Intracranial regulation & ICP
This part of the brain is made up of gray and white matter and is responsible for muscle movement, balance, and control.
Cerebellum
Any ICP greater than____ mmHg in an adult is a medical emergency.
20
The presence of the ___________ reflex after the age of 2 indicates cerebral damage.
Babinski
This part of the brain consists of the midbrain, pons, and medulla oblongata and controls breathing, blood pressure, and heart rate. It regulates vomiting, hiccupping, coughing, and sneezing. Ten pairs of cranial nerves originate in this area. A network of fibers called the reticular activating system (RAS) is located in this part of the brain. The RAS regulates the sleep-wake cycle. The reticular formation within this structure integrates sensory information from the peripheral nervous system and relays the information to the cerebral cortex.
Brainstem
Problems with memory and learning would relate to which of the following lobes? A Frontal B Occipital C Parietal D Temporal
D
This part of the brain is made up of the thalamus and hypothalamus: Thalamus: This is the relay center for all information coming into the brain. Hypothalamus: This is the autonomic control center of the body and regulates heart rate, blood pressure, respirations, pain, pleasure, fear, body temperature, food and water intake and balance, sleep cycles, and digestion.
Diencephalon
This is the autonomic control center of the body and regulates heart rate, blood pressure, respirations, pain, pleasure, fear, body temperature, food and water intake and balance, sleep cycles, and digestion.
Hypothalamus
This lobe contains the visual cortex to process vision.
Occipital
This lobe processes sensory information such as shapes, temperature, pain, and two-point discrimination.
Parietal
This lobe stores memory, interprets auditory stimuli, and interprets smell.
Temporal
This is the relay center for all information coming into the brain
Thalamus
A client has a CVP monitor in place via a central line. Which would be included in the nursing plan of care for this client? a notify the dr of readings less than 3 cm or more than 8 cm of water b. use the clean technique to change the dressing at the insertion site c elevate the had of the bed to 90 degrees to obtain cvp readings d the 0 mark on the manometer should align with the clients right clavicle for readings
a
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
A nurse caring for a client who was recently admitted to the ER following a head on MVA. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which is the priority nursing action at this time? a keep neck stabalized b insert nasogastric tube c monitor pulse and BP frequently d establish IV access and start fluid replacement
a
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A Side-lying, with legs pulled up and head bent down onto the chest B Side-lying, with a pillow under the hip C Prone, in a slight Trendelenburg's position D Prone, with a pillow under the abdomen
a
The nurse is preparing to assess the cranial nerve function of Esther Moskowicz, an 85-year-old client who is experiencing a stroke. Which technique should the nurse use to determine Mrs. Moskowicz's extraocular movements? a Watch the eyes move as an H is drawn in the air b Observe for location and strength of eyelids c Place a Snellen chart on the wall d Shine a light into each eye
a
The spouse of a client who has increased intracranial pressure (IICP) asks the nurse what is happening in her husband's brain. Based on the pathophysiology, which is the best response by the nurse? a "Something in the brain, its blood, or surrounding fluid is off balance and has caused an increased pressure." b "The blood flow to the brain has increased and is causing an increased pressure." c "There must be a tumor causing the increase in pressure we are seeing." d "Your husband's low blood pressure is causing the brain to have too much fluid in it.
a
What should the nurse do to reduce the risk of traumatic brain injury in people over the age of 65? a Conduct a home safety assessment b Restrict movement with chemical restraints c Suggest a reduction in activity d Prevent participation in contact sports
a
Which of the following values is considered normal for ICP? A 0 to 15 mm Hg B 25 mm Hg C 35 to 45 mm Hg D 120/80 mm Hg
a
Which phrase describes a reflex? a Rapid, involuntary, predictable motor response to a stimulus b Relay center for all information coming into the brain c Brain matter responsible for muscle movement and balance d Control center that regulates heart rate and blood pressure
a
Why should the neurological assessment of an older client be modified? a Easily fatigued b Less efficient long-term memory c Increased reaction to stimuli d Shorter attention span
a
a nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose? a. hyperventilation per mechanical ventilation b. insertion of a ventricular shunt c. furosemide d solu medrol
a
Mr. Tacy is a 62-year-old man who developed a brain abscess and experienced an increase in intracranial pressure. His initial symptoms were headaches upon rising, blurred vision, elevated temperature, and occasional slurring of his speech. He received intravenous antibiotics and supportive treatment. In teaching Mr. Tacy about his care, which instructions would you provide? a "Avoid coughing and blowing your nose." b "Push with your arms and legs when moving up in bed." c "Take a laxative every other day so you do not become constipated." d "When resting in bed, tighten your leg muscles and relax them several times an hour."
a Coughing and blowing the nose increase intracranial pressure and should be avoided. The action of tightening and relaxing leg muscles is a form of isometric exercises, which increases intracranial pressure. It is important not to strain at stool or to become constipated. Monitoring stools is important, but a laxative may not be needed, especially every 2 days. Repositioning in bed while using the arms and legs to move initiates the Valsalva maneuver, which increases intracranial pressure; it should be avoided.
