Chapter 56: Acute Intracranial Problems
When performing a neurologic assessment, what is the nurse assessing when comparing the pupils? Select all that apply. Size Shape Reactivity Movement Visual acuity Corneal reflex
Size Shape Reactivity Movement
What will be the Glasgow Coma Scale score of a patient who has a moderate type of head injury? 3 5 10 14
10
What is the appropriate action by the nurse if an assessment of a patient scheduled for a lumbar puncture reveals increased intracranial pressure (ICP)? Cancel the lumber puncture. Schedule the lumbar puncture for the next day. Perform the lumbar puncture immediately. Administer intravenous fluids before the lumber puncture.
Cancel the lumber puncture.
The nurse is performing a neurologic assessment for a patient and observes a fixed unilateral dilated pupil. Which cranial nerve does the nurse suspect is being compressed? III IV V VIII
III
When a patien'ts systemic arterial pressure is altered, how does the brain respond? It decreases intracranial pressure. It autoregulates. It increases intracranial pressure. It increases brain compliance.
It autoregulates.
A patient with a brain tumor reports inability to eat. What appropriate actions should the nurse perform? Select all that apply. Encourage the patient to eat. Ensure adequate nutritional intake. Assess the patient's nutritional status. Advise the patient to reduce water intake. Advise the patient to consume a low-calorie diet.
Encourage the patient to eat. Ensure adequate nutritional intake. Assess the patient's nutritional status.
A nurse in the neurologic intensive care unit is caring for a patient with intracranial pressure (ICP) monitoring through an intracranial device. Which aspect of the patient's care requires follow-up by the nurse? Using aseptic technique for intracranial device care Intracranial device monitoring for greater than 5 days Assessing the intracranial device insertion site routinely Monitoring the cerebrospinal fluid (CSF) for a change in color
Intracranial device monitoring for greater than 5 days
What is the gold standard for measuring intracranial pressure (ICP)? Ventriculosotomy Fiberoptic catheter Air pouch/pneumatic Transcranial Doppler
Ventriculosotomy
A patient with head trauma has a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which action should the nurse perform first? Evaluate the urine specific gravity. Prepare the patient for acute hemodialysis. Continue to monitor urine output over the next hour. Slow the IV rate and notify the primary health care provider.
Evaluate the urine specific gravity.
Which intervention should be performed to prevent cranial nerve III palsy in a patient with meningitis? Providing low lighting Administering antibiotics Elevating the head of the bed Performing cooling techniques
Performing cooling techniques
The nurse is preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF). What surgery should the nurse ensure the consent is signed for? Burr hole Craniotomy Shunt placement Stereotactic procedure
Shunt placement
At which stage of increased intracranial pressure (ICP) does a loss of autoregulation occur? Stage I Stage II Stage III Stage IV
Stage III
Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need to be prepared for which treatment modality? Surgery Chemotherapy Radiation therapy Biologic drug therapy
Surgery
A patient sustained head trauma during a skiing accident and lost consciousness but was then awake and alert. What complication of a head trauma might this patient have developed that results in bleeding between the dura and the inner surface of the skull? Contusion Epidural hematoma Subdural hematoma Intracerebral hematoma
Epidural hematoma
The family of a patient who was admitted 12 hours ago with suspected meningitis approaches the charge nurse stating "We do not understand. We were told the spinal tap looks good. Why is everyone still wearing gowns and masks"? What is the best response by the nurse? "I apologize. The isolation should have been discontinued." "These precautions need to be continued as long as the patient is in the hospital." "I will check with the health care provider and see if we can get the isolation discontinued." "The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."
"The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."
A patient sustained a concussion after a motor vehicle crash and is fully alert when arriving at the emergency department. What does the nurse document that the Glasgow Coma Scale score is? 3 6 8 15
15
The nurse is caring for four patients in the intensive care unit (ICU). Which patient with an infection is at the highest risk for the development of cerebral edema? A patient with encephalitis A patient with cerebral thrombosis A patient who sustained a contusion from a fall A patient with hydrocephalus from a malfunctioning shunt
A patient with encephalitis
The nurse is performing an assessment of a patient with a closed head injury from a blunt object. What is the most reliable clinical manifestation to determine the patient may be developing increased intracranial pressure (ICP)? Steady vital signs Reports of a headache Increased motor function An altered level of consciousness (LOC)
ALOC
The nurse is providing discharge instructions for a patient and a caregiver for the first three days after a head injury. Which information is important for the nurse to include? Resume driving. Abstain from alcohol. Restrict sodium in the diet. Wear a helmet when riding a bike.
Abstain from alcohol.
