Week 6

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed5.Neck and jaw flexed forward when opening the mouth

1,2,3

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which sign is an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. mild drowsiness 2. drooping eyelids 3. ptosis of the left eyelid 4. sight slurring of speech 5. less frequent spontaneous speech

1,4,5

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1. Blood pressure 2. Motor response 3. Pupillary response 4. Level of consciousness

1. Blood pressure Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated to monitoring for Cushing's reflex.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

1. Confusion Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern; pupillary sluggishness and dilatation appear in the late stages.

.The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the best information about these cranial nerves? 1. Eye movements 2. Response to verbal stimuli 3. Affect, feelings, or emotions 4. Insight, judgment, and planning

1. Eye movementsEye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client might have wanted a visit from the hospital chaplain. 4. The family could benefit from a conference with the health care provider.

1. It is possible the client can hear the family. Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. Additionally, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client. Options 2, 3, and 4 are incorrect interpretations.

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which sign is an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. Mild drowsiness 2. Drooping eyelids 3. Ptosis of the left eyelid 4. Slight slurring of speech 5. Less frequent spontaneous speech

1. Mild drowsiness 4. Slight slurring of speech 5. Less frequent spontaneous speech Early changes in LOC relate to orientation, alertness and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? 1. Normal condition 2. Increased pressure 3. Borderline situation 4. Compensating condition

1. Normal condition The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1. Sounds will not be heard clearly unless they are loud. 2. Obtain assistance with ambulation if client is lightheaded. 3. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4. Use a check-off system for administering anticonvulsant medications to avoid missing

1. Sounds will not be heard clearly unless they are loud. The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1. The left side of the body 2. The right side of the body 3. Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response

1. The left side of the body Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

What is the greatest risk for a patient with dysfunction of cranial nerves IX and X? 1. Dehydration 2. Aspiration pneumonia 3. Constipation 4. Weight loss

2

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activités 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed at 30 degrees elevation

2,4,5

The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as for the head. How should the nurse document these findings? 1. Normal 2. Abnormal 3. Insignificant 4. Inconclusive

2. Abnormal In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 1. Discouraging the family from touching the client 2. Explaining equipment and procedures on an ongoing basis 3. Ensuring adherence to visiting hours to ensure the client's rest 4. Encouraging the family not to "give in" to their feelings of grief

2. Explaining equipment and procedures on an ongoing basis Families often need assistance to cope with the illness of a loved one. The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the health care provider. Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure 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. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 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 occur.

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1. Wears a turban to cover the incision 2. Indicates that facial puffiness will be a permanent problem 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until hair has grown back

2. Indicates that facial puffiness will be a permanent problem After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

A client was seen and treated in the hospital emergency department for treatment of a concussion. The nurse determines that the family needs reinforcement of the discharge instructions if they verbalize to call the health care provider (HCP) for which client sign or symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

2. Minor headache A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the HCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

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

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is present in the client? 1. Dilated pupils 2. Lumbar trauma 3. A cervical cord injury 4. Altered level of consciousness

3. A cervical cord injury In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3. Contact the health care provider (HCP).Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. Options 1, 2, and 4 are inappropriate nursing actions in this situation.

Acetazolamide (Diamox) is prescribed for a client hospitalized with a diagnosis of a supratentorial lesion. The nurse understands that which is the primary action of the medication? 1. Prevention of hypertension 2. Prevention of hyperthermia 3. Decrease in cerebrospinal fluid production 4. Maintenance of blood pressure adequate for cerebral perfusion

3. Decrease in cerebrospinal fluid production Acetazolamide (Diamox) is a carbonic anhydrase inhibitor. It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production. Options 1, 2, and 4 are not actions of this medication.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should avoid placing the client in which positions? 1. Head midline 2. Neck in neutral position 3. Flat, with head turned to the side 4. Head of bed elevated 30 to 45 degrees

3. Flat, with head turned to the side The client who is at risk for or with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The post-head injury client opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1. GCS = 3 2. GCS = 6 3. GCS = 9 4. GCS = 11

