Giddens Chapter 13 Intracranial Regulation
A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. When assessing the client, what does the nurse expect to observe? 1 Hyperextension of both the upper and lower extremities 2 Spastic paralysis of both the upper and lower extremities 3 Hyperflexion of the upper extremities and hyperextension of the lower extremities 4 Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities
1
The nurse is caring for a patient in the neurologic intensive care unit with increased intracranial pressure (ICP). What assessment data obtained by the nurse indicates a worsening of the patient's condition? 1Presence of fixed unresponsive pupils 2Sluggish reaction of pupil in response to light 3Brisk constriction of pupil in response to light 4Slight constriction in the opposite pupil in response to light
1
A 20-year-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.
B
When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia. b. hypertension, and tachycardia. c. hypotension, and bradycardia. d. hypotension, and tachycardia.
A
Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a.Encourage the use of effective insect repellents during mosquito season .b.Remind patients that most cases of viral encephalitis can be cared for at home. c.Teach about the importance of prophylactic antibiotics after exposure to encephalitis .d.Arrange for screening of school-age children for West Nile virus during the school year.
A
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. 1 ICP monitoring 2 Cerebral angiography 3 Elevating the head of the bed 30 degrees 4 Maintaining PaO2 of 90 mm Hg or greater 5 Taking a patient history and physical examination 6 Maintaining a systolic arterial pressure of 100-160 mm Hg
136
A client has surgery, Which early clinical manifestation of meningeal irritation does the nurse assess in the client? 1 Sunset eyes 2 Kernig sign 3 Plantar reflex 4 Homans sign
2
The nurse is reviewing the cerebrospinal fluid (CSF) laboratory findings of four neurologically compromised clients. Which client does the nurse suspect to have had a previous meningeal hemorrhage? 1 yellow 2 brown 3 unclear or hazy 4 pink red- orange
2
Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c. Loss of primitive reflexes d. Unequal pupil size
A
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-year-old receiving IV antibiotics for meningococcal meningitis b.A 25-year-old admitted with a skull fracture and craniotomy the previous day c.A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d.A 35-year-old with ICP monitoring after a head injury last week
A
The nurse is caring for a comatose patient admitted following cardiopulmonary arrest. The patient is intubated, mechanically ventilated, and receiving vasopressors to maintain the pulse and blood pressure. The nurse knows a clinical diagnosis of brain death requires what? Select all that apply. 1 Apnea 2 Comatose or unresponsive 3 Poor quality of life prognosis 4 Irreversible cognitive damage 5 Absence of brainstem reflexes
125
A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment? Select all that apply. 1 Monitor fluid intake and sodium levels regularly. 2 Monitor patient's sleep and diet routine regularly. 3 Perform blood glucose monitoring at least every six hours. 4 Avoid taking any antacids along with corticosteroid treatment. 5 Start concurrent treatment with antacids or proton pump inhibitors.
135
A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan 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.
B
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. 1 Acne or skin abscess 2 Prior brain trauma or surgery 3 Prior leg fracture or ligament tears 4 Distant spread from a pulmonary infection 5 Direct extension from an ear or sinus infection
245
While playing on a jungle gym in the school playground, a school-aged child falls and sustains head trauma. The nurse suspects dysfunction of the brainstem at a low level when the child assumes the posturing depicted in the illustration. How should the nurse document this posturing in the child's hospital record? 1 Orthotonos 2 Decorticate 3 Decerebrate 4 Opisthotonos
3
A 46-year-old patient with a head injury opens the 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.
B
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.
B
Which outcomes indicate effective treatment in a patient with increased intracranial pressure who underwent a tracheostomy to help maintain adequate ventilation? Select all that apply. 1 PaO2 of the patient is 80 mm Hg 2 PaO2 of the patient is 90 mm Hg 3 PaO2 of the patient is 110 mm Hg 4 PaCO2 of the patient is 40 mm Hg 5 PaCO2 of the patient is 30 mm Hg
34
A nurse is caring for a patient for whom the health care team suspects cerebral death. Which diagnostic procedure will the nurse prepare the patient for that will confirm this suspicion? 1Reflex test 2Myelogram 3Lumbar puncture 4Cerebral angiography
4
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. Which complication does the nurse suspect? 1Tetany 2Spina bifida 3Hyperkalemia 4Intracranial hemorrhage
4
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.Elevate the head of the bed 20 degrees. b.Restrict oral fluids to 1000 mL daily. c.Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d.Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
B
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.
74
A 42-year-old 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.
A
A 68-year-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.Verify Glasgow Coma Scale (GCS) score. d.Palpate the head for hematoma or bony irregularities.
A
A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a.Short-term memory b.Muscle coordination c.Glasgow Coma Scale d.Pupil reaction to light
A
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.
A
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a.Blood pressure 154/68, pulse 56, respirations 12 b.Blood pressure 134/72, pulse 90, respirations 32 c.Blood pressure 148/78, pulse 112, respirations 28 d.Blood pressure 110/70, pulse 120, respirations 30
A
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 b.2 c.3 d.4
A
The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be a. change in level of consciousness. b. inability to focus visually. c. loss of primitive reflexes. d. unequal pupil size.
A
The nurse preparing to care for a patient after a suspected stroke would question an order for a(n) a. antihypertensive. b. antipyretic. c. osmotic diuretic. d. sedative.
A
The nurse preparing to care for a patient after a suspected stroke would question which order? a. Antihypertensive b. Antipyretic c. Osmotic diuretic d. Sedative
A
When admitting a 42-year-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.
A
When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings? a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia
A
After endotracheal suctioning, the nurse notes that the intracranial pressure 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.
