Head Injury Practice Questions
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.
1 *1. Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all signs of postconcussion syndrome—that would warrant the significant other's taking the client back to the emergency department.* 2. The nurse should monitor for signs of increased intracranial pressure (ICP), but a layman, the significant other, would not know what these signs and medical terms mean. 3. Hypervigilance, increased alertness and super-awareness of the surroundings, is a sign of amphetamine or cocaine abuse, but it would not be expected in a client with a head injury. 4. The client can eat food as tolerated, but feeding the client every three (3) to four (4) hours does not affect the development of postconcussion syndrome, the signs of which are what should be taught to the significant other.
The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.
1 *1. Purposeless movement indicates that the client's cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.* 2. Flaccidity would indicate a worsening of the client's condition. 3. Decerebrate posturing would indicate a worsening of the client's condition. 4. The eyes respond to light, not painful stimuli, but a 6-mm nonreactive pupil indicates severe neurological deficit.
The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.
1 *1. The head of the client's bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.* 2. Active range-of-motion exercises require that the client participate in the activity. This is not possible because the client is in a coma. 3. The client is at risk for pressure ulcers and should be turned more frequently than every shift, and research now shows that massaging bony prominences can increase the risk for tissue breakdown. 4. The nurse should always talk to the client, even if he or she is in a coma, but this will
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. 1. Systolic blood pressure. 2. Urine output. 3. Breath sounds. 4. Cerebral perfusion pressure. 5. Level of pain.
1, 4 1. Systolic blood pressure. 4. Cerebral perfusion pressure. The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.
When evaluating an arterial blood gas report from a client with a subdural hematoma who had surgery and is now on a ventilator, the nurse notes the PaCO2 is 35 mm Hg (4.7 kPa). The ventilator settings are: TV 400, respiration rate 24, FIO2 100%. What should the nurse do first? 1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. 2. Position the client with the head of bed elevated. 3. Continue to monitor the client. 4. Inform the charge nurse of the results of the report.
1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Since the client's PaCO2 level is normal (35 to 45 mm Hg or 4.7 to 6.0 kPa), paging the respiratory technician to change the respiration rate is an appropriate action. Elevating the head of the client's bed is contradicted with this client's condition: that would lower blood pressure and care of these patients involves maintenance of a flat position in bed for 24 hours after surgery. Continuing to monitor the client is inappropriate because the PaCO2 level is normal and the respiratory technician needs to adjust the hyperventtilation setting to normal on the ventilator since the lab indicates that PaCo2 is normal. Informing the charge nurse about the change in ventilator settings is not necessary at this time because this is expected care for this client.
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.
1. Assessing the neurological status is important, but ensuring an airway is priority over assessment. 2. Monitoring vital signs is important, but maintaining an adequate airway is higher priority. 3. Initiating an IV access is an intervention the nurse can implement, but it is not the priority intervention. *4. The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.*
An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? 1. Establishing an airway. 2. Replacing blood loss. 3. Stopping bleeding from open wounds. 4. Checking for a neck fracture.
1. Establishing an airway. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? 1. Slow, irregular respirations. 2. Rapid, shallow respirations. 3. Asymmetric chest excursion. 4. Nasal flaring.
1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1. The head of the bed elevated 30 to 45 degrees. 2. Trendelenburg's position. 3. Left Sims' position. 4. The head elevated on two pillows.
1. The head of the bed elevated 30 to 45 degrees. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.
A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? 1. Unequal pupil size. 2. Decreasing systolic blood pressure. 3. Tachycardia. 4. Decreasing body temperature.
1. Unequal pupil size. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.
2 1. The client in rehabilitation is at risk for the development of deep vein thrombosis; therefore, this is an appropriate medication. *2. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.* 3. Clients with head injuries are at risk for post-traumatic seizures; thus an oral anticonvulsant would be administered for seizure prophylaxis. 4. The client is at risk for a stress ulcer; therefore, an oral proton pump inhibitor would be an appropriate medication.
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.
2 1. The client is at risk for seizures and does not process information appropriately. Allowing him to return to his occupation as a forklift operator is a safety risk for him and other employees. Vocational training may be required. *2. "Cognitive" pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes.* 3. The client's ability to dress self addresses self-care problems, not a cognitive problem. 4. The client's ability to regain bowel and bladder control does not address cognitive deficits.
The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.
2 1. The scalp is a very vascular area and a moderate amount of bleeding would be expected. *2. These signs/symptoms—weak pulse, shallow respirations, cool pale skin—indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.* 3. This is a normal pupillary response and would not warrant intervention. 4. A headache that resolves with medication is not an emergency situation, and the nurse would expect the client to have a headache after the fall; a headache not relieved with Tylenol would warrant further investigation.
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of- motion exercises.
