ICP
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to a. assist the patient to eat with the left hand. b. provide oral care before and after meals. c. teach the patient the "chin-tuck" technique. d. provide a wide variety of food choices.
Correct Answer: A Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity
When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.
Correct Answer: A Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal. Cognitive Level: Comprehension Text Reference: p. 1472 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)
Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan. Cognitive Level: Application Text Reference: pp. 1509, 1511-1512 Nursing Process: Implementation NCLEX: Physiological Integrity
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? (Select all that apply.) a. Suction tubing b. Oxygen mask c. Nasogastric tube d. Siderail pads e. Tongue blade f. Oral airway
Correct Answer: A, B, D Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades or oral airways during a seizure is contraindicated. Cognitive Level: Application Text Reference: pp. 1539-1540 Nursing Process: Planning NCLEX: Physiological Integrity
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
Correct Answer: B Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Planning NCLEX: Physiological Integrity
When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a. The blood pressure increases from 120/54 to 136/62. b. The patient is more difficult to arouse. c. The patient complains of a headache at pain level 5 of a 10-point scale. d. The patient's apical pulse is slightly irregular.
Correct Answer: B Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. Cognitive Level: Application Text Reference: p. 1470 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first? a. Administer acetaminophen (Tylenol) 650 mg orally. b. Administer 5% hypertonic saline intravenously. c. Draw blood for arterial blood gases (ABGs). d. Send patient to radiology for computed tomography (CT) of the head.
Correct Answer: B Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. Cognitive Level: Application Text Reference: p. 1470 Nursing Process: Implementation NCLEX: Physiological Integrity
Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 23-year-old patient who had a skull fracture and craniotomy the previous day b. A 30-year-old patient who has an ICP monitor in place after a head injury a week ago c. A 44-year-old patient receiving IV antibiotics for meningococcal meningitis d. A 61-year-old patient who has increased ICP and is receiving hyperventilation therapy
Correct Answer: C Rationale: An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The post-craniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. Cognitive Level: Application Text Reference: pp. 1495-1497 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. obtain a specimen of the fluid and send for culture and sensitivity. b. take the patient's temperature to determine whether a fever is present. c. check the nasal drainage for glucose with a Dextrostik or Testape. d. have the patient to blow the nose and then check the nares for redness.
Correct Answer: C Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage. Cognitive Level: Application Text Reference: p. 1481 Nursing Process: Implementation NCLEX: Physiological Integrity
When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.
Correct Answer: C Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury. Cognitive Level: Comprehension Text Reference: p. 1470 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30
Correct Answer: C Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. Cognitive Level: Application Text Reference: p. 1469 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about a. preparation for an MRI. b. purpose of EEG testing. c. antiparkinsonian drugs. d. oral corticosteroids.
Correct Answer: C Rationale: The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it. Cognitive Level: Application Text Reference: p. 1550 Nursing Process: Planning NCLEX: Physiological Integrity
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates a. high blood flow to the brain. b. normal intracranial pressure (ICP). c. impaired brain blood flow. d. adequate cerebral perfusion.
Correct Answer: C Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg. Cognitive Level: Application Text Reference: p. 1468 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed. c. Notify the health care provider about the assessments. d. Check the patient's pupillary response to light.
Correct Answer: C Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and monitoring are inadequate responses to the patient's problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information. Cognitive Level: Analysis Text Reference: pp. 1468-1469 Nursing Process: Implementation NCLEX: Physiological Integrity
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.
Correct Answer: C Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective. Cognitive Level: Application Text Reference: p. 1475 Nursing Process: Evaluation NCLEX: Physiological Integrity
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. document the timing and description of the seizure. b. notify the patient's health care provider about the seizure. c. give the scheduled dose of divalproex (Depakote). d. assess the patient for a possible head injury.
Correct Answer: D Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury. Cognitive Level: Application Text Reference: p. 1535 Nursing Process: Implementation NCLEX: Physiological Integrity
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. heparin via continuous intravenous infusion. b. prophylactic clipping of cerebral aneurysms. c. therapy with tissue plasminogen activator (tPA). d. oral administration of ticlopidine (Ticlid).
Correct Answer: D Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA. Cognitive Level: Application Text Reference: p. 1505 Nursing Process: Implementation NCLEX: Physiological Integrity
