. Administration of loop diuretics

3 (For the small subset of patients in whom standard therapy fails to achieve ICP control, judicious, carefully monitored and administered high-dose barbiturate therapy is beneficial.)

Which intervention should be considered last in treating elevated ICP? 1. Sedatives 2. Analgesics 3. Barbiturates 4. Hyperventilation

4 (Carbon dioxide retention (hypercapnia) leads to cerebral vasodilation, which increases cerebral blood volume resulting in increased ICP.)

Which of the following conditions is most likely to result in increased intracranial pressure (ICP)? 1. Hypoxia 2. Hyperoxia 3. Hypocapnia 4. Hypercapnia

2 (In the noncompliant brain, small increases in volume may cause major elevations in ICP.)

Which of the following correctly expresses the relationship between volume and pressure in the intracranial compartment of a noncompliant brain? 1. Small increases in volume may yield small increases in intracranial pressure. 2. Small increases in volume may yield large increases in intracranial pressure. 3. Intracranial compartments are separated by the tentorium, preventing pressure fluctuations. 4. Large increases in volume may decrease intracranial pressure.