NUR 4135 PrepU Chapter 16
Which intracranial pressure (ICP) would the nurse consider a normal reading? 30 to 45 mm Hg 0 to 15 mm Hg 45 to 60 mm Hg 15 to 30 mm Hg
0 to 15 mm Hg Explanation: The cranial cavity contains blood, cerebrospinal fluid, and brain tissue. Each of these three volumes contributes to ICP, which is normally maintained within a range of 0 to 15 mm Hg when measured in the lateral ventricles.
According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score? 4 3 2 1
2 Explanation: Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which pathophysiologic condition has contributed to this client's diagnosis? Increased levels of cerebrospinal fluid Impaired synthesis of clotting factors Deficits in the autonomic control of blood pressure Weakness in the muscular wall of an artery
Weakness in the muscular wall of an artery Explanation: Aneurysms are direct manifestations of a weakness that exists in the muscular wall of an arterial vessel. Hypertension is a significant risk factor, but autonomic contributions are not common. Levels of cerebrospinal fluid (CSF) and hypo- or hypercoagulability are not implicated in the pathogenesis of aneurysms.
The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced: unknown type of seizure. focal seizure without impairment of consciousness. generalized seizure. focal seizure with impairment of consciousness.
generalized seizure. Explanation: When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be: "Infants never have symptoms from hydrocephalus." "The cranial sutures are fused and decrease brain damage." "Because the skull sutures are not fused there may be no brain damage." "Unfortunately, there usually is significant brain dysfunction."
"Because the skull sutures are not fused there may be no brain damage." Explanation: When hydrocephalus develops in utero, before the cranial sutures have fused, the head can swell and decrease intracranial pressure, thereby decreasing the amount of brain tissue that is compressed.
A child with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. The child has a brief loss of contact with the environment and then is ready to resume normal activity. What type of seizure did this client most likely experience? Absence seizure Atonic seizure Simple partial seizure or focal seizures without impairment of consciousness Myoclonic seizure
Absence seizure Explanation: Absence seizures, which typically occur only in children, often are accompanied by automatisms, and there is often a brief loss of consciousness. The seizure usually lasts only a few seconds and the person is able to immediately resume normal activity. These symptoms do not accompany simple partial seizures. Atonic seizures are characterized by loss of muscle tone. Myoclonic seizures involve brief involuntary muscle contractions induced by stimuli of cerebral origin.
The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed? Administration of antibiotics Administration of TPN Administration of pain medication Administration of oxygen
Administration of antibiotics Explanation: The nurse should prepare to administer antibiotics as ordered by the physician while the diagnostic tests are being completed. Delay in initiation of antimicrobial therapy, most frequently due to medical imaging prior to lumbar puncture or transfer to another medical facility, can result in poor client outcomes.
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury? Change in behavior Altered level of consciousness Loss of eye movement reflexes Respiratory instability
Altered level of consciousness Explanation: In contrast to focal injury, which causes focal neurologic deficits without altered consciousness, global injury nearly always results in altered levels of consciousness ranging from inattention to stupor or coma. The other answers are manifestations of different types of brain injury, not a global injury.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first? Contact physician for anti-nausea medication orders. Document the finding as it is an expected symptom. Assess for signs/symptoms of cerebrovascular accident (stroke). Assess for other signs/symptoms of increased intracranial pressure.
Assess for other signs/symptoms of increased intracranial pressure. Explanation: The tumor may be causing increased intracranial pressure. Vomiting, with or without nausea, is a common symptom of increased intracranial pressure and/or brain stem compression. The nurse's first action is to assess for other signs/symptoms of increased intracranial pressure. Once the assessment is completed, the nurse should contact the physician if indicated by the findings.
Much like brain death, there are criteria for the diagnosis of a persistent vegetative state which has lasted for more than 1 month. What are criteria for the diagnosis of persistent vegetative state? Select all that apply. Lack of language comprehension Bowel and bladder incontinence Variable preserved cranial nerve reflexes Lack of enough hypothalamic function to maintain life Ability to open the eyes
Bowel and bladder incontinence Lack of language comprehension Variable preserved cranial nerve reflexes Explanation: The criteria for diagnosis of vegetative state include the absence of awareness of self and environment and an inability to interact with others; the absence of sustained or reproducible voluntary behavioral responses; lack of language comprehension; sufficiently preserved hypothalamic and brain stem function to maintain life; bowel and bladder incontinence; and variably preserved cranial nerve (e.g., pupillary, gag) and spinal cord reflexes. People in a persistent vegetative state can open their eyes and have enough hypothalamic function to maintain life.