What is the purpose of a serum osmolality test in the diagnosis of increased intracranial pressure? a To determine hydration status b To indicate adequacy of serum protein levels c To identify serum lactic acid levels d To assess serum pH
a For a client with an altered intracranial pressure, serum osmolality measures hydration status. Overly hydrated clients have additional pressure within the intracranial cavity. Serum osmolality does not measure serum protein levels, lactic acid levels, or serum pH.
What is the optimal position of head and neck that would promote adequate venous drainage of the cerebral tissue? a Head and neck in normal body alignment b Lateral rotation of the head to either side c Slight flexion of the neck d Slight hyperextension of the neck
a Having the head and neck in normal body alignment promotes venous drainage from the veins of the cerebral tissue. Positions of hyperextension, flexion, and rotation may reduce venous drainage by applying a twisting pressure on the veins of the neck
In addition to measuring intracranial pressure, what is the purpose of inserting an intraventricular catheter for a client with alteration of intracranial pressure? a To drain cerebrospinal fluid b To administer medication to reduce cerebral inflammation c To shunt excess cerebrospinal fluid around an obstruction in the ventricular system d To resect excess brain tissue
a In addition to measuring intracranial pressure, an intraventricular catheter is used to drain cerebrospinal fluid. It does not shunt fluid around an obstructed area, act as a conduit for medication administration, or resect excess brain tissue.
A client recovering from a stroke is unable to swallow and has an absent gag reflex. Which cranial nerve should the nurse suspect is affected in this client? a Spinal accessory b Glossopharyngeal c Hypoglossal d Trigeminal
b
The nurse caring for the client with a closed head injury obtains an intracranial pressure (ICP) reading of 17mmHg. The nurse should recognize that: a The ICP is elevated and the Dr. should be notified b. The ICP is normal therefore no further action is needed c. The ICP is low and the client needs additional IV fluids d. The ICP reading is not as reliable as the Glascow coma scale
a Normal ICP ranges 4mmHG-10 mmHg with upper limits of 15 mmHG
The nurse is caring for a client with a traumatic brain injury. Which assessment finding indicates that the client would benefit from a histamine H2 antagonist? a Stool guaiac positive b Blood pressure increasing to 168/88 mmHg c Body temperature of 101degrees°F d Restlessness and easily agitated
a Rationale A positive stool guaiac indicates bleeding somewhere within the gastrointestinal tract. A histamine H2 antagonist reduces the risk of developing gastric stress ulcers. A body temperature elevation indicates the need for an antipyretic. Restlessness and agitation indicates an increase in intracranial pressure. A rising blood pressure could indicate pain or the need for vasoactive medication to control intracranial pressure.
Mrs. Williamson is a 45-year-old woman who came to the hospital via ambulance after a car accident in which she experienced a fractured right femur, internal bleeding, and a severe head injury. Which intravenous solution would you anticipate the healthcare provider ordering? a 5% dextrose in normal saline b 0.9% normal saline c Ringer lactate d 0.45% normal saline
a The osmolality of the hypertonic intravenous solution in intended to pull fluid from the cerebral tissue into the venous circulation, thus reducing fluid retention in the intracranial cavity. 5% dextrose in normal saline is a hypertonic solution. 0.9% normal saline, 0.45% normal saline, and Ringer lactate are either isotonic or hypotonic solutions, which would not pull edema from cerebral tissue.
What is the cause of vasogenic cerebral edema? a An increase in capillary permeability of cerebral vessels resulting in extracellular edema b Alteration in hormonal or electrolyte balance resulting in diffuse brain swelling c An increase in fluid retention of the neurons and endothelial brain cells related to sodium and water imbalance d Infiltration of brain cells by bacterial microorganisms resulting in a shift in osmotic pressure
a Vasogenic cerebral edema is caused by an increase in capillary permeability of cerebral vessels. Retained fluid in the neurons and endothelial cells associated with sodium and water retention is the cause of cytotoxic cerebral edema. Hormonal and sodium alterations that result in diffuse brain tissue swelling are characteristics of cytotoxic cerebral edema. Bacterial invasion of brain tissue results in encephalitis, not cerebral edema.