A patient is diagnosed with viral encephalitis and is hospitalized. What drug does the nurse anticipate administering? Acyclovir Ampicillin Vidarabine Vancomycin
Acyclovir
A patient with meningitis has a weakness of the left upper limb and lower limb, blurred speech, and reduced vision. The symptoms did not resolve after treatment. What does the nurse infer from these symptoms? Cerebral abscess Acute cerebral edema Neurologic dysfunction Increased intracranial pressure
Cerebral abscess
A patient with a head injury is scheduled for a lumbar puncture. What should the nurse closely monitor this patient for? Cerebral edema Myelosuppression Total body collapse Cerebral herniation
Cerebral herniation
An older adult patient fell and hit their head on a coffee table 2 weeks previously. What type of hematoma should the nurse suspect may have occurred in this patient? Epidural hematoma Intracerebral hematoma Acute subdural hematoma Chronic subdural hematoma
Chronic subdural hematoma
A patient with meningitis developed loss of the corneal reflex. Which cranial nerve irritation would have led to the loss of the corneal reflex? Cranial nerve II Cranial nerve V Cranial nerve IV Cranial nerve VII
Cranial nerve V
A patient sustains a skull fracture and has loose fragments of bone. For which procedure will the nurse prepare the patient? Cranioplasty Craniotomy Craniectomy Conservative treatment
Craniotomy
A patient is suspected of having disruption of motor fibers in the midbrain after sustaining a head injury. What clinical manifestation does the nurse anticipate finding as a result? Projectile vomiting Tentorial herniation Decorticate posturing Decerebrate posturing
Decerebrate posturing
The nurse is assessing the waveforms for a patient receiving intracranial pressure (ICP) monitoring and observes a waveform representing venous pulsations. What type of waveform does the nurse document? Tidal wave Dicrotic wave Rebound wave Percussion wave
Dicrotic wave
A patient with a brain tumor presents with symptoms of visual disturbances and seizures. When evaluating the patient, the nurse knows that this tumor is most likely located in which area of the brain? Subcortical Parietal lobe Occipital lobe Temporal lobe
Occipital lobe
A patient develops hydrocephalus. When planning for patient care, which cause does the nurse determine could be a contributing factor? Select all that apply. Overproduction of CSF Underproduction of CSF Defective reabsorption of CSF Rupture of cerebral blood vessels Obstruction to flow of cerebrospinal fluid (CSF)
Overproduction of CSF Defective reabsorption of CSF Obstruction to flow of cerebrospinal fluid (CSF)
A patient with a brain tumor reports speech disturbances and inability to write. Which part of the cerebral hemisphere may be affected by the tumor? Frontal lobe Parietal lobe Occipital lobe Temporal lobe
Parietal lobe
The nurse is caring for a patient who sustained a head injury during a fall. Which factors influence intracranial pressure (ICP)? Select all that apply. Posture Swallowing Drowsiness Temperature Carbon dioxide levels Intraabdominal pressure
Posture Temperature Carbon dioxide levels Intraabdominal pressure
A patient with increased intracranial pressure (ICP) has an order for phenytoin. What does the nurse anticipate the expected outcome of administering phenytoin will be for the patient? Decreased ICP Prevention of seizures Decreased systolic pressure Prevention of gastrointestinal (GI) ulcers
Prevention of seizures
The nurse is educating a patient about care after a head injury. Which symptoms should the nurse instruct the patient and caregiver to immediately notify a health care provider about? Select all that apply. Sneezing Seizures Stiff neck Constipation Increased drowsiness
Seizures Stiff neck Increased drowsiness
The nurse is preparing to administer a hypertonic saline infusion to a patient to manage increased intracranial pressure (ICP). Which parameters require frequent monitoring? Select all that apply. Blood glucose Serum sodium Blood pressure Level of sedation Gastrointestinal disturbances
Serum sodium Blood pressure
The laboratory reports of a patient with a brain tumor, who reports uncontrolled urination and excessive thirst, show high sodium levels. The nurse also observes involuntary eye movements and suspects which type of brain tumor? Subcortical tumors Cerebellopontine tumor Thalamus and sellar tumor Fourth ventricle and cerebellar tumors
Thalamus and sellar tumor
The nurse notes watery sanguineous drainage from the nares of a patient who is being evaluated after falling from a roof. What is the best method for the nurse to validate suspicion of rhinorrhea? Gram stain The halo test Use a Dextrostix Slide smear for presence of leukocytes
The halo test
A patient with bacterial meningitis has a severe headache. Which symptoms should be monitored by the nurse to prevent complications? Select all that apply. Skin rash Vomiting Irritability Photophobia Neck stiffness
Vomiting Irritability
A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? A halo sign on the nasal drip pad Decreased blood pressure and urinary output A positive reading for glucose on a test-tape strip Clear nasal drainage along with the bloody discharge
A halo sign on the nasal drip pad
A patient's cerebrospinal fluid (CSF) culture findings showed a white blood cell count of 1200 cells/µL, protein 600 mg/dL, and glucose 25 mg/dL. What could be the diagnosis for the patient? Brain abscess Viral meningitis Viral encephalitis Bacterial meningitis
