Lippincott Q & A The client with a head injury

16) Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? Hemorrhagic skin rash Edema Cyanosis Dyspnea on exertion

1. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

3. A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? _____________________ mm Hg.

3. 80 mm Hg To obtain the MAP, use this formula: MAP = [systolic BP + (2 × diastolic BP)] ÷ 3 MAP = [120 + (2 × 60)] ÷ 3 MAP = 240 ÷ 3 = 80.

9) 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? Sternal rub Pressure on the orbital rim Squeezing the sternocleidomastoid muscle Nail bed pressure

4. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

18) The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. Head tilt Vomiting Polydipsia Lethargy Increased appetite Increased pulse

1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

22) Which of the following assessment data indicated nuchal rigidity? Positive Kernig's sign Negative Brudzinski's sign Positive homan's sign Negative Kernig's sign

1. A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition

4) Which of the following values is considered normal for ICP? 0 to 15 mm Hg 25 mm Hg 35 to 45 mm Hg 120/80 mm Hg

1. Normal ICP is 0-15 mm Hg.

19) A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? Cloudy CSF, decreased protein, and decreased glucose Cloudy CSF, elevated protein, and decreased glucose Clear CSF, elevated protein, and decreased glucose Clear CSF, decreased pressure, and elevated protein

2. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.

10) The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? Side-lying, with legs pulled up and head bent down onto the chest Side-lying, with a pillow under the hip Prone, in a slight Trendelenburg's position Prone, with a pillow under the abdomen.

1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.

12) 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? 1.)Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. 2.)Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. 3.)Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. 4.)Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

2. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

2. 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 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.

3) 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? Urine output increases Pupils are 8 mm and nonreactive Systolic blood pressure remains at 150 mm Hg BUN and creatinine levels return to normal

1. 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.

21. 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 plan- tar flexion of feet. 3. Supination of arms, dorsiflexion of the feet. 4. Back arched, rigid extension of all four extremities.

21. 4. 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, prona- tion 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.

18. 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.

18. 3. 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.

23. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when position- ing 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

23. 2. 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.

13) The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A positive Brudzinski's sign A negative Kernig's sign Absence of nuchal rigidity A Glascow Coma Scale score of 15

1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

24) Which of the following pathologic processes is often associated with aseptic meningitis? Ischemic infarction of cerebral tissue Childhood diseases of viral causation such as mumps Brain abscesses caused by a variety of pyogenic organisms Cerebral ventricular irritation from a traumatic brain injury

2. Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.

13. A client is being admitted with a spinal cord transection at C7. Which of the following assess- ments take priority upon the client's arrival? Select all that apply. ■ 1. Reflexes. ■ 2. Bladder function. ■ 3. Blood pressure. ■ 4. Temperature. ■ 5. Respirations.

13. 3, 4, 5. The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs and the body loses core temperature to environmental tem- perature. The nurse must treat the client immedi- ately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefly assess major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function

16. A male client with a head injury regains con- sciousness after several days. Which of the follow- ing 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 acci- dent and unconscious."

16. 4. It is important to first explain where a cli- ent is to orient him to time, person, and place. Offer- ing to get his family and asking him questions to determine whether he is oriented are important, but the first comments should let the client know where he is and what happened to him. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" when he first awakens is not helpful and may cause him anxiety.

8) While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? Frontal Occipital Parietal Temporal

3. The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

7) Problems with memory and learning would relate to which of the following lobes? Frontal Occipital Parietal Temporal

4. The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

5) Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? Ataxia and confusion Sodium depletion Tonic-clonic seizure Urinary incontinence

1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

1. Following a craniotomy, a client has been admitted to the neurologic intensive care unit. The nurse has established a goal to maintain intracra- nial pressure (ICP) within the normal range. What should the nurse do? Select all that apply. 1.Encourage the client to cough and take deep breaths. 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-mo- tion exercises.

2, 3, 4. The nurse should maintain ICP by elevating the head of the bed and monitoring neuro- logic status. An ICP greater than 20 mm Hg indi- cates 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.

15) During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? Limiting conversation with the child Keeping extraneous noise to a minimum Allowing the child to play in the bathtub Performing treatments quickly

2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

23) Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? Congenital anatomic abnormality of the meninges Lack of acquired resistance to the various etiologic organisms Occlusion or narrowing of the CSF pathway Natural affinity of the CNS to certain pathogens

2. Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibilit

17) When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? Bladder infection Middle ear infection Fractured clavicle Septic arthritis

2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumonococcus. A chronically draining ear is frequently also found.