3. GCS = 9

A client is being hyperventilated by a mechanical ventilator to decrease the client's intracranial pressure (ICP). On monitoring arterial blood gas results, the nurse should expect values that are within which ranges? 1. Pao2 60 to 100 mm Hg, Paco2 25 to 30 mm Hg 2. Pao2 60 to 100 mm Hg, Paco2 30 to 35 mm Hg 3. Pao2 80 to 100 mm Hg, Paco2 25 to 30 mm Hg 4. Pao2 80 to 100 mm Hg, Paco2 35 to 40 mm Hg

3. Pao2 80 to 100 mm Hg, Paco2 25 to 30 mm Hg Hyperventilation with a Paco2 of 25 to 30 mm Hg causes cerebral vasoconstriction, which decreases intracranial blood volume and ICP. The Pao2 is not allowed to fall below 80 mm Hg, to prevent cerebral vasodilation from hypoxemia. Therefore, the remaining options are incorrect.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position immediately after the procedure? 1. Prone in semi-Fowler's position 2. Supine in semi-Fowler's position 3. Prone with a small pillow under the abdomen 4. Lateral with the head slightly lower than the rest of the body

3. Prone with a small pillow under the abdomen After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. Options 1, 2, and 4 are incorrect.

A nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1. 5 mm Hg 2. 8 mm Hg 3. 14 mm Hg 4. 22 mm Hg

4. 22 mm Hg Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1. Brain death 2. A cerebral lesion 3. A temporal lesion 4. An intact brainstem

4. An intact brainstemCaloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? 1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Encouraging multiple visitors at one time

4. Encouraging multiple visitors at one time Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4. Exhaling during repositioning Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1. Keep the window blinds open. 2. Turn on a small spotlight above the client's head. 3. Make sure the door to the room is open at all times. 4. Prohibit or limit the use of a radio or television and reading.

4. Prohibit or limit the use of a radio or television and reading .Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the health care provider.

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse should plan to do to ensure client safety? 1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. 4. Provide a clear path for ambulation without obstacles.

4. Provide a clear path for ambulation without obstacles. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1. Unchanged weight 2. Shift intake 950 mL, output 900 mL 3. Blood urea nitrogen (BUN) 10 mg/dL 4. Serum osmolality 280 mOsm/kg H2O

4. Serum osmolality 280 mOsm/kg H2O After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL is within normal range and does not indicate overhydration or underhydration.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg's position 4. Side-lying with the legs pulled up and the head bent down onto the chest

4. Side-lying with the legs pulled up and the head bent down onto the chest A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

The nurse is planning care for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1. Place the client in Sims position .2. Change the drainage tubing every 48 hours. 3. Level the transducer at the lowest point of the ear. 4. Use strict aseptic technique when touching the monitoring system.

4. Use strict aseptic technique when touching the monitoring system. Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims is side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30% to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? A walker Eyeglasses A hearing aid A bath thermometer

A hearing aid

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A negative Kernig's sign Absence of nuchal rigidity A positive Brudzinski's sign A Glasgow Coma Scale score of 15

A positive Brudzinski's sign

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

ANS: 74Calculate the CPP: (CPP = Mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.

A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Palpate the head for injuries d. Verify Glasgow Coma Scale (GCS) score.

ANS: A Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis b. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury c. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day d. A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

A patient has a tumor in the cerebellum. The nurse will plan interventions to a. prevent falls. c. avoid aspiration. b. stabilize mood. d. improve memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient withdysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowingability.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

ANS: A Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? a. Pale yellow urine output of 1200 mL over the past 2 hours. b. Ventriculostomy drained 40 mL of fluid in the past 2 hours. c. Intracranial pressure spikes to 16 mm Hg when patient is turned. d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

ANS: A The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Restrict oral fluids to 1000 mL/day. b. Elevate the head of the bed 20 degrees. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

ANS: A The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally

ANS: A The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

ANS: A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

When admitting an acutely confused patient with a head injury, which action should the nursetake? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain healthhistory information from others who have knowledge about the patient's health. Waiting untilthe patient is oriented or obtaining only physiologic data will result in incomplete assessmentdata, which could adversely affect decision making about treatment. Asking leading questionsmay result in inaccurate or incomplete information.

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. (1) hands curled up to chest. b.(2) hands flexed and externally rotated to side of torso. c.(3) one hand on chest and one hand on the side of the torso. d.(4)Torso prosturing

ANS: A With decorticate posturing, the patient exhibits internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing.