Bacterial meningitis
A nurse is screening patients who are at risk of stroke. Which tests would be appropriate to perform when screening these patients? Select all that apply. Blood pressure Routine urinalysis Stool examination Blood sugar level Serum cholesterol
Blood pressure Blood sugar level Serum cholesterol
An intubated and mechanically ventilated patient is ordered dexmedetomidine. Which side effect of the medication would the nurse monitor for in this patient? Insomnia Blood pressure changes Hyperanxiety Sedative effect
Blood pressure changes
A patient presents with a head injury and is suspected to have a temporal fracture. Which manifestations should the nurse assess further? Select all that apply. Optic nerve injury Periorbital ecchymosis Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region
Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region
Which are characteristics of Cushing's triad? Select all that apply. <p>Which are characteristics of Cushing’s triad? <b>Select all that apply.</b> </p> Tachycardia Bradycardia Systolic hypotension Systolic hypertension Widening pulse pressure Narrowing pulse pressure
Bradycardia Systolic hypertension Widening pulse pressure
The nurse is caring for a patient who is diagnosed with bacterial meningitis. What are the priority actions by the nurse? Select all that apply. Collect specimens for a culture to confirm the diagnosis. Wait for a confirmed diagnosis before starting antibiotics. Wait and watch until the fever reduces and next signs appear. Administer a corticosteroid along with the first dose of antibiotics. Initiate antibiotic therapy without waiting for a confirmed diagnosis.
Collect specimens for a culture to confirm the diagnosis. Administer a corticosteroid along with the first dose of antibiotics. Initiate antibiotic therapy without waiting for a confirmed diagnosis.
What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces? Linear Depressed Compound Comminuted
Comminuted
The nurse determines that a patient's mean arterial pressure (MAP) is below 70 mm Hg. What outcome of this MAP should be of most concern to the nurse? Decreased cerebral blood flow (CBF) Increased intracranial pressure (ICP) Increased cerebral perfusion pressure (CPP) Normal intracranial pressure (ICP)
Decreased cerebral blood flow (CBF)
Otorrhea is suspected in a patient with head trauma. Which tests may be used to detect cerebral spinal fluid (CSF)? Select all that apply. Dextrostix Litmus test Guaiac test Tes-Tape strip Imaging scans Quantitative hCG
Dextrostix Tes-Tape strip Imaging scans
The registered nurse is teaching a student nurse about treatment outcomes of a patient with meningitis. Which statement made by the student nurse about treatment outcomes would need correction? Pain can be controlled. Hearing loss can be resolved. Facial paresis can be resolved. Neck stiffness can be resolved.
Hearing loss can be resolved.
A nurse is caring for a patient who has increased intracranial pressure and diabetes insipidus. When monitoring urine output, for what is the nurse assessing the patient? Hypernatremia Decreased urine output Dilutional hyponatremia Elevated blood glucose level
Hypernatremia
The nurse is caring for a patient with increased intracranial pressure (ICP). Which osmotic diuretic does the nurse prepare to administer to lower the ICP? Mannitol Cimetidine Dexamethasone Hypertonic saline
Mannitol
A patient with meningitis is suffering from mental distortion. Which intervention should be performed to reduce mental distortion? Provide low lighting. Elevate the head of the bed. Minimize environmental stimuli. Apply a cool cloth over the eyes.
Minimize environmental stimuli.
The nurse is admitting a patient with a diagnosis of meningitis. When planning the care for this patient, what nursing actions should the nurse include? Select all that apply. Monitor temperature. Check for muscle pains. Check for retinal damage. Assess intraocular pressure. Assess the eye for sensitivity to light.
Monitor temperature. Check for muscle pains. Assess the eye for sensitivity to light.
The nurse hears snoring sounds in a patient with increased intracranial pressure (ICP). What does the nurse recognize these sounds indicate that require immediate action? Obstruction Oversedation Normal finding Decreasing ICP
Obstruction
The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? Tonic spasms of the legs Curling in a fetal position Arching of the neck and back Resistance to flexion of the neck
Resistance to flexion of the neck
The nurse is performing an assessment of the central nervous system (CNS) for a patient. What should the nurse be sure to include when documenting the assessment? Select all that apply. Speech Seizures Contusions Oxygen saturation Bowel and bladder incontinence Decerebrate or decorticate posturing
Speech Seizures Bowel and bladder incontinence Decerebrate or decorticate posturing
A patient who sustained a head injury received initial management and is being discharged. The nurse is teaching measures to be followed by the caregiver. Which statements made by the caregiver indicate the need for further teaching? Select all that apply. "I should maintain a calm environment if the patient is angry." "I should assist with a walker if the patient has difficulty walking." "I should not allow the patient to drive under the influence of morphine." "I should give hot baths if the patient experiences shivering and drowsiness." "I should report to the primary health care provider if the patient has numbness in fingers."