The nurse is caring for a client with a closed head injury. A late sign of ICP is: a. changes in pupil reactivity and equality b. restlessness and irritability c. complaints of headache d. irritability
a all other answers are early signs
Which set of vital signs would BEST indicate to the nurse that a client has an increase in intracranial pressure? a. BP 180/70 Pulse 50, RR 16, Temp 101 F b. BP 100/70, pulse 64, RR 20, Temp 98.6 c. BP 96/70, pulse 132, RR 20. Temp 98.6 d. BP 130/80. pulse 50. RR 18. Temp 99.6
a elevated BP, widening pulse pressure, decreased HR, temp elevation
The nurse is caring for a client with a head injury who has an icp monitor in place. Assessment reveals the ICP reading is 66. What is the nurses best action? a. Notify the provider immediately. b. record the reading as the only action c. turn the client and recheck the reading d. place the client supine
a normal ICP is 10-20
A Dr ordered neurological checks every 30 minutes for a client injured in a bike accident. Which finding indicates that the clients condition is satisfactory? a. a score of 13 on the Glascow coma scale b. the presence of dolls eye movements c. the absence of deep tendon reflexes d, decerebate posturing
a scale ranges 0-15 a 13 is satisfactory
A client with a hemorrhagic stroke has a temp of 103F. Efforts to reduce the temp have not been effective. The most likely explanation for the elevated temp is the damage has occured to the : a. hypothalamus b. pituitary c. carotid baroreceptors d. frontal lobe
a they hypothalamus helps to regulate body temp
The nurse is concerned that a client recovering from a stroke may have parietal lobe damage. Which observations made by the nurse support this concern? (Select all that apply.) a Client did not respond when foot was caught in the side rail. b Client did not respond when hot coffee was spilled on the hand. c Client is unable to move the left hand independently. d Client is unable to speak. e Client did not react when the trash can in the room caught on fire.
a,b Rationale The parietal lobes process sensory information such as shapes, temperature, pain, and two-point discrimination. Speech and spontaneous movement are controlled by the frontal lobe. The temporal lobe interprets smell.
What stimulates the compensatory mechanisms of the cerebral blood vessels to regulate cerebral pressure? (Select all that apply.) a Lactic acid b Carbon dioxide c Carbonic acid d Hypokalemia e Elevated serum uric acid level
a,b,c Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure. Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in response to the amount of blood flow within the brain. Elevated serum acid levels and reduced potassium levels (hypokalemia) do not affect cerebral pressure.
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a hyperglycemia b hyponatremia c hypervolemia d oliguria
b
A client is admitted with an L4-L5 injury. Which diagnostic tests should the nurse anticipate would be prescribed for this client? (Select all that apply.) a MRI b Myelogram c Nerve conduction studies d Brain echogram e Cerebral angiogram
a,b,c Rationale An L4-L5 injury is a low spinal cord injury. Diagnostic tests most likely to be prescribed for this client include an MRI, myelogram, and nerve conduction studies. Brain echogram and cerebral angiogram would not be indicated because the client does not have a brain injury.
Which assessments should the nurse include when examining a client with an alteration in intracranial pressure? (Select all that apply.) a Level of consciousness b Motor status and strength c Vital signs d Fluid intake for the past 24 hours e Pupillary responses to light
a,b,c,e Neurologic assessments of a client with a head injury include assessment of the level of consciousness, which will be the first indication of an increase in intracranial pressure. Additional assessments are vital signs, motor status and strength, and pupillary response to light. Previous oral fluid intake is not associated with a head injury, but ongoing fluid monitoring and limitation may be part of the treatment plan.
A nurse in the emergency department is providing care for a client who has increased intracranial pressure (IICP) from a traumatic brain injury from a motor vehicle crash. The nurse anticipates orders for which diagnostic tests in the care of this client? (Select all that apply.) a ABGs b Cardiac monitoring c CT of the head d Electromyogram e Intracranial pressure monitor
a,b,c,e Rationale An intracranial pressure monitor will give information about intracranial pressure. This information can be used to manage the medications and fluids for this client. A CT of the head will give information about possible hemorrhage and diffuse axonal injuries. Cardiac monitoring would be essential to monitor cardiac rate and rhythm. Arterial blood gases give information about oxygen and carbon dioxide levels in the blood. This information is used to manage artificial airways and mechanical ventilation. Electromyography is used to measure skeletal muscle activity. It would not be used in the diagnosis of a client with traumatic brain injury.