A teenager has been in a car accident and experienced an acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication? Status epilepticus Brain contusions and hematomas Momentary unconsciousness TIAs and cerebrovascular infarction
Brain contusions and hematomas Explanation: Contusions (focal brain injury) cause permanent damage to brain tissue. The bruised, necrotic tissue is phagocytized by macrophages, and scar tissue formed by astrocyte proliferation persists as a crater. The direct contusion of the brain at the site of external force is referred to as an acceleration injury, whereas the opposite side of the brain receives the deceleration injury from rebound against the inner skull surfaces. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas. TIAs and cerebral vascular infarction (stroke) are often caused by atherosclerotic brain vessel occlusions that cause ischemic injuries. In mild concussion head injury, there may be momentary loss of consciousness without demonstrable neurologic symptoms or residual damage, except for possible residual amnesia. Status epilepticus is not related to this situation.
Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors? Tumor infiltration and decreased ICP Tumor infiltration and increased blood pressure Brain compression and decreased ICP Brain edema and disturbances in blood flow
Brain edema and disturbances in blood flow Explanation: Intracranial tumors give rise to focal disturbances in brain function and increased ICP. Focal disturbances occur because of brain compression, tumor infiltration, disturbances in blood flow, and brain edema. Blood pressure, either increased or decreased, is not a manifestation of a brain tumor.
The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include? CT scan MRI Pain medication Intravenous antibiotics
CT scan Explanation: The nurse should anticipate that the client will be ordered a CT scan to rule out hemorrhagic stroke that would preclude the administration of tissue plasminogen activator (tPA).
Which intracranial volume is most capable of compensating for increasing intracranial pressure? Brain cell tissue Surface sulci fluid Cerebrospinal fluid Intravascular blood
Cerebrospinal fluid Explanation: Initial increases in intracranial pressure (ICP) are largely buffered by a translocation of cerebrospinal fluid (CSF) to the spinal subarachnoid space and increased reabsorption of CSF. Of the intracranial volumes, the tissue volume is least capable of undergoing change. Surface sulcus fluid is negligible and not a factor in increased ICP. The compensatory ability of the intravascular blood compartment is also limited by the small amount of blood that is in the cerebral circulation. As the volume-buffering capacity of this compartment becomes exhausted, venous pressure increases and cerebral blood volume and ICP rise.
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply. Metabolic function Sensory function Level of consciousness Motor function Cognition
Cognition Level of consciousness Motor function Sensory function Explanation: Brain injuries can cause changes in level of consciousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a client with a traumatic brain injury should assess for changes in these areas.
Brain death is the term that is used when the loss of function of the entire brain is irreversible. A clinical examination must be done and repeated at least 6 hours later with the same findings for brain death to be declared. What is not assessed in the clinical examination for brain death? Electrocardiogram Responsiveness Respiratory effort Blink reflex
Electrocardiogram Explanation: Clinical examination must disclose at least the absence of responsiveness, brain stem reflexes, and respiratory effort. Brain death is a clinical diagnosis, and a repeat evaluation at least 6 hours later is recommended. An electrocardiogram is not assessed in an examination for brain death.
Following surgical removal of a large malignant brain tumor, the nurse should anticipate discussing which treatment option that allows delivery of high-dose radiation to deep tumors while sparing surrounding brain tissue? Chemotherapy Immunotherapy Gamma knife radiation Stem cell transplant
Gamma knife radiation Explanation: Most malignant brain tumors respond to external irradiation. Irradiation can increase longevity and sometimes can allay symptoms when tumors recur. The treatment dose depends on the tumor's histologic type, responsiveness to radiation, and anatomic site and on the level of tolerance of the surrounding tissue. A newer technique called gamma knife combines stereotactic localization of the tumor with radiosurgery, allowing delivery of high-dose radiation to deep tumors while sparing the surrounding brain. Chemotherapy for brain tumors is somewhat limited by the blood-brain barrier, although in some cases it can be administered directly into the spinal canal.