"I should maintain a calm environment if the patient is angry." "I should assist with a walker if the patient has difficulty walking." "I should give hot baths if the patient experiences shivering and drowsiness."
A nurse is explaining the National Institutes of Health Stroke Scale (NIHSS) to a graduate nurse. Which statement best indicates that the graduate nurse understands the purpose of performing the NIHSS? "The NIHSS helps prevent a second stroke." "The NIHSS evaluates the effects of a stroke." "The NIHSS is used primarily for research data collection." "The NIHSS is an invasive procedure that measures stroke severity."
"The NIHSS evaluates the effects of a stroke."
How many doses of meningococcal conjugate vaccine are recommended for prevention of bacterial meningitis? One Two Three Four
2
The nurse is assessing the health status of a patient who is unconscious. While assessing, the nurse finds that the patient is opening the eye in response to pain but not to any other stimulus. The patient is moaning to any verbal communication and is showing flexion withdrawal. What is the Glasgow Coma Scale value for this patient? 4 6 8 10
8
The nurse is caring for a group of patients on the acute care unit. Which patient is at greatest risk for the development of bacterial meningitis? A patient with a skull fracture A patient with prior brain trauma A patient with a pulmonary infection A patient with bacterial endocarditis
A patient with a pulmonary infection
A patient experiences a head injury in a motor vehicle crash. Which priority actions does the nurse anticipate providing when planning the care of the patient? Select all that apply. Anticipate intubation. Administering oxygen. Maintain neck alignment. Maintaining normothermia. Administer fluids cautiously. Establish intravenous (IV) access.
Administering oxygen. Maintain neck alignment. Establish intravenous (IV) access.
A nurse from the acute care unit is reassigned for the shift to the neurologic intermediate care unit. An appropriate assignment would include which patient? A patient just returning from a craniotomy for evacuation of subdural hematoma. A patient with traumatic brain injury who is being transferred to a rehabilitative facility. An alert patient with viral encephalitis who has a scheduled dose of intravenous (IV) acyclovir. An unconscious patient with bacterial meningitis who is needing another lumbar puncture for repeat cultures.
An alert patient with viral encephalitis who has a scheduled dose of intravenous (IV) acyclovir.
The nurse is performing an initial assessment on a patient to obtain baseline data about the patient's neurologic status. Which actions should the nurse perform relevant to a neurologic assessment? Select all that apply. Assess patient's temperature and pulse rate. Assess patient when performing daily activities. Assess patient's integrated function and balance. Assess patient's weight, height, and waist-to-hip ratio. Assess patient's level of consciousness and motor abilities.
Assess patient when performing daily activities. Assess patient's integrated function and balance. Assess patient's level of consciousness and motor abilities.
When performing an assessment on a patient with a head injury, which objective data does the nurse record? Select all that apply. Headache Battle's sign Projectile vomiting Past health history Mechanism of injury Cranial nerve deficits
Battle's sign Projectile vomiting Cranial nerve deficits
The nurse is reviewing a patient's imaging studies, which show the presence of lateral displacement of brain tissue beneath the falx cerebri. Which type of herniation does the nurse suspect may be present? Uncal herniation Central herniation Tentorial herniation Cingulate herniation
Cingulate herniation
The nurse reviews the x-ray reports of a patient who has a skull fracture, which reveals multiple linear fractures and the presence of a fragmented bone. Which type of skull fracture does the nurse suspect? Linear type Depressed type Compound type Comminuted type
Comminuted type
A patient with bacterial meningitis develops seizures. What are the appropriate nursing actions for this patient? Select all that apply. Convey an attitude of caring. Administer antiseizure medications. Forbid the patient from seeing visitors. Use a commanding voice to give explanations. Keep a familiar person at the patient's bedside.
Convey an attitude of caring. Administer antiseizure medications. Keep a familiar person at the patient's bedside.