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for amyelogram. Which information communicated by the nurse to the health care provider beforethe procedure would change the procedural plans? a. The patient is anxious about the test results. b. The patient reports a previous allergy to shellfish. c. The patient has back pain when lying flat for more than 4 hours. d. The patient drank apple juice 4 hours before the scheduled procedure.

ANS: B A contrast medium containing iodine is injected into the subarachnoid space during amyelogram. The patient's allergy would contraindicate the use of this medium. The healthcare provider may need to modify the orders to prevent back pain, but this can be done afterthe procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic orsurgical procedure. The patient's anxiety should be addressed, but procedural plans would notneed to be changed.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

ANS: B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, and surgery are not usually indicated in a patient with a concussion.

Which problem can the nurse expect for a patient who has a positive Romberg test result? a. Pain c. Aphasia b. Falls d. Confusion

ANS: B A positive Romberg test result indicates that the patient has difficulty maintaining balancewhen standing with the eyes closed. The Romberg does not test for orientation,thermoregulation, or discomfort.

An unconscious male patient has just arrived in the emergency department with a head injurycaused by a motorcycle crash. Which order should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increasedintracranial pressure, and herniation of the brain could result if lumbar puncture is performed.The other orders are appropriate.

Which statement by patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

ANS: B After a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

Which information about a 76-yr-old patient should the nurse report as uncharacteristic ofnormal aging? a. Triceps reflex response graded at 1/5 b. Unintended weight loss of 15 pounds c. 10 mm Hg orthostatic drop in systolic blood pressure d. Patient complaint of chronic difficulty in falling asleep

ANS: B Although changes in appetite are normal with aging, a 15-lb weight loss requires furtherinvestigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing ofreflexes are normal changes in aging.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patientwill the nurse assess first? a. A patient with a transient ischemic attack (TIA) returning from carotid duplexstudies b. A patient with a brain tumor who has just arrived on the unit after a cerebralangiogram c. A patient with a seizure disorder who has just completed an electroencephalogram(EEG) d. A patient prepared for a lumbar puncture whose health care provider is waiting forassistance

ANS: B Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding isa possible complication. The nurse will need to check the pulse, blood pressure, and thecatheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies andEEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon aspossible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

ANS: B Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP.

Which finding would the nurse expect when assessing the legs of a patient who has a lowermotor neuron lesion? a. Spasticity c. Impaired sensation b. Flaccidity d. Hyperactive reflexes

ANS: B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to theneuron will decrease motor activity of the affected muscles. Spasticity and hyperactivereflexes are caused by upper motor neuron damage. Sensation is not impacted by motorneuron lesions.

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits? a. "Do you have difficulty in hearing?" b. "Are you experiencing visual problems?" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?

ANS: B Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

ANS: B Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). Therefore the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Teach about prophylactic antibiotics after exposure to encephalitis. b. Encourage the use of effective insect repellent during mosquito season. c. Remind patients that most cases of viral encephalitis can be cared for at home. d. Arrange to screen school-age children for West Nile virus during the school year.

ANS: B Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a. Pulse of 102 beats/min b. Temperature of 101.6° F c. Intracranial pressure of 15 mm Hg d. Mean arterial pressure of 90 mm Hg

ANS: B Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse only require ongoing monitoring at this time.

Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous systemactivity, is prescribed for a patient who has extreme anxiety about public speaking. The nursemonitors the patient for a. dry mouth. c. constipation. b. bradycardia. d. urinary retention.

ANS: B Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth,constipation, and urinary retention are associated with peripheral nervous system blockade.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face.

ANS: B Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? a. Emphasize the importance of hand washing. b. Immunize adolescents and college freshman. c. Support serving healthy nutritional options in the college cafeteria. d. Encourage adolescents and young adults to avoid crowds in the winter.

ANS: B The Neisseria meningitides vaccination is recommended for children ages 11 and 12 years, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, and good nutrition may increase resistance to infection. but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a. expressive aphasia. b. impaired judgment. c. right-sided weakness d. difficulty swallowing.

ANS: B The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

Which action will the nurse include in the plan of care for a patient with impaired functioningof the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? a. Assist to stand and ambulate. c. Insert an oropharyngeal airway. b. Withhold oral fluids and food. d. Apply artificial tears every hour.

ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. Apatient with impaired function of these nerves is at risk for aspiration. An oral airway may beneeded when a patient is unconscious and unable to maintain the airway, but it will notdecrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance andcoordination are cerebellar functions.

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

ANS: B The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal andcommunicate to the health care provider? a. Specific gravity of 1.007 b. Protein of 65 mg/dL (0.65 g/L) c. Glucose of 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count of 4 cells/L

ANS: B The protein level is high. The specific gravity, WBCs, and glucose values are normal.

Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes whohas peripheral nerve dysfunction? a. Sharp pin c. Reflex hammer b. Tuning fork d. Calibrated compass

ANS: B Vibration sense is testing by touching the patient with a vibrating tuning fork. The otherequipment is needed for testing of pain sensation, reflexes, and two-point discrimination.

The priority nursing assessment for a patient being admitted with a brainstem infarction is a. pupil reaction. c. reflex reaction time. b. respiratory rate. d. level of consciousness.

ANS: B Vital centers that control respiration are located in the medulla and part of the brainstem, andwill require priority assessments because changes in respiratory function may be lifethreatening. The other information will also be obtained by the nurse but is not as urgent.

Which assessments will the nurse make to monitor a patient's cerebellar function (select allthat apply)? a. Test for graphesthesia. b. Observe arm swing with gait. c. Perform the finger-to-nose test. d. Assess heat and cold sensation.e. Measure strength against resistance.

ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patient's gaitand the finger-to-nose test. The other assessments will be used for other parts of theneurologic assessment.

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

ANS: BShort and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety.

Which nursing action will be included in the plan of care for a patient who has had cerebralangiography? a. Monitor for headache and photophobia. b. Keep patient NPO until gag reflex returns. c. Check pulse and blood pressure frequently. d. Assess orientation to person, place, and time.

ANS: C Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebralangiography, the nurse should assess for bleeding after this procedure that can affect pulse andblood pressure. The other nursing assessments are not needed after angiography

During the neurologic assessment, the patient is unable to respond verbally to the nurse butcooperates with the nurse's directions to move his hands and feet. The nurse will suspect a. cerebellar injury. c. frontal lobe damage. b. a brainstem lesion. d. a temporal lobe lesion.

ANS: C Expressive speech (ability to express the self in language) is controlled by Broca's area in thefrontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptivespeech (ability to understand language input). The cerebellum and brainstem do not affecthigher cognitive functions such as speech.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. c. decorticate posturing. b. localization of pain. d. decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure c. Intracranial pressure b. Oxygen saturation d. Hemoglobin and hematocrit

ANS: C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve as a result of mannitol administration.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees .c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

ANS: C Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.

ANS: C The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing .b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

ANS: C The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

The nurse performing a focused assessment of left posterior temporal lobe functions willassess the patient for a. sensation on the left side of the body. b. reasoning and problem-solving ability. c. ability to understand written and oral language. d. voluntary movements on the right side of the body.

ANS: C The posterior temporal lobe integrates the visual and auditory input for languagecomprehension. Reasoning and problem solving are functions of the anterior frontal lobe.Sensation on the left side of the body is located in the right postcentral gyrus. Voluntarymovement on the right side is controlled in the left precentral gyrus.

To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should a. check for unilateral eyelid droop. b. shine a light into the patient's pupil. c. touch a cotton wisp strand to the cornea. d. have the patient read a magazine or book.

ANS: C The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve istested by having the patient read a Snellen chart or a newspaper. Assessment of pupil responseto light and ptosis are used to evaluate function of the oculomotor nerve.

The charge nurse is observing a new staff nurse who is assessing a patient with a traumaticspinal cord injury for sensation. Which action indicates a need for further teaching of the newnurse about neurologic assessment? a. The new nurse tests for light touch before testing for pain. b. The new nurse has the patient close the eyes during testing. c. The new nurse asks the patient if the instrument feels sharp. d. The new nurse uses an irregular pattern to test for intact touch.

ANS: C When performing a sensory assessment, the nurse should not provide verbal clues. The otheractions by the new nurse are appropriate.

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 120 beats/minute

ANS: C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hr. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

ANS: CExperienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN)-level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Call the family's pastor or spiritual advisor to take them to the chapel. b. Ask the family to stay in the waiting room until the assessment is completed. c. Allow the family to stay with the patient and briefly explain all procedures to them. d. Refer the family members to the hospital counseling service to deal with their anxiety.