A client begins to exhibit manifestations of a stroke while attending a community health fair. What type of emergency care should the staff at the health fair implement first? Going to an urgent care center Going to the nearest emergency room Going to the nearest stroke center Going to visit his or her family physician
Going to the nearest stroke center Explanation: Salvaging brain tissue, preventing secondary stroke, and minimizing long-term disability are the treatment goals for an acute ischemic stroke. The care of clients with stroke has shifted away from the "nearest hospital" to certified stroke centers. These are hospitals that have been certified by some external agency, most commonly the state or Joint Commission, the federal agency overseeing all facilities that care for Medicare clients.
A high school student sustained a concussion during a football game. The school nurse will educate the family about postconcussion syndrome and ask them to watch for and report which manifestations of its presence? Neck pain and decreased neck range of motion Unilateral weakness and decreased coordination Recurrent nosebleeds and hypersomnia Headaches and poor concentration
Headaches and poor concentration Explanation: Postconcussion syndrome includes mild symptoms, such as headache, irritability, insomnia, and poor concentration and memory. Nosebleeds, hypersomnia, unilateral motor changes, and neck pain are indicative of more severe brain injury and/or soft tissue injury.
The spouse of a client who has been in a long-term care facility for a few months due to a brain injury that caused a vegetative state asks the nurse why the client is still being fed through the gastrostomy tube. What is the nurse's best response? "The client will recover from this state." "It is mandated by law to do so." "To avoid aspiration into the lungs." "Feeding the client allows for comfort."
"To avoid aspiration into the lungs." Explanation: A persistent vegetative state can occur with survival of a coma. In this state, a person continues to have reflex functions and sleep-wake cycles and may have spontaneous eye movements without awareness. People in this state do not have an awareness of the environment or self and require non-oral feedings to reduce the risk of aspiration of food and fluid into the lungs.
What medication teaching should be done for a woman of childbearing age with a seizure disorder? Some antiseizure drugs can interfere with vitamin K metabolism. Antiseizure drugs do not interact with oral contraceptives. All women of childbearing age should be advised to take a vitamin C supplement. Antiseizure drugs increase the risk for congenital abnormalities.
Antiseizure drugs increase the risk for congenital abnormalities. Explanation: For women with epilepsy who become pregnant, antiseizure drugs increase the risk for congenital abnormalities and other perinatal complications. Many of the antiseizure medications interact with oral contraceptives and can interfere with vitamin D metabolism. All women should be advised to take folic acid supplementation.
The nurse is planning an inservice on hypoxia versus ischemia in brain-injured clients. The nurse should include which of the following? Hypoxia produces a generalized depressive effect on the brain. Ischemia does not interfere with delivery of glucose. Hypoxia denotes an interruption in blood flow. Ischemia denotes a deprivation of oxygen with maintained perfusion.
Hypoxia produces a generalized depressive effect on the brain. Explanation: Hypoxia denotes a deprivation of oxygen with maintained blood flow (perfusion), whereas ischemia is a situation of greatly reduced or interrupted blood flow. Hypoxia produces a generalized depressant effect on the brain. Ischemia interferes with delivery of oxygen and glucose as well as the removal of metabolic wastes.
A family is sitting in the intensive care unit with a client who sustained significant head injuries in a motorcycle accident. They are questioning the nurse about why the client's eyes open but do not stay open for long. The nurse explains that the client is probably in which state? In a stuporous state due to a reticular activated system (RAS) injury In an obtunded state due to possible brain injury In a stuporous state due to acidosis In an obtunded state due to a concussion
In a stuporous state due to a reticular activated system (RAS) injury Explanation: Injury to the RAS would be suspected due to the change in the level of consciousness. The RAS and functional cerebral hemispheres are necessary for arousal and wakefulness; damage to either will negatively affect a person's level of consciousness.