A patient is diagnosed with a brainstem tumor. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. Crossed eyes Diabetes insipidus Tinnitus and vertigo Facial muscle weakness Headache on awakening
Crossed eyes Facial muscle weakness Headache on awakening
The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is suspected to have encephalitis. What type of encephalitis does the nurse anticipate the patient is at risk for? La Crosse encephalitis West Nile encephalitis Cytomegalovirus encephalitis Herpes simplex virus encephalitis
Cytomegalovirus encephalitis
The nurse is reviewing the laboratory results for a patient with bacterial meningitis. Which does the nurse anticipate observing in cerebrospinal fluid analysis? Decrease in neutrophils Decrease in lymphocytes Decrease in glucose level Decrease in protein level
Decrease in glucose level
The nurse is performing an assessment of a patient suspected of having a brain tumor. Which diagnostic procedure does the nurse anticipate preparing the patient for that will give an accurate diagnosis? Select all that apply. Lumbar puncture Electron microscopy Immunohistochemical stains Computed tomography (CT) scan Computer-guided stereotactic biopsy
Electron microscopy Immunohistochemical stains Computer-guided stereotactic biopsy
The nurse observes the presence of cerebrospinal fluid (CSF) rhinorrhea. What is the priority action by the nurse? Insert a nasogastric tube. Elevate the head of the bed. Have the patient blow their nose. Pack the nasal cavity with 4x4' to stop the flow of CSF.
Elevate the head of the bed.
The nurse is providing care for a patient who has been admitted to the hospital with a head injury and requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS)? Select all that apply. Judgment Eye opening Abstract reasoning Best verbal response Best motor response Cranial nerve function
Eye opening Best verbal response Best motor response
The nurse is caring for a patient with meningitis that has a fever. Which parameter should be monitored to prevent complications for this patient? Fluid intake Urine output Blood pressure Respiratory rate
Fluid intake
Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? Hypertension Hyperlipidemia Alcohol consumption Oral contraceptive use
HTN
A patient is reported to have a brain abscess in the occipital lobe. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. Visual field defects Headache and fever Nausea and vomiting Psychomotor seizures Visual impairment and hallucinations
Headache and fever Nausea and vomiting Visual impairment and hallucinations
A patient reports a headache, which is worse in the morning and aggravated with movements, as well as vomiting without any preceding nausea. When assessing the patient, which common causes should the nurse consider when suspecting increased intracranial pressure? Select all that apply. Sinusitis Glaucoma Hematoma Head injury Brain tumor
Hematoma Head injury Brain tumor
Which are components of a secondary intracranial injury? Select all that apply. Hypoxia Ischemia Hypotension Blunt force trauma Impact of a car accident Increased intracranial pressure
Hypoxia Ischemia Hypotension Increased intracranial pressure
The nurse is caring for a patient in the neurologic intensive care unit with increased intracranial pressure (ICP). What nursing actions will promote the most positive outcome for the patient? Select all that apply. ICP monitoring Cerebral angiography Elevating the head of the bed 30 degrees Maintaining PaO 2 of 90 mm Hg or greater Taking a patient history and physical examination Maintaining a systolic arterial pressure of 100-160 mm Hg
ICP monitoring Elevating the head of the bed 30 degrees Maintaining a systolic arterial pressure of 100-160 mm Hg
Which findings will the nurse suspect in a patient who reports a headache and disturbed consciousness and whose imaging studies indicate cerebral edema in the white matter? Decreased oxygen supply to brain Presence of intact blood-brain barrier Increase in the extracellular fluid volume Abnormal accumulation of cerebrospinal fluid in brain
Increase in the extracellular fluid volume
A patient with a head injury presents to the emergency department. For which potential complication related to cerebral hemorrhage and edema should the nurse evaluate this patient? Anxiety Hyperthermia Impaired physical mobility Increased intracranial pressure
Increased intracranial pressure
The nurse is reviewing the interventions prescribed by the health care provider for a patient with a basilar skull fracture. The nurse should collaborate with the health care provider about which intervention? Apply soft cervical collar. Avoid flexion of hip joints. Keep head of bed elevated to 30 degrees at all times. Insert nasal gastric tube and connect to low, intermittent suction.
Insert nasal gastric tube and connect to low, intermittent suction.