B
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 is most important to communicate to the health care provider?a.Pulse 102 beats/minb.Temperature 101.6° Fc.Intracranial pressure 15 mm Hgd.Mean arterial pressure 90 mm Hg
B
After shunt procedure, the nurse would monitor the patient's neurologic status by using the a. electroencephalogram. b. GCS. c. National Institutes of Health Stroke Scale. d. Monro-Kellie doctrine.
B
After shunt procedure, the nurse would monitor the patient's neurologic status by using which test? a. Electroencephalogram b. Glasgow Coma Scale c. National Institutes of Health Stroke Scale d. Monro-Kellie doctrine
B
An unconscious 39-year-old male 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.Ask the family to stay in the waiting room until the initial assessment is completed. b.Allow the family to stay with the patient and briefly explain all procedures to them. c.Refer the family members to the hospital counseling service to deal with their anxiety. d.Call the family's pastor or spiritual advisor to take them to the chapel while care is given.
B
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? 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."
B
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.
B
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.
B
The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. Clustering many nursing activities c. Elevating the head of the bed 30 degrees d. Providing stool softeners or laxatives as ordered
B
The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. Clustering many nursing activities c. Elevating the head of the bed 30 degrees d. Providing stool softeners or laxatives as ordered
B
To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? 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?"
B
Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a.Intracranial pressure is 16 mm Hg when patient is turned. b.Pale yellow urine output is 1200 mL over the last 2 hours. c.LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d.Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.
B
Which statement by a 40-year-old 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."
B
hich 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.
B
The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a.Encourage adolescents and young adults to avoid crowds in the winter. b.Vaccinate 11- and 12-year-old children against Haemophilus influenza. c.Immunize adolescents and college freshman against Neisseria meningitides. d.Emphasize the importance of hand washing to prevent the spread of infection.
C
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. b. localization of pain. c.decorticate posturing. d.decerebrate posturing.
C
Which information about a 30-year-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/hour c.Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d.Cardiac monitor shows sinus tachycardia at 128 beats/minute
C
A patient in the intensive care unit (ICU) was admitted to the unit following brain attack. The vital signs are stable. The nurse assesses vital signs 1 hour later. Which of the following would concern the nurse? Blood pressure 110/70, pulse 120, respirations 30 Blood pressure 154/68, pulse 56, respirations 12 Blood pressure 134/72, pulse 90, respirations 32 Blood pressure 148/78, pulse 112, respirations 28
Blood pressure 154/68, pulse 56, respirations 12
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to 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.
C
A patient has increased intracranial pressure and a ventriculostomy after a head injury. 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.
C
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.
C
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 b.Oxygen saturation c.Intracranial pressure d.Hemoglobin and hematocrit
C
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most 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.
C
Which of the following processes have the strongest links to intracranial regulation? (Select all that apply.) Cognition Mobility Oxygenation Perfusion Safety
Cognition Mobility Oxygenation Perfusion
A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention 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.
D
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a.The bedrails at the head and foot of the bed are both elevated. b.The patient receives a regular diet from the dietary department. c.The lights in the patient's room are turned off and the blinds are shut. d.Unlicensed assistive personnel enter the patient's room without a mask.
D
After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of 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.
D
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-year-old patient whose cranial x-ray shows a linear skull fracture b.A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c.A 40-year-old patient who lost consciousness for a few seconds after a fall d.A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
D
Components of the GCS the nurse would use to assess a patient after a head injury include a. blood pressure. b. cranial nerve function. c. head circumference. d. verbal responsiveness.
D
Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness
D
Primary prevention strategies to reduce the occurrence of head injuries would include a. blood pressure control. b. smoking cessation. c. maintaining a healthy weight. d. violence prevention.
D
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 is most important to report 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)
D
The nurse should teach a patient that which is a primary prevention strategy to reduce the occurrence of head injuries? a. Blood pressure control b. Smoking cessation c. Maintaining a healthy weight d. Violence prevention
D
When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? 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.
D
Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture? a.A b.B c.C d.D
D
The nurse assesses a patient who responds to nail bed pressure by exhibiting internal rotation, adduction, and flexion of the arms. The nurse assesses this response as: Flexion withdrawal Decorticate posturing Localization of pain Decerebrate posturing
Decorticate posturing
The nurse manager of a neuro-medical surgical unit reviewing potential manifestations of seizures with an orientee would become concerned if the new nurse included which of the following dysfunctions as a manifestation? Family Sensory Motor Autonomic
Family
An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication of this type of surgery should the nurse explain to the home caregivers to prepare them for the patient's discharge? Eyes with sclera visible above the irises Fever accompanied by decreased responsiveness Violent involuntary muscle contractions Excessive fluid accumulation in the abdomen
Fever accompanied by decreased responsiveness
Intracranial function can be disrupted by which degenerative disease of the brain? Brain tumors Encephalitis Parkinson's disease Meningitis
Parkinson's disease
When caring for a patient on the neuro-trauma unit, the nurse should assess for which signs and symptoms of increased intracranial pressure? Vomiting Nausea Hunger Dehydration
Vomiting
The wife of a 30-year-old male patient with a traumatic brain injury ask the nurse why her husband needs to have intracranial pressure monitoring. Which response by the nurse is best? The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure. The monitoring system helps show whether blood flow to the brain is adequate. This monitoring system has multiple benefits, including facilitation of cerebrospinal fluid drainage. This type of monitoring system is complex and it is managed by skilled staff.
The monitoring system helps show whether blood flow to the brain is adequate.
Intracranial regulation would be a priority concern for the nurse caring for a patient with which admitting diagnosis? Failure to thrive Upper respiratory infection Urinary tract infection Tramatic brain injury
Traumatic Brain Injury