ANS: CThe need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV .b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

ANS: D Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure,the nurse will plan to a. enforce NPO status for 4 hours. b. transfer the patient to radiology. c. administer a sedative medication. d. help the patient to a lateral position.

ANS: D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure doesnot usually require a sedative, is done in the patient room, and has no risk for aspiration.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The patient receives a regular diet tray .b. The bedrails on both sides of the bed are elevated. c. Staff have turned off the lights in the patient's room. d. Staff have entered the patient's room without a mask.

ANS: D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

ANS: D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours

ANS: D ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

The nurse will anticipate teaching a patient with a possible seizure disorder about which test? a. Cerebral angiography c. Electromyography (EMG) b. Evoked potential studies d. Electroencephalography (EEG)

ANS: D Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnoseproblems with the visual or auditory systems. Cerebral angiography is used to diagnosevascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 88/42 mm Hg.

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b. A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 c. A 30-yr-old patient who lost consciousness for a few seconds after a fall d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

A pt is admitted or a severe head injury and develops dry mucous membranes. The urine output is 400 mL/hr for the last 8-hr shift. Prioritize the nurses next actions: 1.) Notify the physician 2.) Complete a neurological assessment 3.) Assess the pts urine specific gravity and blood Na+ levels 4.) Start IV fluids & administer nasal desmopressin (DDAVP)

ANSWER=2, 1, 3, 4 RATIONALE:-After sustaining a head injury, a UO of 400 mL/hr would be suspicious for DI. DI is the failure to produce an antidiuretic hormone due to damage to the pituitary gland from increased ICP. W/a recent head injury, the nurse should 1st perform a neuro exam-Notify the HCP is appropriate in order for the nurse to obtain orders for additional tests-The nurse should then gather more info by assessing for low specific gravity & elevated serum osmolarity, as ordered by the HCP-The HCP may order tx's including IV fluids for dehydration & DDAVP to replace vasopressin

On the ICU, a pt w/head trauma is on continuous mechanical ventilation The pt develops increased ICP. Which among the following interventions should the nurse implement FIRST?: a.) Call the HCP anticipating orders to hyperventilate the pt b) Increase the O2 concentration c.) Position in Trendelenburg d.) Suction the ET tube

ANSWER=A RATIONALE:-CO2 has a potent vasodilatingeffect & this can increase cerebral blood flow leading to higher ICP. Cerebral hypoxia may result if the high ICP puts too much pressure on the brain. The HCP should be called to get orders to hyperventilate the pt. Hyperventilation is the 1st-line intervention to decrease ICP b/c it decreases CO2 levels -High O2 levels may decrease ICP, but too much O2 can cause pulmonary fibrosis & seizures. Hyperventilation should be the FIRST intervention

A nurse is performing a neurological check on a pt who is 1 day post-craniotomy notices that the pts right eye does not turn laterally. Which of the following cranial nerves should the nurse suspect is damaged? a.) Cranial nerve II b) Cranial nerve V c) Cranial nerve VI d.) Cranial nerve VII

ANSWER=C (CN VI)RATIONALE:-CN's III, IV & VI deal w/movement of the eye-The abducens nerve (CN VI) fxns specifically as a motor nerve innervating the lateral rectus muscle of the eye. A medial deviation or an inability to laterally deviate the eye would indicate damage to this nerve

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? a.) Document the findings b.) Reinforce the dressing c.) Notify the HCP d.) Mark the area of drainage w/a pen and monitor for further drainage

ANSWER=C RATIONALE:CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes presence of this type of drainage, the HCP needs to be notified. The remaining options are inappropriate nursing actions

A pt who just underwent infratentorial craniotomy for a brain tumor is newly admitted to the ICU. Which of the following should the nurse include in the plan of care?: (SATA) a.) Infuse IV fluids at 175 mL/hr b) Keep the HOB flat c.) Maintain elevation of the HOB at 30-45 degrees w/a large pillow under the pts head & shoulders d.) Monitor the neurological status & VS every 4 hours e.) Place a small pillow under the neck f.) Prevent stiffness of the pts neck by flexing it every 2 hours