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted? Clear cerebrospinal fluid Increased glucose Decreased protein count Large number of polymorphonuclear neutrophils
Large number of polymorphonuclear neutrophils Explanation: Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The CSF typically contains large numbers of polymorphonuclear neutrophils (up to 90,000/mm3), increased protein content, and reduced sugar content.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be: Sputum culture CT of the head Blood cultures Lumbar puncture
Lumbar puncture Explanation: The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem? Administration of hypertonic intravenous solution Placement of a shunt Lumbar puncture Aggressive diuresis
Placement of a shunt Explanation: Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in cerebrospinal fluid (CSF) volume. This increase in CSF volume can be resolved by the placement of a shunt to drain the offending fluid volume. Diuresis, hypertonic solution administration, and lumbar puncture are not usual treatment modalities.
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client's care? Assessment of: Respiratory status and oxygen saturation Urine output and continence ECG for arrhythmias Ability to grasp hands and squeeze on command
Respiratory status and oxygen saturation Explanation: Tonic-clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom? Pupils that react to light Stupor Chest pain Wheezing
Stupor Explanation: The most frequent sign of brain dysfunction is an altered level of consciousness such as stupor. Pupils that react to light, wheezing, and chest pain are not symptoms of brain function.
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with: Thrombotic stroke Lacunar infarct Encephalitis Subarachnoid hemorrhage
Subarachnoid hemorrhage Explanation: The rupture of a berry aneurysm leads to a subarachnoid hemorrhage.
A nurse at a long-term care facility provides care for a client who has had recent transient ischemic attacks (TIAs). What significance should the nurse attach to the client's TIAs? - TIAs result in an accumulation of small deficits that may eventually equal the effects of a CV. - TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke. - The small bleeds that define TIAs can be a warning sign of an impending stroke. - TIAs are relatively benign phenomena that necessitate monitoring, but not treatment.
TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke. Explanation: TIAs can be considered a warning sign for future strokes. They are not hemorrhagic in nature and their effects are not normally cumulative. They may require treatment medically or surgically.
A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose? Thrombolysis Hemolysis Hemostasis Thrombogenesis
Thrombolysis Explanation: Synthetic tissue plasminogen activators work with the body's natural tissue plasminogen activators to convert plasminogen to plasmin, which breaks down clots to allow for the reestablishment of blood flow. There are two causes of strokes: hemorrhagic and thrombotic, with thrombotic strokes occurring much more frequently. Thrombolytics play a large role in increased outcomes seen with thrombotic strokes.
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to: administer analgesics for the relief of pain. monitor vital signs closely for improvement. administer IV tissue plasminogen activator (tPA). prepare the client for emergency surgery.
administer IV tissue plasminogen activator (tPA). Explanation: tPA administration is the treatment of choice for an ischemic stroke after confirmation that it is not a hemorrhagic stroke. Monitor vital signs and provide pain relief to prevent complications.
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should: contact the physician. prepare the client for EEG testing. instruct the spouse not to let the client fall asleep until the physician has assessed the client. assess the client for additional signs/symptoms of increased intracranial pressure.
assess the client for additional signs/symptoms of increased intracranial pressure. Explanation: Since decreased alertness and/or drowsiness can be an early sign of increased intracranial pressure, the nurse should assess for additional signs/symptoms of increased intracranial pressure. Then, once the assessment is complete, the nurse should contact the physician as needed. There is no indication that the client will undergo EEG testing at this time and the spouse should not be instructed to keep the client awake.
A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be that: hypoxia to the brain occurred. transient neurogenic dysfunction caused by mechanical force to the brain occurred. tearing of brain tissue occurred. bruising on the surface of the brain occurred.
bruising on the surface of the brain occurred. Explanation: Contusions represent bruising on the surface of the brain, and lacerations are a tearing of brain tissue. A cerebral concussion is a transient neurogenic dysfunction caused by mechanical force to the brain. Hypoxia usually is seen in conditions such as exposure to reduced atmospheric pressure, carbon monoxide poisoning, severe anemia, and failure of the lungs to oxygenate the blood.
The most common cause of ischemic stroke is: vasospasms. cryptogenesis. thrombosis. arterial vasculitis.
thrombosis. Explanation: Ischemic stroke includes those caused by large artery thrombosis (20%), small artery thrombosis (25%), cardiogenic embolism (20%) and cryptogenic (undetermined cause)(30%), making thrombosis the most common cause (45%).