A nurse is providing care for a client with a traumatic head injury. The nurse should monitor the client for which manifestations consistent with increased intracranial pressure? (Select all that apply.) a Headache b Blurred vision c Double vision d Increased heart rate e Drowsiness
a,b,c,e Rationale Double vision and blurred vision can occur with IICP. Headache is common with IICP. Drowsiness can occur with IICP. The client may also report other generalized manifestations such as dizziness. The heart rate generally decreases with IICP.
A client with a stroke is demonstrating signs of increasing intracranial pressure. Which actions should the nurse take at this time? (Select all that apply.) a Reduce environmental stimuli b Assess vital signs c Assess cranial nerve function d Provide hypotonic fluids e Monitor pupillary response
a,b,c,e Rationale Nursing actions for the client demonstrating signs of increasing intracranial pressure include assessing vital signs, monitoring pupillary response, assessing cranial nerve function, and reducing environmental stimuli. Intravenous fluids administered at this time would be isotonic or hypertonic.
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? SELECT ALL THAT APPLY a. headache b dilated pupils c tachycardia d decorticate posturing e hypotension
a,b,d
After a nursing assessment, the nurse documents that a client is confused. Which behaviors did the nurse assess to determine this client's level of consciousness? (Select all that apply.) a Does not remember home address b Does not know why hospitalization is required c Responds to verbal stimuli but quickly falls back asleep d Uses inappropriate words to describe situations e Moans in response to painful stimuli
a,b,d Rationale Confusion is the inability to think rapidly and clearly. Additional characteristics include easily bewildered, poor memory, short attention span, misinterprets stimuli and impaired judgment. Semicomatose is moaning in response to painful stimuli. Obtundation is responding to verbal stimuli but quickly falling asleep.
The client is being treated for increased intracranial pressure (IICP). Which of these manifestations should indicate to the nurse that the outcomes are being met for this client? (Select all that apply.) a Blood pressure = 118/76 b No redness or drainage at site of intraventricular catheter c Verbalizes need to increase stimuli d Lethargic e Intracranial pressure = 14 mmHg
a,b,e Rationale The client should maintain ICP less than< 20 mmHg. The blood pressure should be normal. Client and significant others will verbalize the reasons for, and how to maintain, a low-stimuli environment, not high stimuli. The client will remain free of infection including redness and drainage at the sites of insertion. The client will maintain adequate cerebral perfusion, and level of consciousness should return to normal and not be lethargic.
Which tasks should NOT be delegated to the UAP? Select all that apply a bathing a client with a closed head injury b performing a tube feeding on a client with an established line c admin of parenteral meds d providing perineal care to a client with an indwelling cath
a,c
The nurse is preparing to conduct a neurologic assessment interview with a client. Which general questions should the nurse use when conducting this assessment? (Select all that apply.) a "Are you experiencing any pain?" b "How many fingers am I holding up at this time?" c "Do you have a history of seizures or fainting?" d "Do you have any problems with balance or coordination?" e "Are you having any problems with your memory?"
a,c,d,e Rationale General questions to include in a neurologic assessment interview include asking about pain, history of seizures or fainting, and asking about problems with memory and coordination or balance. Asking to identify the number of fingers would focus on the client's vision.
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A Abnormal flexion of the upper extremities and extension of the lower extremities B Rigid extension and pronation of the arms and legs C Rigid pronation of all extremities D Flaccid paralysis of all extremities
b
A nurse in the intensive care unit is providing care for a client with increased intracranial pressure (IICP). The nurse monitors the client for which manifestations of IICP? (Select all that apply.) a Decreased level of consciousness b Decreased blood pressure c Projectile vomiting d Increased heart rate e Dilated pupils
a,c,e Rationale Projectile vomiting is a manifestation of increased intracranial pressure. This is caused by pressure on the brainstem from swollen brain tissue. Dilated pupils are a manifestation of increased intracranial pressure. This is caused by pressure on the cranial nerves and vision pathways within the brain. A decreased level of consciousness is a manifestation of increased intracranial pressure. This is caused by pressure on the cerebral cortex and decreased oxygenation of the brain tissues. Increased intracranial pressure causes increased blood pressure, especially the systolic blood pressure. This worsens until there is a wide difference between the systolic blood pressure and the diastolic blood pressure. Increased intracranial pressure causes lowered heart rate. This is caused by the body's attempt to compensate for increased blood pressure.
