intercranial regulations practice questions

A client with a spinal cord injury and head trauma may exhibit signs of increased intracranial pressure. Which clinical manifestations will the nurse observe for? Select all that apply. a)Hypotension b) Pupillary changes c) Posturing d) Headache e) Bradycardia

1. Answer: b, c, d Rationale: Increased intracranial pressure is anything greater than 15 mmHg. S/S include: Decreased LOC Early S/S: Restlessness, irritability, confusion, headache Nausea and vomiting Change in speech pattern, slurred, aphasia Pupillary changes - dilated and nonreactive, Papilledema (edema of the optic disc) Ataxia Seizures Severe hypertension Abnormal posturing - decerebrate or decorticate-late sign

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1. A positive Brudzinski's sign 2. A negative Kernig's sign 3. Absence of nuchal rigidity 4. A negative Brudzinski's sign

1. a positive brudzinski's sign

The nurse is told in report that an assigned client suffered a right cerebral hemisphere brain attack (stroke). The nurse expects to note which manifestations on assessment of the client? (Select all that apply.) 1. Impulsiveness 2. Aphasia 3. Right-sided weakness 4. Short attention span 5. Impaired ability to think analytically

1. impulsiveness 4. short attention span

The nurse is taking care of a client with a new diagnosis of left-sided cerebral vascular accident. What clinical manifestations would you expect to see on assessment? (Select all that apply). 1. Cautious behavior 2. Impulsive behavior 3. Left-sided weakness 4. Impaired communication 5. Vision changes

1.Cautious behavior 4. Impaired communication 5. Vision changes

10. A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by return of reflex activity d. the patient will have complete loss of motor and sensory functions below the level of the injury for the rest of his life.

10. C. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock.

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3. Clear CSF, elevated protein, and decreased glucose 4. Clear CSF, decreased pressure, and elevated protein

2. Cloudy CSF, elevated protein, and decreased glucose

The nurse monitors a client who experienced a head injury. Which of the following manifestations indicates to the nurse an increase in intracranial pressure (ICP)? (Select all that apply.) 1. Hypotension 2. Restlessness 3. Tachycardia 4. Pupillary changes 5. Abnormal posturing

2.Restlessness 4. Pupillary changes 5. Abnormal posturing

3. The nurse suspects the presence of an epidural hematoma in the patient who experiences: a. venous bleeding between the dura mater and the skull. b. a slow deterioration of neurologic function within 3-5 days following a head injury c. no loss of consciousness or changes in neurologic status d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

3. D Rationale: An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury.

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3. Schedule for A STAT computer tomography (CT) scan of the head.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure

3. restlessness and confusion

4. A client is exhibiting signs of Cushing's Triad. What vital signs would the nurse observe for at this time? a) Increased pulse b) Decreased blood pressure c) Decreased respirations d) Increased oxygen saturations

4. c) decreased respirations Rationale: Cushing's Triad is exhibited by decreased pulse, increased blood pressure, and decreased respirations. Cushing's Triad is present in clients with increased intracranial pressure. The vital signs are opposite of hypovolemic shock.

A client presents with the following position above after a spinal cord injury. How will the nurse document this finding? Arms extended with wrists rotated, legs extended with feet internally rotated. a) Decerebrate posturing b) Decorticate posturing c) Brudzinski sign d) Kernig's sign

5. A) Decerebrate posturing Rationale: A client with this posturing will have problems within the midbrain or Pons, which controls. The brainstem plays an important role in the regulation of cardiac and respiratory function. It also regulates the central nervous system, and is pivotal in maintaining consciousness and regulating the sleep cycle. The brainstem has many basic functions including heart rate, breathing, sleeping, and eating

6. A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

6.Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.

7. A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c. loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

7. Answer: D. Rationale: Neurogenic shock can result in the loss of sympathetic nervous system innervation resulting in peripheral vasodilation.

8.A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

8.D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilator support as needed is the priority intervention.

9.Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, a. you will have more normal function when spinal shock resolves and the reflex arc returns b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be

9. Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.

11. Which statement accurately describes Brown-Sequard Syndrome? A. Asymmetric injury with ipsilateral loss of motor function and sensation and contralateral loss of pain and temperature. B. Symmetrical injury with loss of motor function bilaterally. C. Asymmetric injury with ipsilateral loss of pain and temperature and contralateral loss of motor function and sensation. D. Loss of awareness, but preserved motor, pain, temperature, and light touch.

A

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 75-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

A 75-year-old African American male.

A nurse is reviewing the record of a client with increased ICP and notes that the client has exhibited signs of decorticate posturing. On assessment of the client, the nurse would expect to note which of the following if this type of posturing was present? 1. Flaccid paralysis of all extremities 2. Rigid pronation of all extremities 3. Abnormal flexion of the upper extremities and extension of the lower extremities 4. Rigid extension and pronation of the arms and legs

Abnormal flexion of the upper extremities and extension of the lower extremities

2. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. Encourage deep breathing and coughing b. Keep the client flat without raising the head of the bed c. promote carbon dioxide elimination. d. maintain PaO2 below 80 mm Hg

Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP.

The client is diagnosed with ALS. As the disease progresses, which priority intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.

Assist the client to prepare an advance directive.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding: 1. Flaccid paralysis and lack of sensation below the level of the injury. 2. Hypertension, bradycardia, and warm extremities. 3. Involuntary, spastic movements of the arms and legs. 4. The presence of hyperactive reflex activity below the level of the injury.

Flaccid paralysis and lack of sensation below the level of the injury.

The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? 1. BP 101/77 mmHg; RR 12 breaths per minute; HR 116 beats per minute 2. Temperature 104 degrees F; RR 33 breaths per minute; HR 111 beats per minute 3. HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute 4. Temperature 96.9 degrees F; RR 9 breaths per minute; HR 49 beats per minute

HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute

Which of the following is expected in clients with the diagnosis of amyotrophic lateral sclerosis (ALS)? 1. Many clients live long lives with minimal complications. 2. Many clients pass away from complications of a stroke. 3. Muscle weakness spreads downward until a flaccid quadriplegia develops. 4. Clients will experience a very low creatine kinase (CK).

Muscle weakness spreads downward until a flaccid quadriplegia develops.

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? 1. Abnormal flexion of the upper extremities and extension of the lower extremities 2. Rigid extension and pronation of the arms and legs 3. Rigid pronation of all extremities 4. Flaccid paralysis of all extremities

Rigid extension and pronation of the arms and legs

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: 1. decreased intravascular volume. 2. increased intracranial pressure. 3. ischemic cerebrovascular accident. 4. brain tissue synthesis.

increased intracranial pressure.