A patient is brought to the emergency room with a head injury and is at risk of developing increased intracranial pressure. Which is the most reliable indicator that the nurse should use for assessing the patient's neurologic status? Dim vision Papilledema Body temperature Level of consciousness
Level of consciousness
The nurse is caring for a patient that sustained a traumatic brain injury in a motor vehicle crash. Which condition indicates to the nurse when planning the care of the patient to maintain closure of the eyes? Diplopia Otorrhea Periorbital ecchymosis Loss of the corneal reflex
Loss of the corneal reflex
he nurse is planning care for a group of patients on a stroke unit. What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. Measuring and recording oral intake and urine/bowel output Screening patients for tissue plasminogen activator therapy Assessing neurologic status using the Glasgow Coma Scale Providing oral and lip care at least every 2 hours and as needed Placing equipment needed for seizure precautions in the patient's room Assisting with positioning the patient and turning the patient at least every two hours
Measuring and recording oral intake and urine/bowel output Providing oral and lip care at least every 2 hours and as needed Placing equipment needed for seizure precautions in the patient's room Assisting with positioning the patient and turning the patient at least every two hours
The nurse is evaluating the use of surgical therapy in a patient with a brain tumor. Which important factors should the nurse consider? Select all that apply. Tumors of all types, sizes, and location can be completely removed. More invasive gliomas and medulloblastomas can be partially removed. More invasive gliomas and medulloblastomas can be completely removed. Meningiomas and oligodendrogliomas can usually be completely removed. The outcome of surgical therapy depends on the type, size, and location of tumor.
More invasive gliomas and medulloblastomas can be partially removed. Meningiomas and oligodendrogliomas can usually be completely removed. The outcome of surgical therapy depends on the type, size, and location of tumor.
Using the Glasgow Coma Scale (GCS), the nurse assesses the patient and records a score of 5. What is the nurse's priority action? Notify the charge nurse. Continue to monitor the patient. Reassess the patient in an hour. Notify the rapid response team.
Notify the rapid response team.
A patient has visual impairment and hallucinations. Which lobe of the brain would show a presence of an abscess on a computed tomography scan? Frontal lobe Parietal lobe Occipital lobe Temporal lobe
Occipital lobe
A patient is admitted with elevated intracranial pressure (ICP). What factors should the nurse be sure are avoided that may create further elevation in intracranial pressure? Select all that apply. Pain and agitation Extreme hip flexion Slow and gentle movements Elevation of head of the bed Increased intrathoracic pressure
Pain and agitation Extreme hip flexion Increased intrathoracic pressure
A nurse is assessing four patients with different types of skull fractures. Which patient would have a low-velocity injury as the cause of skull fracture? Patient A- linear Patient B- depressed Patient C- comminuted Patient D- compound
Patient A
The nurse is assessing a comatose patient. Which findings does the nurse anticipate observing? Select all that apply. Patient can cough and swallow. Patient has bowel and bladder control. Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent.
Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent.
A patient with meningococcal meningitis is suspected to have Waterhouse-Friderichsen syndrome. Which possible findings would the nurse observe regarding this complication? Select all that apply. Diplopia Petechiae Pulmonary effusion Adrenal hemorrhage Disseminated intravascular coagulation (DIC)
Petechiae Adrenal hemorrhage Disseminated intravascular coagulation (DIC)
When managing a fever in a patient with acute meningitis, what actions should the nurse perform? Select all that apply. Encourage shivering in the patient to help reduce fever. Reduce fever with the use of acetaminophen. Use a cooling blanket on the patient to reduce fever. Reduce body temperature rapidly to provide relief. Lower temperature by the use of tepid water sponge baths.
Reduce fever with the use of acetaminophen. Use a cooling blanket on the patient to reduce fever. Lower temperature by the use of tepid water sponge baths.
When planning the care of a patient with a brain tumor, which goals should the nurse select as primary goals? Select all that apply. Making patient walk Removing tumor mass Managing patient's family Identifying the tumor type and location Managing increased intracranial pressure (ICP)
Removing tumor mass Identifying the tumor type and location Managing increased intracranial pressure (ICP)
The nurse is caring for a patient with increased intracranial pressure (ICP) resulting from a mass lesion in the brain. About what treatment option does the nurse educate the patient that will have the best outcome? Surgery Cimetidine Craniectomy Corticosteroids
Surgery
A patient with a head injury has a score of five on the Glasgow Coma Scale. How should the nurse interpret the score? The patient is alert and oriented. The patient is unresponsive and comatose. The patient is awake but lethargic and drowsy. The patient responds appropriately to commands.
The patient is unresponsive and comatose.
A patient with bacterial meningitis is given antibiotic therapy and symptomatic treatment. What is the expected treatment outcome? The patient may experience muscle aches. The patient may return to maximal neurologic function. The patient may have a chance of recurrence of infection. The patient may experience some discomfort while performing daily activities.
The patient may return to maximal neurologic function. `
The nurse is caring for a patient that had a craniotomy. In planning long-term care for the patient, what must the nurse include when teaching the patient, family, and caregiver? Seizure disorders may occur in weeks or months. The family will be unable to cope with role reversals. There are often residual changes in personality and cognition. Referrals will be made to eliminate residual deficits from the damage.
There are often residual changes in personality and cognition.