What does the Glasgow Coma Scale assess? (Select all that apply.) a Verbal response b Corneal reflex c Cerebellar function d Motor response e Eye opening
a,d,e
A pediatric client is admitted for a head injury after falling off of a skateboard. The client was at first combative but is now becoming lethargic. Which actions should the nurse take for this client who has increasing intracranial pressure? (Select all that apply.) a Elevate the head of the bed 30 degrees b Install suction equipment at the bedside c Insert a nasogastric tube d Raise the side rails e Pad the side rails
a,d,e Rationale Nursing actions for the client with increasing intracranial pressure include padding and raising the siderails to prevent injury in the event that the client begins to seize. Elevating the head of the bed will help reduce increasing pressure in the head. Inserting a nasogastric tube would cause unnecessary stimulation and further raise intracranial pressure. Suction equipment would be necessary if the client has a seizure disorder or is experiencing status epilepticus.
A client with a minor head injury has a Glasgow Coma score of 15. What does this score indicate to the nurse? (Select all that apply.) a Client is oriented to person, place, and time. b Client withdraws to pain. c Client withdraws to touch. d Client uses appropriate words and phrases. e Client spontaneously opens the eyes.
a,d,e Rationale The maximum Glasgow Coma score is 15. This means that the client uses appropriate words and phrases, spontaneously opens the eyes, and is oriented to person, place, and time. Withdrawing to pain or touch would cause the Glasgow Coma score to be less than 15.
What is obtundation? (Select all that apply.) a Responsive to stimuli but drifts back to sleep b Easily bewildered, with poor memory and short attention span c Unresponsive but may be aroused by vigorous, repeated, or painful stimuli d Not aware of or not oriented to time, place, or person e Lethargic and somnolent
a,e
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A Vomiting continues B Intracranial pressure (ICP) is increased C The client needs mechanical ventilation D Blood is anticipated in the cerebrospinal fluid (CSF)
b
The mother of 2-week-old Miriam Shroeder is concerned when the nurse measures the circumference of the baby's head. Which explanation about the assessment is appropriate to share with the mother? a "The size of the head correlates to the amount of fluid that is within the body organs." b "The head circumference helps determine if there is extra fluid accumulating in the child's brain." c "This measurement helps determine when primitive reflexes are going to disappear." d "The size of the head helps determine if cranial nerves are developing and functioning."
b
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
b
The nurse is drawing an arterial blood sample from Jamal Lemmington, a 22-year-old male diagnosed with a traumatic brain injury. What should the nurse explain to Jamal's father about the purpose of this blood sample? a Estimates the length of time it will take for the client to resume consciousness b Measures the amount of carbon dioxide in the blood to predict the presence of increased intracranial pressure c Determines the response of medications to remove excess fluid from the brain tissue and reduce swelling d Predicts the number and depth of respirations that the client will have during one minute
b
A client experiences fractures of the left leg and a traumatic brain injury in a dirt bike accident and is admitted to the intensive care unit. Which assessment finding indicates increased intracranial pressure (IICP)? a Nausea b Irritability c Hypotension d Oliguria
b Rationale Irritability may indicate that the client is experiencing an increase in intracranial pressure, especially if associated with additional signs of bradycardia, increased systolic pressure, increased pulse pressure, vomiting, headache, lethargy, and change in mental status. Nausea does not accompany the vomiting associated with increased intracranial pressure. Hypotension and oliguria are not associated with increased intracranial pressure.
A client is to be discharged from the hospital first thing in the morning. However, overnight the client developed symptoms of "not being able to see well." The client also cannot move either the left arm or the left leg to get out of bed. What is the priority response by the nurse? a Ask the client if he has a family history of strokes b Assess the client's vital signs c Assist the client to dress for discharge d Instruct the client on the use of assistive devices to assist in mobility
b Rationale The change in assessment should signal the nurse to follow the nursing process and assess the client further. Although family history is important, it is not the priority in this situation. These symptoms are consistent with worsening condition and possible increased intracranial pressure. Continuing with the tasks associated with discharge would not be appropriate.
