Ch 16 jk
The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury. How much of a size difference between the two pupils is still considered normal? a.1 mm b.1.5 mm c.2 mm d.2.5 mm
a.1 mm Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description. Most people have pupils of equal size, between 2 and 5 mm. A discrepancy up to 1 mm between the two pupils is normal.
The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? a.A waves b.B waves c.C waves d.D waves
a.A waves A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure.
The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. What must the nurse verify before performing the test? a.Absence of cervical injury b.Depth and rate of respiration c.Patient's ability to swallow d.Patient's ability to follow a verbal command
a.Absence of cervical injury In an unconscious patient, assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF) is performed by eliciting the doll's eyes reflex. If the patient is unconscious as a result of trauma, the nurse must ascertain the absence of cervical injury before performing this examination.
The nurse is caring for a severely head injured comatose patient who is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show which signs? a.Bradycardia, systolic hypertension, and widening pulse pressure b.Tachycardia, systolic hypotension, and tachypnea c.Headache, nuchal rigidity, and hyperthermia d.Bradycardia, aphasia, and visual field disturbances
a.Bradycardia, systolic hypertension, and widening pulse pressure The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem.
The nurse is caring for a patient who has just had a cerebral angiogram. Which intervention should be part of the nursing management plan? a.Ensuring that the patient is adequately hydrated b.Maintaining the patient on an NPO status c.Administering antibiotics to the patient d.Keeping the patient flat in bed for 24 hours
a.Ensuring that the patient is adequately hydrated After the cerebral angiogram, adequate hydration is necessary to assist the kidneys in clearing the heavy dye load. Inadequate hydration may lead to renal dysfunction and renal shutdown.
What sites can be used for monitoring ICP? (Select all that apply.) a.Intraventricular space b.Epidural space c.Jugular veins d.Subdural space e.Parenchyma
a.Intraventricular space b.Epidural space d.Subdural space e.Parenchyma The five sites for monitoring intracranial pressure are: (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural space, (4) the subdural space, and (5) the parenchyma.
The nursing management plan for a patient undergoing an oil-based contrast myelogram should include intervention? a.Maintain the patient flat in bed for 4 to 8 hours. b.Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding. c.Keep the patient's head elevated 30 to 45 degrees for 8 hours. d.Administer a sedative to keep the patient from moving around.
a.Maintain the patient flat in bed for 4 to 8 hours. Postprocedure care of the patient undergoing an oil-based iophendylate myelogram includes keeping the patient's flat in bed for 4 to 8 hours.
A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2: a.greater than 20 mm Hg. b.less than 15 mm Hg. c.between 15 and 20 mm Hg. d.between 10 and 20 mm Hg.
a.greater than 20 mm Hg. In a patient with head injury, the goal of treatment is to maintain the PbtO2 greater than 20 mm Hg. Factors that decrease PbtO2 include tissue hypoxia, hypocapnia, hypovolemia, decreased blood pressure, low hemoglobin levels, intracranial hypertension, and hyperthermia. Treatment is directed at the underlying cause.
The patient is ordered a CT scan with contrast. Which question should the nurse ask the conscious patient before the procedure? a."Are you allergic to penicillin?" b."Are you allergic to iodine-based dye?" c."Are you allergic to latex?" d."Are you allergic to eggs?"
b."Are you allergic to iodine-based dye?" If the patient is scheduled to receive contrast for computed tomography (CT) scanning, questions about possible sensitivity to iodine-based dye must be asked beforehand, if possible. During infusion of the dye and for 10 to 30 minutes afterward, the patient is observed closely for an anaphylactic reaction. Fewer than 1% of all patients undergoing contrast-enhanced CT have severe anaphylactic reactions, shock, or cardiac arrest.
A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a.Abnormal flexion b.Abnormal extension c.Localization d.Withdrawal
b.Abnormal extension Outcome studies indicate that abnormal extension or decerebrate posturing has a more serious prognosis than does abnormal extension or decorticate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. Localization and withdrawal are abnormal neurologic findings; however, these findings are less serious than abnormal extension.
A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner performed a lumbar puncture. Which result is an abnormal finding? (Select all that apply.) a.Fluid is clear and colorless b.Glucose of 20 mg/dL c.Protein of 20 mg/dL d.Bloody fluid in first sample only e.Pressure of 250 mm H2O
b.Glucose of 20 mg/dL e.Pressure of 250 mm H2O Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells. Blood in the first sample is indicative of a traumatic spinal tap and is not considered abnormal.
A patient is admitted immediately after a craniotomy. The patient has no history of eye surgery. When assessing the size and shape of the patient's pupils, the nurse observes the patient's left pupil is oval. What does this finding indicate? a.Cortical dysfunction b.Intracranial hypertension c.Optic nerve damage d.Opioid overdose
b.Intracranial hypertension Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape. An oval pupil is not indicative of cortical dysfunction, optic nerve damage, or an opioid overdose.
