Module 9

The nurse is assessing a patient who has increased intracranial pressure. Which assessment finding should remain stable? A. Vital signs B. Motor function C. Pupillary function D. Level of consciousness

A Vitals signs of the patient with increased intracranial pressure remain unchanged during assessment.

Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury?(select all that apply) A. Assess for tinnitus or hearing difficulty. B. Observe the area behind the ears. C. Observe the area around the eyes. D. Test ability to follow complex directions. E. Check the ear cavity for leaking fluid.

ABCE

Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? A. Nausea B. Lethargy C. Sunset eyes D. Hyperthermia

B Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases.

Which assessment finding is a sensitive indicator of increased intracranial pressure (ICP)? A. Eye sensitivity to light B. New onset of neck pain C. Decreased level of consciousness D. Reduction in lower extremity function

C Numerous signs and symptoms of increased ICP can be observed. A change in the level of consciousness (LOC) is the most sensitive indicator. Eye sensitivity to light and a new onset of neck pain are symptoms of meningitis. Reduction in lower extremity function could be an indication of Guillain-Barré syndrome.

Name 2 characteristics of CSF

1.+ glucose 2.Halo

A patient has a mean arterial pressure (MAP) of 65 mm Hg. The cerebral perfusion pressure (CPP) is 50 mm Hg. What is the patient's intracranial pressure (ICP)? Record your answer using a whole number. Enter numeral only.

15

Patient has an epidural hematoma after a 10-foot fall. Which is true about epidural hematomas? A. They are usually arterial in nature. B. Usually have a better mortality rate than subdural hematomas. C. They are associated with a permanent loss of consciousness. D. Clinical signs and symptoms include bilateral pupil dilation

A

A young adult is unconscious after an accident. As part of the assessment, the nurse applies a painful stimulus to the client's left lower leg. Which response is expected in a healthy adult? A. Withdrawing the leg B. Making no movement C. Plantar-flexing the left foot D. Flexing the upper extremities

A Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.

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? A. Purposeless movement in response to painful stimuli. B. Flaccid paralysis in all four extremities. C. Decerebrate posturing when painful stimuli are applied. D. Pupils that are 6 mm in size and nonreactive on painful stimuli.

A 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. Flaccidity would indicate a worsening of the client's condition. Decerebrate posturing would indicate a worsening of the client's condition. The eyes respond to light, not painful stimuli, but a 6-mm nonreactive pupil indicates severe neurological deficit.

Which condition is associated with secondary injury experienced after a traumatic brain injury (TBI)? A. Hypoxia B. Contusion C. Laceration D. Hemorrhage

A Secondary injury is the biochemical and cellular response to the initial trauma that can exacerbate the primary injury (caused by a TBI) and cause additional damage and impairment in brain recovery. Secondary injury is caused most commonly by hypoxia or hypotension, and it can also be caused by ischemia, hypercapnia, cerebral edema, seizures, or metabolic derangements. Contusion, laceration, and hemorrhage are examples of primary injury experienced as part of a TBI.

Which of these nursing interventions is important for a patient with acute intracranial hemorrhage?Select all that apply. A. Maintain neutral head position. B. Place client in Trendelenburg. C. Provide supplemental oxygen. D. Assess pain management. E. Perform vigorous nerve stimulation.

ACD To decrease intracranial pressure resulting from an intracranial hemorrhage, supportive measures must be maintained to minimize the body's metabolic demand. Measures such as maintaining neutral head and body positioning, providing oxygen support, reducing pain, and monitoring for hypotension can help prevent further complications of this event.

Which action will the nurse take to detect an electrolyte disturbance in a patient receiving mannitol to control increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. A. Measure daily weight. B. Evaluate capillary refill. C. Evaluate laboratory values. D. Monitor intake and output. E. Monitor central venous pressure.

ACDE The most widely used osmotic diuretic is mannitol to control increased ICP. However, the most common difficulty associated with the use of osmotic agents is electrolyte disturbances. To detect the onset of an electrolyte disturbance, the patient's body weight must be closely monitored. Laboratory values will provide direct evidence of an electrolyte imbalance. Intake and output will help determine fluid balance. The central venous pressure needs to be monitored to prevent the development of hypovolemia. Capillary refill is not an action that will help the nurse determine whether an electrolyte disturbance exists.

Nurse is caring for patient with ICP monitor and ICP is 28. Which action is appropriate for the nurse to take? A. Lower the head of the bed B. Notify the HCP C. Administer extra dose of Decatron D. Document the finding

B

The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial pressure (ICP). Which nursing intervention should be initiated to prevent increased ICP? A. Keep neck flexed. B. Keep the head of the bed elevated to at least 30 degrees. of motion on extremities. C. Perform passive range D. Suction airway as needed for at least 15 seconds each time.