A client recovering from a stroke has an absent gag reflex and has lost 7 lb over the last 5 days. Which intervention does the nurse anticipate for this client? a Intramuscular injection of a corticosteroid b Placement of a feeding tube c Administration of hypotonic intravenous fluids d Administration of dextrose 50% and water
b Rationale The client is losing fluid and is unable to safely eat or drink. The nurse should prepare for this client to have a feeding tube placed. Dextrose 50% and water is a treatment for status epilepticus. Corticosteroids are indicated to treat inflammation. Hypotonic fluids will increase intracranial pressure. Isotonic or hypertonic fluids would be indicated for this client.
A nurse in the emergency department is providing care for a client diagnosed with increased intracranial pressure (IICP). The client is experiencing a decreasing level of consciousness. Which collaborative treatment would the nurse question for this client? a Place client on mechanical ventilator to increase oxygen and eliminate carbon dioxide b Administer intravenous 0.45% saline infusion c Intubate the client with an endotracheal tube d Administer intravenous mannitol
b Rationale The nurse would not administer hypotonic intravenous fluids for this client. Hypotonic fluids will cause water to move into the brain cells. This will increase intracranial pressure. The other interventions are expected and appropriate for clients with IICP.
The client has an increase in intracranial pressure caused by an increase in capillary permeability. The nurse should recognize this as which type of cerebral edema? a Hormonal b Vasogenic c Bacterial d Cytotoxic
b Rationale Vasogenic cerebral edema is caused by an increase in capillary permeability of cerebral vessels. Retained fluid in the neurons and endothelial cells associated with sodium and water retention is the cause of cytotoxic cerebral edema. Hormonal and bacterial are not types of cerebral edema.
When planning care for a client with a posterior fossa craniotomy which action in contraindicated? a keeping the client flat on one side b elevating the head of the bed 30 degrees c log rolling or turning as a unit d keeping the neck in a neutral position
b client required to lie flat
a client with ICP is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of hyperventilation is to: a. prevent the development of acute respiratory failure b. decrease the cerebral blood flow c. increase systemic tissue perfusion d. prevent cerebral anoxia
b hyperventilation reduces swelling and ICP by decreasing cerebral blood flow
What would be used to provide respiratory support for an alteration in intracranial regulation? (Select all that apply.) a Metered-dose inhaler b Endotracheal intubation c Oropharyngeal airway d Mechanical ventilation e Nebulizer treatments
b,c,d
Which are independent nursing interventions for an alteration in intracranial regulation? (Select all that apply.) a Provide antianxiety medication through intravenous site b Reduce the lights in the room c Shine a light into the client's eyes d Raise the head of the bed e Insert an indwelling urinary catheter
b,c,d
A nurse in the intensive care unit is providing care for a client with increased intracranial pressure from a traumatic brain injury. The client has a fever of 102 °F. Which interventions will the nurse use to promote normal intracranial pressure? (Select all that apply.) a Flex the neck to open the airway b Monitor level of consciousness c Provide supplemental oxygen d Suction for no more than 10 seconds per pass e Administer acetaminophen per order
b,c,d,e Rationale Hyperthermia increases intracranial pressure. Hyperthermia also affects hypothalamic function in clients with increased intracranial pressure; therefore, administering an antipyretic medication is appropriate. Prolonged suctioning can increase intracranial pressure. It also causes decreased oxygen levels. Increased intracranial pressure can cause irregular and ineffective respirations. Supplemental oxygen helps prevent hypoxia. It also helps prevent excess carbon dioxide, which is a vasodilator. A decreased level of consciousness can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased oxygen levels in the brain. Flexing the neck increases intracranial pressure by preventing blood return from the brain. The head and neck must be kept in neutral position.