The nurse is admitting a neurologically impaired patient. The patient's family is present. How comprehensive should the initial history be? a.It should be limited to the chief complaint and personal habits. b.It should be all-inclusive, including events preceding hospitalization. c.It should be confined to current medications and family history. d.It should be restricted to only information that the patient can provide.
b.It should be all-inclusive, including events preceding hospitalization. The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding hospitalization. If the patient is incapable of serving as the historian, family members or significant others who have contact with the patient on a daily basis should provide that information as soon as possible.
The nurse is precepting a nursing student. The student asks about testing of extraocular eye movements. What should the nurse tell the student? a.It tests the pupillary response to light. b.It tests function of the three cranial nerves. c.It tests the ability of the eyes to accommodate to a closer moving object. d.It tests the oculocephalic reflex.
b.It tests function of the three cranial nerves. Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI).
The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? a.Patient's eyes move in the same direction as the patient's head when turned. b.Patient's eyes move in the opposite direction as the patient's head when turned. c.Patient's eyes move in opposite directions from each other when the patient's head is turned. d.Patient's eyes move up and down and then back and forth when the patient's head is turned.
b.Patient's eyes move in the opposite direction as the patient's head when turned. To assess the oculocephalic reflex, the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll's eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent
The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? a.Pupils are equal and reactive b.Widening pulse pressure c.Eupnea d.Decreased intracranial pressure
b.Widening pulse pressure Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP.
The nurse is caring for a patient with an intracranial pressure monitoring device that provides access to CSF for sampling. Which type of device does the patient have? a.Subarachnoid bolt b.Epidural catheter c.Intraventricular catheter d.Fiberoptic catheter
c.Intraventricular catheter An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid (CSF) for drainage or sampling. A subarachnoid bolt, epidural catheter, and fiberoptic catheter provide no access for CSF sampling.
The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? a.Patient is in vegetative state. b.Patient is a paraplegic. c.Patient is in a coma. d.Patient is able to obey commands.
c.Patient is in a coma. The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of neurologic injury.
The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? a.Lethargic b.Obtunded c.Stuporous d.Comatose
c.Stuporous Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient
The nurse is teaching a nursing student about the importance of assessing the patient's level of conscious (LOC). Which statement indicates the nursing student understood the information? a."The LOC is the most prognostic indicator of the patient's neurologic outcome." b."The LOC limited to the Glasgow Coma Scale making it the quickest part of the assessment." c."The LOC is the easiest part of the neurologic exam and thus is generally performed first." d."In most situations, the LOC deteriorates before any other neurologic changes are observed."
d."In most situations, the LOC deteriorates before any other neurologic changes are observed." Assessment of the level of consciousness is the most important aspect of the neurologic examination.
The nurse is precepting a new graduate nurse. The new graduate asks about testing the oculovestibular reflex. What should the nurse tell the new graduate? a."The test should not be performed on an unconscious patient because of the risk of aspiration." b."An abnormal response is manifested by conjugate, slow, tonic nystagmus, deviating toward the irrigated ear." c."This test should be included in the nursing neurologic examination of a patient with a head injury." d."This test is performed by the practitioner and one of the final clinical assessments of brainstem function."
d."This test is performed by the practitioner and one of the final clinical assessments of brainstem function." The oculovestibular reflex is one of the final clinical assessments of brainstem function and is only performed by a practitioner. In a normal response, eye movement is in the direction of the injection site. An abnormal response is disconjugate eye movement, which indicates a brainstem lesion, or no response, which indicates little to no brainstem function.
A patient is admitted with an anoxic brain injury. The nurse notes abnormal extension of both extremities to noxious stimuli. This finding indicates dysfunction in which area of the central nervous system? a.Cerebral cortex b.Thalamus c.Cerebellum d.Brainstem
d.Brainstem Abnormal extension occurs with lesions in the area of the brainstem. The cerebral cortex, cerebellum, and thalamus are all located above the brainstem.
The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? a.Central neurogenic hyperventilation b.Apneustic breathing c.Ataxic respirations d.Cheyne-Stokes respirations
d.Cheyne-Stokes respirations Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long periods of apnea. They are usually seen in lesions of the lower pons or upper medulla. Ataxic respirations are irregular, random patterns of deep and shallow respirations with irregular apneic periods. They are usually seen in lesions of the medulla.
The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure, the patient reaches over with his left hand and tries to remove the noxious stimuli. How would the nurse document this response? a.Decorticate posturing b.Decerebrate posturing c.Withdrawal d.Localization
d.Localization Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.