B

The nurse is caring for a client who has a traumatic brain injury with increased intracranial pressure. Which health care provider prescription would the nurse question? A. Continue anticonvulsants B. Teach isometric exercises C. Continue osmotic diuretics D. Keep head of bed at 30 degrees

B The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.

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? A. A 4-cm area of bright red drainage on the dressing. B. A weak pulse, shallow respirations, and cool pale skin. C. Pupils that are equal, react to light, and accommodate. D. Complaints of a headache that resolves with medication.

B The scalp is a very vascular area and a moderate amount of bleeding would be expected. 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. This is a normal pupillary response and would not warrant intervention.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 is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. A. Maintain the head of the bed at 60 degrees of elevation. B. Administer stool softeners daily. C. Ensure the pulse oximeter reading is higher than 93%. D. Perform deep nasal suction every two (2) hours. E. Administer mild sedatives.

BCE The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intra- cranial pressure. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. Noxious stimuli, such as suctioning, increase intracranial pressure and should be avoided Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness.

List 3 differences between subdural and epidural hematomas

Bleed type Pupil change timing Location

A patient with a diffuse axonal injury (DAI) involves which consideration? A. Neurologic assessments should be performed once a shift. B. Patient will need a CT scan for definitive diagnosis of the injury. C. Patient will be in a comatose state. D. Patient is at risk for volume overload because of SIADH.

C

Patient opens eyes to speech, moans, and pushes your hand away with opposite arm to nailbed pressure. What is the GCS? A. 9 B. 13 C. 10 D. 11

C

The nurse is administering mannitol to a patient with increased ICP. Which action will the nurse plan? A. Calculating the drop factor of the medication and using microtubing. B. Titrating the medication according to the blood pressure. C. Drawing up the medication with a filtered needle and giving IV push. D. Keeping the medication refrigerated until ready to use.

C

Mr. Vera suffered a right hemispheric stroke. He does not open his eyes, extends his left arm, makes grunting sounds to central pain, and picks at the bed linen with his right hand. What is his score on the Glasgow Coma Scale. A. 5 B. 7 C. 8 D. 9

C 1 (eye opening); 2 (verbal); 5 (motor). Purposeful movement (picking at bed linen) is localization with his right hand. Choose the best response for each category.

The nurse is assessing a client who has a head injury. Which movement of the client's arm after the nurse applies nailbed pressure would cause the most concern? A. Flexing B. Localizing C. Extending D. Withdrawing

C Greater cerebral injury leads to less purposeful movement. Abnormal upper arm extension is characteristic of decerebrate (extension) posturing in severe brain injury; the only more serious response is total lack of response. Flexion (characteristic of decorticate posturing), withdrawing, or localizing are associated with less severe brain injuries.

Which finding for a client with a head injury indicates increasing intracranial pressure? A. Polyuria B. Tachypnea C. Increased restlessness D. Intermittent tachycardia

C Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. Urine output is not related to increased intracranial pressure. The respiratory rate will decrease. The pulse will be slow and bounding.

Which description matches that of a subdural hematoma (SDH)? A. Dura mater is torn during a fracture. B. After striking an object, the brain hits the back of the skull. C. Blood accumulates between the dura mater and the arachnoid membrane. D. Pressure in the cranial vault leads to compromised brain function.

C SDH is the accumulation of blood between the dura mater and the underlying arachnoid membrane. It is most often related to a rupture in the bridging veins between the cerebral cortex and the dura mater. The dura mater being torn during a fracture is the description of an open skull fracture. The impact of the brain hitting the back of the skull after striking an object is the description of a contrecoup injury. Pressure in the cranial vault leading to compromised brain function is the description of cerebral edema.

The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

C 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. A diagnostic test, MRI, would be an expected test for a client with left-sided weakness and would not require immediate attention. 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 nurse would expect a client diagnosed with a CVA (stroke) to have some sequelae of the problem, including the inability to speak.

A strategy to minimize secondary brain injury in head-injured patients is A. Hyperventilation to keep PCO2less than 30. B. Maintaining body temperature more than 37.5° C. C. Fluid restriction to keep CVP less than 6 cm H2O. D. Fluid resuscitation as needed to keep the SBP > 90.

D

MVC patient in ED with head injury. What is the earliest indicator of increased ICP the nurse should assess for? A. cushing's triad B. ipsilateral pupil dilation C. headache D. LOC change

D

A client with a head injury has a computed tomography (CT) scan that shows a subdural hematoma. How would the nurse interpret this finding? A. Blood within the brain tissue B. Blood in the subarachnoid space C. Blood between the dura and the skult D. Blood between the dura mater and the arachnoid layer

D A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges. Blood within the brain tissue is an intracerebral hematoma. Blood in the subarachnoid space is below the arachnoid and is called a subarachnoid hematoma. Epidural hematoma refers to blood between the dura and the skull.

