AQ Neuro

Which position would the nurse expect a patient to display as decerebrate posturing when diagnosed with an elevated intracranial pressure (ICP) causing serious disruption of motor fibers in the midbrain and brain stem?

2

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and BP of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number. _______ mm Hg

39

For the patient who sustained a head injury in a motor vehicle crash, which primary injury interventions would the nurse include in the patient's plan of care? Select all that apply.

Administer oxygen. Maintain neck alignment. Establish/maintain IV access.

The nurse provides care for a patient who is suspected of having a spinal cord injury and is immobilized with a cervical collar. Which initial actions does the nurse take during the primary survey of this patient? Select all that apply.

Administer oxygen. Monitor airway patency. Maintain the patient in a supine position.

For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the health care provider?

An ICP of 20 mm Hg

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

An altered level of consciousness (LOC)

Which clinical manifestation would the nurse associate with a patient reporting a headache, with disturbed consciousness, and whose imaging studies indicate cerebral edema in the white matter?

An increase in the cerebral extracellular fluid volume occurred.

For the patient with a brain tumor, for which diagnostic test would the nurse prepare the patient when needing to localize and detect tumor blood flow?

Angiography

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Applying a rigid cervical collar and using a backboard to transport the patient

Which interventions would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply.

Begin parenteral nutrition if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

When preparing to administer a hypertonic saline infusion to a patient with an increased intracranial pressure (ICP), which parameters would the nurse monitor frequently? Select all that apply.

Blood glucose Serum sodium BP

For the patient admitted with a subdural hematoma following a motor vehicle accident, which vital sign change would the nurse interpret as a clinical manifestation of an increasing intracranial pressure (ICP)?

Bradycardia

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply.

Bradycardia Irregular respirations Increasing systolic BP

Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled?

Cancel the lumbar puncture and contact the prescribing provider.

Which clinical manifestations of severe serum sodium level decline would the nurse assess in a patient who has cerebral edema associated with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply.

Coma Lethargy Confusion Headache

Which interventions would the nurse implement to comfort the patient with a brain tumor who is experiencing disorientation and confusion due to perceptual problems? Select all that apply.

Create a routine Use reality orientation. Minimize environmental stimuli.

Which interventions would the nurse implement for a patient who is unable to eat, secondary to a brain tumor? Select all that apply.

Encourage the patient to eat. Ensure adequate nutritional intake. Assess the patient's nutritional status.

A patient is admitted to the emergency department following a motor vehicle accident; a head injury is suspected. The patient is scheduled for a CT scan of the brain with contrast. Prior to the procedure, which actions does the nurse take? Select all that apply.

Evaluate renal function. Implement NPO status. Ask whether the patient is allergic to shellfish.

Which assessments would the nurse perform when utilizing the Glasgow Coma Scale (GCS) to assess a patient admitted with a head injury and requiring regular neurologic and vital sign assessments? Select all that apply.

Eye opening Best verbal response Best motor response

Which manifestations in a patient with a T4 spinal cord injury alerts the nurse to the possibility of autonomic dysreflexia?

Headache and increased BP

The nurse suspects that which electrolyte abnormality is a cause of cerebral edema in a patient with chronic kidney disease?

Hyponatremia

A patient with a new cervical spinal cord injury is hospitalized. The nurse identifies that which interventions are appropriate to include in the patient's nutrition plan? Select all that apply.

Insert a nasogastric tube. Evaluate swallowing before starting oral feeding. If oral feeding is not possible, enteral nutrition must be provided.

The nurse is providing care to a patient with a spinal cord injury (SCI). The patient's assessment findings include varying control of legs and pelvis, instability of the lower back, and good sitting balance. The patient has full use of the wheelchair and can ambulate with long leg braces. Which level of spinal cord injury would have caused this manifestation?

L1

Which medication is an osmotic diuretic that the nurse would prepare to administer when needing to lower a patient's intracranial pressure (ICP)?

Mannitol

Which interventions would the nurse implement to promote positive outcomes for the patient experiencing increased intracranial pressures (ICPs) in the neurologic intensive care unit? Select all that apply.

Monitor ICP. Elevate the head of the bed to 30 degrees. Maintain systolic arterial pressure of 100 to 160 mm Hg.

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? Select all that apply.

Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Start concurrent treatment with antacids or proton pump inhibitors

Which factors would the nurse consider when preparing to administer the pharmacologic therapy for a patient with an increased intracranial pressure (ICP)? Select all that apply.

Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous intravenous sedatives. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

While monitoring a patient's intracranial pressure (ICP) via an intracranial device in the neurologic intensive care unit, which aspect of care requires collaborative actions by the nurse?

Monitoring the intracranial device for greater than five days

When developing the plan of care for a patient with an elevated intracranial pressure (ICP), which factors guide the nursing interventions? Select all that apply.

Pain and agitation may elevate the patient's ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return.

When experiencing speech disturbances and an inability to write, which part of the patient's cerebral hemisphere would the nurse associate with the patient's brain tumor?

Parietal lobe

Which factors would the nurse associate with influencing a patient's intracranial pressure (ICP) readings? Select all that apply.

Posture Temperature Carbon dioxide levels Intraabdominal pressure

Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating?

Presence of fixed unresponsive pupils

Which expected outcome would the nurse anticipate after administering phenytoin (Dilantin) for a patient with an increased intracranial pressure (ICP)?

Prevention of seizures

A woman with a T4 level complete spinal cord injury (SCI) asks the nurse about the impact of the injury on her sexuality. Which information does the nurse provide? Select all that apply.

Protection against unplanned pregnancy is needed. The patient has the capacity to become pregnant. The injury does not affect the ability to deliver normally through the birth canal. Pregnancy is associated with a higher rate of autonomic dysreflexia (AD).

Which outcome would the nurse expect after administration of IV mannitol (Osmitrol) prescribed for a patient experiencing an increased intracranial pressure (ICP)?

Reduced ICP

Which primary goals would the nurse identify when planning the care of a patient with a brain tumor? Select all that apply.

Removing the tumor mass Identifying the tumor type and location Managing increased intracranial pressure (ICP

A nurse has just received a report from the emergency department on a patient admitted with a closed head injury after falling down a flight of stairs. The nurse is reviewing the patient's lab results: sodium level of 128 mEq/L, serum osmolality of 271 mOsm/kg, and a urine specific gravity of 1.030. This data is indicative of which condition?

SIADH

The nurse would instruct the patient recovering from a head injury and his or her caregiver to report the development of which symptoms immediately to the health care provider? Select all that apply.

Seizures Stiff neck Increased drowsiness

Which rationale supports the nurse contacting the prescribing health care provider regarding an order of benzodiazepine for a patient with an increased intracranial pressure (ICP)?

Side effects include a hypotensive effect.

A patient experiences a spinal cord injury as a result of a motor vehicle accident. The patient exhibits a loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. The nurse identifies that the findings are consistent with which condition?

Spinal shock

A patient with a spinal cord injury (SCI) at the C7 level experiences autonomic dysreflexia. Which signs and symptoms occur with this condition? Select all that apply.

Sudden onset of severe headache Sweating above the level of the SCI

Which factors would the nurse consider when assessing the surgical outcome of a patient with a brain tumor? Select all that apply.

Surgery can reduce the tumor mass provide relief of symptoms extend survival time.

Which cardiac manifestations will the nurse notify the health care provider about in a patient who suffered a severe closed head injury? Select all that apply.

Systolic hypertension Widening pulse pressure Bradycardia with a full and bounding pulse

Of the four assigned patients in the intensive care unit (ICU), which patient with an infection has the highest risk for developing cerebral edema?

The patient diagnosed with encephalitis

Which interpretation would the nurse associate with a patient's Glasgow Coma Scale score of 5 after sustaining a head injury?

The patient is unresponsive and comatose.

Which intervention does the nurse perform in the acute care of a patient with autonomic dysreflexia?

Urinary catheterization

A patient with a T1 level spinal cord injury (SCI) is scheduled to be discharged from the hospital. The nurse creates a neurogenic bowel management plan and includes which information? Select all that apply.

Use of stool softeners Dietary choices for a high-fiber diet Use of suppositories for evacuation Instructions for how to perform digital stimulation of the rectum

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intracranial pressures (ICP) caused by a brain tumor?

Use strict aseptic technique with all procedural dressing changes.

The nurse provides emergency care for a patient following a spinal cord injury. The patient is unresponsive and apneic. The nurse opens the patient's airway using the jaw-thrust maneuver and applies a cervical collar. Which is the next priority action?

Ventilating with 100% oxygen using a bag-valve-mask

Which method of measurement is the gold standard for obtaining intracranial pressures (ICPs)?

Ventriculostomy