The nurse is preparing to administer temozolomide to a patient with a brain tumor and assesses the patient's neutrophil count to verify it is greater than 1500/µL. What is the rationale behind this nursing intervention? To reduce nausea and vomiting To prevent metabolic inactivation To prevent immune-related complications To prevent drug interactions with corticosteroids
To prevent immune-related complications
A patient is diagnosed with a brain tumor. Which surgical techniques and procedures will the nurse prepare the patient for in order to localize brain tumors intraoperatively? Select all that apply. X-ray Ultrasound Cortical mapping Electroencephalogram (EEG) Computer-guided stereotactic biopsy Functional magnetic resonance imaging (MRI)
Ultrasound Cortical mapping Computer-guided stereotactic biopsy Functional magnetic resonance imaging (MRI)
The nurse is conducting a physical assessment for a patient in the emergency room. Which finding is consistent with a left-hemispheric stroke? Good impulse control and judgment Unilateral weakness of the left extremities Unilateral weakness of the right extremities Alert and oriented to time, place, and person
Unilateral weakness of the right extremities
The nurse is educating a patient that is being discharged with a resolved head injury about prevention of further injury. What measures should the nurse include when discussing this? Select all that apply. Use of carpooling Use of car seat belts Use of tinted glasses Use of child car seats Use of helmets by cyclists
Use of car seat belts Use of child car seats Use of helmets by cyclists
Which type of cerebral edema occurs mainly in the white matter and is characterized by leakage of large molecules from the capillaries into the surrounding space? Interstitial cerebral edema Vasogenic cerebral edema Hypoxic cerebral edema Cytotoxic cerebral edema
Vasogenic cerebral edema
The nurse is caring for a patient admitted for surgical removal of a brain tumor. The nurse will plan interventions for this patient based on the knowledge that brain tumors can lead to which complications? Select all that apply. Vision loss Cerebral edema Pituitary dysfunction Parathyroid dysfunction Focal neurologic deficits
Vision loss Cerebral edema Pituitary dysfunction Focal neurologic deficits
Which population has the highest rate of malignant brain tumors? White males Asian males Hispanic males African American males
White males
A patient with a tumor of the frontal lobe is reported to have disorientation and confusion due to perceptual problems. What actions should the nurse perform to comfort the patient? Select all that apply. Create a routine. Use reality orientation. Provide increased stimuli. Make the patient drive a vehicle. Minimize environmental stimuli.
Create a routine. Use reality orientation. Minimize environmental stimuli.
The nurse caring for a patient with a diagnosis of acute meningitis. Which actions should the nurse perform? Select all that apply. Lower the head of the bed. Place the patient in a comfortable position. Instruct the patient to ambulate or walk around the room. Position the patient in a curled up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture.
Place the patient in a comfortable position. Position the patient in a curled up position with the head slightly extended. Slightly elevate the head of the bed if permitted after lumbar puncture.
Which action should the nurse include in the plan of care for a patient who has bacterial meningitis? Restraining the patient in bed Increasing the patient's fluid intake Maintaining the patient in a flat supine position Reducing the patient's environmental stimuli as much as possible
Reducing the patient's environmental stimuli as much as possible
A patient experienced a fall and presented to the emergency department with scalp lacerations and a depressed skull. What initial interventions should the nurse perform as emergency management? Select all that apply. Stabilize the cervical spine. Wrap the patient in tight clothing. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing. Avoid intubation if the Glasgow Coma Scale (GCS) score is less than 8.
Stabilize the cervical spine. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing.
When assessing the outcome of surgery in a patient with a brain tumor, which factors should the nurse consider? Select all that apply. Surgery provides complete cure. Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time. Surgery can increase intracranial pressure (ICP).
Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time.
When teaching a patient about home care following meningitis, which instructions should the nurse provide regarding the patient's diet? Select all that apply. Take small frequent feedings. Avoid eating peanuts and peanut butter. Include chicken and lean meat in the diet. Include whole grains, potatoes, and cereals in the diet. Consume moderate quantities of alcohol and caffeinated beverages.
Take small frequent feedings. Include chicken and lean meat in the diet. Include whole grains, potatoes, and cereals in the diet.
A patient is prescribed temozolomide as a treatment for a brain tumor. Which factors should the nurse evaluate prior to administering the medication? Select all that apply. Temozolomide causes photosensitivity. Temozolomide causes myelosuppression. Temozolomide can cross the blood-brain barrier. Temozolomide can convert to an agent that directly interferes with tumor growth. Temozolomide interacts with other drugs usually taken by brain tumor patients.
Temozolomide causes myelosuppression. Temozolomide can cross the blood-brain barrier. Temozolomide can convert to an agent that directly interferes with tumor growth.