The nurse observes abnormal rigidity with pronation of the arms and plantar flexion while assessing a client. Which condition would the nurse record in the assessment findings? A. Decortication B. Pronator drift C. Babinski sign D. Decerebration

D Abnormal movement with rigidity on extension of the arms and legs, pronation of the arms, and plantar flexion is called decerebration. The condition found in the client related to decerebration should be recorded in the assessment findings. Decortication is abnormal movement in which arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs. Pronator drift is the drifting of the arm on pranating the palm. Babinski sign is dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stroked.

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? A. Assess neurological status. B. Monitor pulse, respiration, and blood pressure. C. Initiate an intravenous access. D. Maintain an adequate airway.

D Assessing the neurological status is important, but ensuring an airway is a priority over assessment Monitoring vital signs is important, but maintaining an adequate airway is higher priority. Initiating an IV access is an intervention the nurse can implement, but it is not the priority intervention. The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

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-car provider to respond to the accident. Which intervention should be implemented first? A. Assess the client's level of consciousness. B. Organize onlookers to remove the client from the lake. C. Perform a head-to-toe assessment to determine injuries. D. Stabilize the client's cervical spine.

D 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 the priority 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 the priority. 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. 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.

Where does blood collect in the incidence of an epidural hematoma? A. Deep within the cerebral tissue B. Within the meninges in the subdural space C. Between the dura mater and the underlying arachnoid membrane D. Between the inner skull and the outermost layer of the dura mater

D Blood collects between the inner skull and the outermost layer of the dura mater in an epidural hematoma. Blood collects deep within cerebral tissue in the incidence of an intracerebral hemorrhage and hematoma. Blood that collects within the meninges in the subdural space takes place in the incidence of an acute subdural hematoma. Blood collects between the dura mater and underlying arachnoid membrane in the incidence of a subdural hematoma.

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. Which action would the nurse take to promote adequate cerebral blood flow? A. Clear the ear of draining fluid. B. Discontinue anticonvulsant therapy. C. Position the client's head turned to the left. D. Monitor serum carbon dioxide levels.

D Carbon dioxide levels must be maintained because carbon dioxide can cause vasodilation, increasing intracranial pressure and decreasing blood flow. The fluid may be cerebrospinal fluid; clearing the ear may cause further damage. Because of manipulation during a craniotomy, anticonvulsants are given prophylactically to prevent seizures. Turning the neck impairs venous drainage from the head and may increase intracranial pressure, thus decreasing cerebral blood flow.

When administering mannitol for raised ICP, which one of the following lab tests is the priority? A. Serum arginine vasopressin (AVP) B. Urine specific gravity C. Serum creatinine D. Serum osmolality

D Mannitol is given to promote osmotic diuresis and reduce cerebral edema. Repeated dosing can cause excessive volume contraction. Osmolality should be measured with regular mannitol dosing. A serum osmolality > 320 mmol/L can be harmful.

A client is prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication is primarily given for which purpose? A. Lower blood pressure B. Prevent hypoglycemia C. Increase cardiac output D. Decrease fluid in the brain

D Osmotic diuretics remove excessive cerebrospinal fluid (CSF), reducing intracranial pressure. Osmotic diuretics increase, not decrease, the blood pressure by increasing the fluid in the intravascular compartment. Osmotic diuretics do not directly influence blood glucose levels. Although there is an increase in cardiac output when the vascular bed expands as CSF is removed, it is not the primary purpose of administering the medication.

Which assessment finding alerts the nurse to increasing intracranial pressure? A. Hypervigilance B. Constricted pupils C. Increased heart rate D. Widening pulse pressure

D Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

The nurse records the following vital signs on a client with a traumatic brain injury: heart rate 135, respiratory rate 12, blood pressure 135/75, O2O2 97%, and ICP 23. Which of the following interventions is appropriate? A. Lower the client's head of bed to 20 degrees. B. Administer 1 L bolus of normal saline. C. Suction the client. D. Reposition the client's head and neck to midline.

D Tachycardia, hypertension, and increased ICP may be a result of client stimulation or a sign of blood flow compromise. Client stimulation should be minimized. The client should be placed in midline positioning with the head of bed elevated at least 30 degrees. Hypertonic saline or mannitol, not normal saline, may be used to reduce ICP.

4 Clinical manifestations of a concussion

HA Dizziness N/V Decreased LOC

List 4 complications of head trauma

Increased ICP CSF leak 2o injury - SDH Herniation

Name 2 manifestations of Basilar skull fx

Periorbital ecchymosis (Racoon Eyes) Battle sign (post-auricular echhymosis