2, 3, 4 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? 1. Muscle relaxation. 2. Intake and output. 3. Widening of the pulse pressure. 4. Pupil dilation
2. Intake and output. After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.
A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply. 1. Find a television so the client can view the football game. 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. 4. Arrange for the client to be with his wife and baby. 5. Administer a sedative.
2, 3 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1. Deep breathing. 2. Turning. 3. Coughing. 4. Passive range-of-motion (ROM) exercises.
3. Coughing. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? *Select all that apply.* 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.
2,3,5 1. The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity. *2. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure.* *3. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema.* 4. Noxious stimuli, such as suctioning, increase intracranial pressure and should be avoided. *5. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness.*
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other. 2. Elevating the head of the bed to 30 degrees. 3. Logrolling or turning as a unit when turning. 4. Keeping the neck in a neutral position.
2. Elevating the head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: 1. Count the rate to be sure that ventilations are deep enough to be suffcient. 2. Notify the physician of the client's breathing pattern. 3. Increase the rate of ventilations. 4. Increase the tidal volume on the ventilator.
2. Notify the physician of the client's breathing pattern. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? 1. Place in a jacket restraint. 2. Wrap the hands in soft "mitten" restraints. 3. Tuck the arms and hands under the drawsheet. 4. Apply a wrist restraint to each arm.
2. Wrap the hands in soft "mitten" restraints. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.
3 *3. The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client's eyes moved, that would indicate that the brainstem is intact.* 4. Decorticate posturing after painful stimuli are applied indicates that the brainstem is intact; flaccid paralysis is the worse neurological response when assessing a client with a head injury.
The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
3 1. A client with a head injury must be awakened every two (2) hours to determine alertness; decreasing level of consciousness is the first indicator of increased intracranial pressure. 2. A diagnostic test, MRI, would be an expected test for a client with left-sided weakness and would not require immediate attention. *3. The Glasgow Coma Scale is used to determine a client's response to stimuli (eye-opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.*
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement *first*? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 × 2 gauze under the nose to collect drainage.
3 1. Prior to notifying the HCP, the nurse should always make sure that all the needed assessment information is available to discuss with the HCP. 2. With head injuries, any clear drainage may indicate a cerebrospinal fluid leak; the nurse should not assume the drainage is secondary to allergies and administer an antihistamine. *3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined.* 4. This would be appropriate, but it is not the first intervention. The nurse must determine where the fluid is coming from.
A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: 1. Exhibit no further episodes of short-term memory loss. 2. Be able to return to his construction job in 3 weeks. 3. Actively participate in the rehabilitation process as appropriate. 4. Be emotionally stable and display pre-injury personality traits.
3. Actively participate in the rehabilitation process as appropriate. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? 1. Give the client a warming blanket. 2. Administer low-dose barbiturates. 3. Encourage the client to hyperventilate. 4. Restrict fluids.
3. Encourage the client to hyperventilate. Normal ICP is 15 mm Hg or less or 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client tissues to collect the fluid. 4. Administer an antihistamine for postnasal drip.
3. Give the client tissues to collect the fluid. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.
4 1. Assessment is important, but with clients with head injury the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority. 2. Removing the client from the water is an appropriate intervention, but the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority. 3. Assessing the client for further injury is appropriate, but the first intervention is to stabilize the spine because the impact was strong enough to render the client unconsciousness. *4. The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis; therefore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water.*
A client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? 1. "I'll get your family." 2. "Can you tell me your name and where you live?" 3. "I'll bet you're a little confused right now." 4. "You are in the hospital. You were in an accident and unconscious."
4. "You are in the hospital. You were in an accident and unconscious." It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" is not helpful and may cause anxiety.
Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet. 3. Supination of arms, dorsifexion of the feet. 4. Back arched, rigid extension of all four extremities.
4. Back arched, rigid extension of all four extremities. Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? 1. Widening pulse pressure. 2. Decrease in the pulse rate. 3. Dilated, fixed pupils. 4. Decrease in level of consciousness (LOC)
4. Decrease in level of consciousness (LOC) A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). b.) Emergent; the client is poorly oxygenated. c.) Normal d.) Significant; the client has alveolar hypoventilation.
a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Rationale: A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space
a.) Laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal
a.) Urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.
A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with: a.) Emergency craniotomy. b.) Elective draining of the hematoma. c.) Burr holes to remove the hematoma. d.) Removal of the affected cranial lobe.
b.) Elective draining of the hematoma.
Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure
c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a.) To reduce intraocular pressure b.) To prevent acute tubular necrosis c.) To promote osmotic diuresis to decrease ICP d.) To draw water into the vascular system to increase blood pressure
c.) To promote osmotic diuresis to decrease ICP Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.