A patient with meningitis is scheduled for a lumbar puncture. When is the appropriate time for the nurse to prepare the patient for the procedure? Select all that apply. After the blood culture test Before starting the antibiotic therapy After the computed tomography (CT) scan Before the magnetic resonance imaging (MRI) scan Before the culture test of nasopharyngeal secretions
After the blood culture test Before starting the antibiotic therapy After the computed tomography (CT) scan Before the magnetic resonance imaging (MRI) scan
The nurse is monitoring a patient's intracranial pressure (ICP) after a craniotomy. Which finding must be reported immediately to the health care provider? An ICP of 5 mm Hg An ICP of 10 mm Hg An ICP of 15 mmHg An ICP of 20 mm Hg
An ICP of 20 mm Hg Normal range: 5-15 mm Hg
The nurse is caring for a patient with a brain tumor. Which diagnostic test would the nurse prepare the patient for to further localize and detect blood flow? Angiography Lumbar puncture Endocrine studies Electroencephalogram (EEG)
Angiography
The nurse is caring for a patient that has developed hydrocephalus. Which surgical procedure does the nurse prepare the patient for? Drainage of abscess Excision of malformation Placement of a ventriculoatrial shunt Debridement of fragments and necrotic tissue
Placement of a ventriculoatrial shunt
The nurse is reviewing the medical records of a patient with acquired immunodeficiency syndrome (AIDS) that has been diagnosed with a brain tumor. What tumor growth is associated with AIDS? Metastatic tumor Acoustic neuroma Pituitary adenoma Primary central nervous system lymphoma
Primary central nervous system lymphoma
A patient is diagnosed with a brain abscess. When performing an assessment on this patient, what causes does the nurse determine for the development of this problem? Select all that apply. Acne or skin abscess Prior brain trauma or surgery Prior leg fracture or ligament tears Distant spread from a pulmonary infection Direct extension from an ear or sinus infection
Prior brain trauma or surgery Distant spread from a pulmonary infection Direct extension from an ear or sinus infection
What medication with a rapid onset and a short half-life can be used for anxiety and agitation in a patient with increased intracranial pressure? Propofol Opioids Benzodiazepines Nondepolarizing neuromuscular blocking agents
Propofol
The nurse is teaching a patient about the onset of embolic stroke. What information does the nurse include in the teaching plan? Embolic stroke rarely recurs. Embolic stroke occurs rapidly. Embolic stroke renders the patient unconscious. Embolic stroke is marked by a surge of blood supply to the brain tissues.
Embolic stroke occurs rapidly.
Why is an older adult patient who falls at a high risk for a chronic subdural hematoma? Larger subdural space Changes in vasculature Decrease in pain sensation Decrease in level of consciousness
Larger subdural space
The nurse is caring for a patient with increased intracranial pressure (ICP). Why will the nurse question an order for a benzodiazepine prescribed by the health care provider? It may cause sedation. It may increase the pain. It increases anxiety levels. It causes a hypotensive effect.
It causes a hypotensive effect.
The nurse is performing an assessment for a patient that has been comatose for seven hours and then awakens. Which manifestations does the nurse anticipate finding while performing the assessment? Select all that apply. Decreased apathy Loss of concentration Loss of social restraint Increase in personal drive Euphoria and mood swings
Loss of concentration Loss of social restraint Euphoria and mood swings
hen evaluating the diagnostic studies for a patient with bacterial meningitis, which factors should the nurse consider regarding lumbar puncture? Select all that apply. Lumbar puncture may require a contrast to be injected. Lumbar puncture is helpful in confirming diagnosis of brain tumor. Lumbar puncture is done after ruling out an obstruction in the foramen magnum. Lumbar puncture is usually helpful in confirming the diagnosis of bacterial meningitis. Lumbar puncture is done to analyze cerebrospinal fluid (CSF) in case of bacterial meningitis.
Lumbar puncture is done after ruling out an obstruction in the foramen magnum. Lumbar puncture is usually helpful in confirming the diagnosis of bacterial meningitis. Lumbar puncture is done to analyze cerebrospinal fluid (CSF) in case of bacterial meningitis.
The nurse is caring for a patient with a head injury that has a temperature of 103° F. Which pathophysiologic processes does the nurse suspect are occurring? Select all that apply. The metabolism is decreased. The metabolic waste is increased. The cerebral blood flow would be increased. The intracranial pressure would be decreased. The cerebral blood volume would be decreased.
The metabolic waste is increased. The cerebral blood flow would be increased.
A nurse is updating the health history of a patient who has been admitted to the hospital with a stroke. What question should the nurse ask the patient's support person? What was the time of onset of symptoms? How much food did the patient eat the previous night? What was the position of the patient when the symptoms arose? Was the patient wearing tight clothes at the time of the stroke?
What was the time of onset of symptoms?