1) 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? Vomiting continues Intracranial pressure (ICP) is increased The client needs mechanical ventilation Blood is anticipated in the cerebralspinal fluid (CSF)

2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

20. 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

20. 3. 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 mobil- ity impairments as well as behavior and personality changes. The client would be expected to partici- pate 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.

20) A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? No precautions are required as long as antibiotics have been started Maintain enteric precautions Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics Maintain neutropenic precautions

3. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

14. The nurse is assessing a client for move- ment after halo traction placement for a C8 frac- ture. The nurse should document which of the following? 1.The client's shoulders shrug against down- ward pressure of the examiner's hands. 2.The client's arm pulls up from a resting posi- tion against resistance. 3.The client's arm straightens out from a flexed position against resistance. 4.The client's hand-grasp strength is equal

14. 4. The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor func- tion check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor func- tion check for C7 is an arm straightening out from a flexed position against resistance.

6. 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. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increas- ing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to per- fuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

10. The nurse is assessing a client with increas- ing 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).

10. 4. A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in level of consciousness, such as restlessness and irritability, may be subtle. Widen- ing of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

11. The client has a sustained increased intrac- ranial 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.

11. 1. 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. The Sims position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.

12. 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.

12. 2. After administering mannitol, the nurse closely monitors intake and output because manni- tol 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 pres- sure and pupil dilation, should not occur because mannitol serves to decrease ICP.

15. Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. ■ 1. Back at the level of the client's scapula. ■ 2. Back and head that are high. ■ 3. Seat that is lower than normal. ■ 4. Seat with firm cushions. ■ 5. Chair controlled by the client's breath.

15. 2, 3, 5. The client with a C3 to C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up his head. There- fore, the head and neck of his wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use his hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use his arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.

17. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)? 1. Place her in a jacket restraint. 2. Wrap her hands in soft "mitten" restraints. 3. Tuck her arms and hands under the drawsheet. 4. Apply a wrist restraint to each arm.

17. 2. It is best for the client to wear mitts, which help prevent the client from pulling on the I.V. 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.

19. Which of the following is most effective in assessing the client suspected of developing diabe- tes insipidus? 1. Taking vital signs every 2 hours. 2. Measuring urine output hourly. 3. Assessing arterial blood gas values every other day. 4. Checking blood glucose levels.

19. 2. Diabetes insipidus results from deficiency of antidiuretic hormone (ADH). The condition may occur in conjunction with head injuries as well as with other disorders. In ADH deficiency, the client is extremely thirsty and excretes large amounts of highly diluted urine. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concen- tration are appropriate measures to determine the onset of diabetes insipidus. The client may be tachy- cardic and hypotensive from fluid deficit; however, altered vital signs in a client with a head injury may occur for other reasons as well. Blood gas analysis and blood glucose levels will not reveal diabetes insipidus.

4. 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 that 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. The nurse should determine if the cli- ent'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.

21) 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? Abnormal flexion of the upper extremities and extension of the lower extremities Rigid extension and pronation of the arms and legs Rigid pronation of all extremities Flaccid paralysis of all extremities

2. Decebrate posturing is characterized by the rigid extension and pronation of the arms and legs.

22. A client receiving vent-assisted mode ven- tilation 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 sufficient. 2. Notify the physician of the client's breathing pattern. 3. Increase the rate of ventilations. 4. Increase the tidal volume on the ventilator.

22. 2. 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 res- pirations 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.

11) A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A cerebral lesion A temporal lesion An intact brainstem Brain death

3. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

2) 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? To reduce intraocular pressure To prevent acute tubular necrosis To promote osmotic diuresis to decrease ICP To draw water into the vascular system to increase blood pressure

3. 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.

14) A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: Tolerate the pain Decrease the perception of pain Escape the source of pain Divert attention from the source of pain.

3. The client's innate responses to pain are directed initially toward escaping from the source of pain. Variations in individuals' tolerance and perception of pain are apparent only in conscious clients, and only conscious clients are able to employ distraction to help relieve pain.

6) Which of the following signs and symptoms of increased ICP after head trauma would appear first? Bradycardia Large amounts of very dilute urine Restlessness and confusion Widened pulse pressure

3. 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.

5. An unconscious client with multiple injuries arrives in the emergency department. Which nurs- ing 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.

5. 1. 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.

7. What should the nurse do first when a client with a head injury begins to have clear drainage from his 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.

7. 3. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebro- spinal 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 inappro- priate 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.

8. 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.

8. 1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow res- pirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

9. Which of the following nursing interventions is appropriate for a client with an increased intrac- ranial 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.

9.3. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vaso- constriction, 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 perfu- sion pressure greater than 80 mm Hg.