A nurse is caring for a client who has a closed head injury with ICP reading ranging from 16-22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? (SELECT ALL THAT APPLY) a. suction the endo tracheal tube frequently b decrease the noise level in the clients room c elevate the clients head on two pillows d administer a stool softner e keep the client well hydrated
b,d suction increases ICP, flexing neck increases ICP
The nurse is using the glascow coma scale to assess the clients motor response. The nurse places pressure at the base of the clients fingernail for 20 seconds, The clients only response is withdrawal of his hand. The nurse interprets the clients response as: a. a score of 6 because he follows command b. a score of 5 because he localizes pain c. a score of 4 because he uses flexion d. a score of 3 because he uses extension
c
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
A client with a traumatic brain injury is intubated and placed on mechanical ventilation. What should the nurse use to evaluate the effectiveness of these respiratory interventions? a Cranial nerve function b Motor and sensory function c Arterial blood gas results d Glasgow Coma score
c
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a. Glasgow Coma scale b cranial nerve function c O2 sat d pupillary response
c
The RN caring for a client with CVA who is complaining of being nauseated and is requesting a emesis basin. Which action should the nurse take first? a. admin ordered antiemetic b. obtain ice bag and apply to clients throat c. turn client to one side d notify the provider
c
The nurse instructs the parents of school-age children on ways to prevent head injuries. Which statement made by a participant indicates that additional teaching is required? a "I need to get my son a helmet to wear when ice skating." b "My daughter needs to wear a helmet when riding the bicycle." c "My son should wear protective shoulder and knee pads when playing football." d "Even though he won't like it, I'll make sure my son wears a helmet when skateboarding."
c
The nurse is preparing a plan of care for Jimmy Williams, a 30-year-old client recovering from a head injury. Which collaborative action should the nurse perform to help reduce cerebral edema? a Regulate the infusion of a proton pump inhibitor b Apply a cooling blanket c Administer ethacrynic acid (Edecrin) as prescribed d Administer antihypertensive medication as prescribed
c
What is the purpose of consulting physical therapy services for a client with an alteration in intracranial pressure? a To assess the living accommodations before the client's discharge to home b To determine if transfer to skilled nursing facility is required c To recommend interventions for resulting hemiparesis or hemiplegia d To work with the nutritionist to determine effective methods to meet nutritional needs
c
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
While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A Frontal B Occipital C Parietal D Temporal
c
a client with ICP is receiving Osmitrol (Mannitol) and furosemide (lasix). The nurse recognizes that these two drugs are given to reverse what effect? a energy failure b excessive intracellular calcium c cellular edema d excessive glutamate release
c
What is the intended action of mannitol in the treatment of a client with increased intracranial pressure? a To enhance renal excretion of retained protein b To create a sodium and potassium balance c To draw fluid from the brain tissue d To prevent tiny stress hemorrhages in the brain
c Mannitol is used in the treatment of increased intracranial pressure to draw fluid out of the brain, reducing intracranial pressure. Mannitol does not establish a sodium and potassium balance. Mannitol does not enhance excretion of serum protein, which is not an intended outcome. The medication does not prevent hemorrhages within the brain.
The nurse assesses a respiratory rate of 8 breaths per minute in a client with a traumatic brain injury. Shortly thereafter the client begins hiccupping. Which part of the brain should the nurse suspect is being affected in this client? a Cerebellum b Occipital lobe c Brainstem d Thalamus
c Rationale The brainstem controls breathing and regulates hiccupping. The thalamus is the relay center for all information coming into the brain. The cerebellum is responsible for muscle movement, balance, and control. The occipital lobe contains the visual cortex to process vision.
During a physical examination, the nurse assesses the reflexes of an older client. Which reflex would require notification to the healthcare provider? a Gag b Achilles c Babinski d Corneal
c Rationale The presence of the Babinski reflex from age 2 years and on indicates cerebral damage. This is the reflex that the nurse should report to the healthcare provider. The gag, corneal, and Achilles reflexes should be present in the older client.
A nurse is caring for a client with a closed head injury Fluid is assessed leaking from the ear. What is the nurses first action? a irrigate the ear canal gently b notify the physician c test the drainage for glucose d apply an occlusive dressing
c cerebrospinal fluid would indicate positive glucose
Which are functions of the parietal lobe within the cerebrum? (Select all that apply.) a Processes information for memory and interprets smell b Processes actions for speech, thought, and learning c Processes information about two-point discrimination d Processes information about temperature and pain e Processes information about vision
c,d
The healthcare provider ordered diagnostic tests for a client with suspected increased intracranial pressure (IICP). Which tests should the nurse expect to show signs of IICP and help confirm the diagnosis and possible treatment needed? (Select all that apply.) a Stool guaiac test b Chest x-ray c CT scan d Serum osmolality e Arterial blood gases (ABGs)
c,d,e Rationale Some tests taken in clients with an intracranial hematoma will be expected to be normal: a chest x-ray and a stool guaiac test. Other tests, such as a CT, arterial blood gases, and serum osmolality can often produce valuable information about the cause of IICP and the treatment.