ANSWERS= B&E RATIONALE:-An infratentorial craniotomy has the incision made at the nape of the neck; the site of surgery is below the tentorium into the infratentorial compartment-The correct position for an infratentorial approach is to keep the HOB flat & place a small pillow under the nape of the neck to promote venous return and reduce ICP-Elevating the HOB at 30-45 degrees is for the supratentorial approach-Post-craniotomy pts must be monitored for neuro & VS every 30 mins-Flexing the neck of this particular pt could disrupt the suture line -Post-craniotomy pts are at risk for cerebral edema and increased ICP. Fluids at 175 mL/hr could lead to fluid overload

A pt is scheduled for a lumbar puncture. Which of the following statements indicates the pt understands the procedure?: (SATA) a.) A dye will be injected into my CSF to help diagnose the cause of my problem b.) Electrical activity in my brain will be recorded c.) Fluid will be removed from my spinal canal d.) I must lay flat after the procedure for at least 4 hours e.) I will have to be in the prone position for the lumbar puncture f.) My nerve impulses will be measured

ANSWERS=C & D RATIONALES:-LP involves the insertion of a needle into the subarachnoid space & the removal of CSF for diagnostic or therapeutic purposes -To prevent injury the pt must NOT MOVE during the insertion of the needle into the spinal canal. The pt will need to lie on his/her side, curling forward so that the knees are flexed toward the chest w/the chin touching the knees

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

Answer: 1, 2, 4 Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure 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

Answer: 2 Rationale: 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 occur.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nailbed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

Answer: 2 Rationale: Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will be careful because the device alters balance." 4. I will wash the skin daily under the lamb's wool liner of the vest."

Answer: 2 Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all, because the device impairs the range of vision.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

Answer: 3 Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder.

721 The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

Answer: 3 Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a 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 flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. 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 Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

Answer: 4 Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is 2051 present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

Answer: 4 Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids, because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

Which symptom is the earliest indicator of increased intracranial pressure? A. Increased pupil size B. Elevated blood pressure C. Agitation and confusion D. Nausea and vomiting

C

The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply.

Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose. Fluid is grossly bloody in appearance and has a pH of 6. Fluid clumps together on the dressing and has a pH of 7. Fluid separates into concentric rings and tests positive for glucose.

Fluid separates into concentric rings and tests positive for glucose.

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. Giving tepid sponge baths Applying a hypothermia blanket Covering the client with blankets Administering acetaminophen per protocol Placing ice packs over the client's abdomen and in the axilla and groin

Giving tepid sponge baths Applying a hypothermia blanket Administering acetaminophen per protocol

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply .Head midline Neck in neutral position Flat, with head turned to the side Head of bed elevated 30 to 45 degrees Head of bed elevated with the neck extended

Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively Head of bed flat, head and neck midline Head of bed flat, head turned to the nonoperative side Head of bed elevated 30 to 45 degrees, head and neck midline Head of bed elevated 30 to 45 degrees, head turned to the operative side

Head of bed elevated 30 to 45 degrees, head and neck midline

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? Head midline Head turned to the side Neck in neutral position Head of bed elevated 30 to 45 degrees

Head turned to the side

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. Keep suction equipment at the bedside. Elevate the head of the bed 30 degrees. Keep the client lying in a supine position. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed.

Keep suction equipment at the bedside Elevate the head of the bed 30 degrees Keep the head and neck in good alignment Administer prescribed respiratory treatments as needed

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? Keeping the client on a stretcher Logrolling the client onto a soft mattress Logrolling the client onto a firm mattress Placing the client on a bed that provides spinal immobilization

Placing the client on a bed that provides spinal immobilization

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? Reduce environmental noise. Allow visitors as desired by the client and family. Awaken the client every 2 to 3 hours to monitor mental status. Cluster nursing activities to reduce the number of interruptions.

Reduce environmental noise

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? Maintain the client in a flat position. Restrict fluid intake for a period of 2 hours. Assess the client's ability to void and move the extremities. Inspect the puncture site for swelling, redness, and drainage.

Restrict fluid intake for a period of 2 hours

The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client should the nurse report immediately?

The client vomits

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? The intracranial pressure reading is normal. The intracranial pressure reading is elevated. The intracranial pressure reading is borderline. An intracranial pressure reading of 8 mm Hg is low.

The intracranial pressure reading is normal