The nurse notes that a client has muscle fasciculations of both bicep muscles. What additional information should the nurse assess in this client? (Select all that apply.) a Blood pressure and pulse b Last solid food intake c Body temperature d Urine output e List of medications taking
c,d,e Rationale Fasciculations occur in clients with disease or trauma to the lower motor neurons, as a side effect of medications, in fever, in sodium deficiency, and in uremia. Fasciculations are not associated with food intake or blood pressure and pulse measurements.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A Sternal rub B Pressure on the orbital rim C Squeezing the sternocleidomastoid muscle D Nail bed pressure
d
A client has signs of ICP, which of the following is an early indicator of deterioration in the clients condition? a widening pulse pressure b decrease in pulse rate c dilated, fixed pupils d decrease LOC
d
How does increased intracranial pressure affect brain tissue? a Transmits sensory and motor impulses to the cerebrum for interpretation b Alters electrical discharges in the brain to cause involuntary movement c Removes fluid from interstitial spaces to reduce excess body fluid d Causes an oxygen deficit that leads to changes in personality, memory, and judgment
d
Mrs. Boyer is a very active, independent 82-year-old woman who lives alone in an assisted living facility. She is in good health and has been treated for mild hypertension and anxiety in the past. She has come to the emergency department of the community hospital via ambulance after falling from a stool in her kitchen and becoming unconsciousness after the fall. During your assessment, Mrs. Boyer says to you, "The x-rays indicate that I didn't break anything, and I only have this bruise on my arm. Why all the fuss with repeatedly checking my blood pressure, my heart, and my eyes and asking me where I am and what time it is?" Which response by the nurse is the most appropriate? a "Sometimes when a person falls, the person doesn't remember what happened and doesn't know simple things like where they are and what day it is. By asking, it helps you remember." b "It is common practice to neurologically assess anyone who has a head injury frequently to identify any swelling that may become visible as the bruised areas fill with fluid over time. We may then need to complete additional tests if we notice any changes." c "Even if bones are not broken, damage to your head could result in a fractured skull, which may show up on a later x-ray because of swelling of your skin." d "Even if there is no indication of external injuries and no broken bones, head trauma from your fall may cause pressure to build up in your head, which could result in some neurologic damage. We are checking frequently to see if that is happening."
d
A client with a traumatic brain injury is diagnosed as being brain dead. Which assessment finding supports this diagnosis? a Aware of environment but unable to communicate b Complete unawareness of self c Neck extended and the jaw is clenched d Absence of spontaneous respirations
d Rationale Brain death is the cessation and irreversibility of all brain functions, including the brainstem. Since the brainstem controls respirations, absence of respirations would be a nursing assessment finding in brain death. Complete unawareness of self describes a persistent vegetative state. An extended neck with clenched jaw describes the decerebrate posturing. Aware of the environment but unable to communicate describes locked-in syndrome
The nurse is assessing a client who leads an active, healthy lifestyle. The client has no history of chronic health conditions, but is seeking health care due to visual changes and occasional headaches over the past few weeks. Upon assessment, which question should the nurse ask the client? a "Do you feel nauseated after eating? b "Are you having trouble moving your bowels? c "Have you noticed an increase in thirst? d "Are your headaches worse upon rising in the morning?
d Rationale With increased intracranial pressure, headaches are noted to be worse in the morning and with position changes. Projectile vomiting may occur, but nausea is not present. Thirst does not increase for clients with IICP. Clients with IICP typically do not experience constipation or trouble with bowel movements.
What is the most frequent cause of increased intracranial pressure (IICP)? a Hemorrhage b Tumors c Abscesses d Cerebral edema
d The pressure exerted by cerebral edema, the increase in fluid that is retained in brain tissue, is the most common cause of increased intracranial pressure. Tumors and abscesses are space-taking lesions that increase the pressure within the cranial cavity. Hemorrhage, the pooling of blood within the cranial cavity, also exerts additional intracranial pressure.
A nurse caring for a client with a head injury would recognize which assessment finding as most indicative of increased ICP? a. vomiting b headache c dizziness d papilledema (eyes swell)
d papilledema is a hallmark symptom of ICP
A client with a head injury has ICP monitor in place. Cerebral perfusion pressure calculations are ordered. The clients ICP is 22 and the mean pressure reading is 70, what is the clients cerebral perfusion pressure? a. 92 b. 72 c. 58 d. 48
d subtract ICP from mean pressure
This lobe is responsible for speech, thought, learning, emotion, and voluntary movement. The advanced processes of judgment, reasoning, and concern for others are also controlled by this lobe.
frontal
