ICP66

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? select all that apply. 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.

1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures

The nurse is caring for a patient with a head injury who has an ICP monitor in place. Assessment reveals an ICP reading of 66. What is the best nursing action? A. Notify the physician. B. Document the reading. C. Turn the patient and recheck the reading. D. Place the patient in a supine position.

A. Correct Notify the physician Normal ICP is 10 to 15 mm Hg; 66 is an extremely high reading. The physician should be notified.

A patient has developed diabetes insipidus after having increased ICP following head trauma. When developing a teaching plan for this patient the nurse should include information about which hormone, commonly lacking in patients with diabetes insipidus? A) Antidiuretic hormone (ADH) B) Thyroid-stimulating hormone (TSH) C) Follicle-stimulating hormone (FSH) D) Luteinizing hormone (LH)

ANS: A ADH is the hormone lacking in diabetes insipidus. The patient's TSH, FSH, and LH levels won't be affected.

You have a patient with an altered level of consciousness. What would be your first action when assessing this patient? A) Assessing the verbal response B) Assessing if the patient follows commands C) Assessing whether the patient will open their eyes D) Assessing response to pain

ANS: A Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. Therefore options B, C, and D are incorrect.

The nursing instructor is discussing increased intracranial pressure (ICP) with the senior nursing students. What would the instructor be correct in telling the students is an early clinical manifestation of ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

ANS: A Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brainstem reflexes such as the corneal reflex.

When 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. Oral temperature 101.6° F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

ANS: A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

When caring for a patient with increased ICP the nurse must monitor for possible secondary complications. One possible complication of increased ICP is SIADH. What nursing interventions would the nurse initiate if the patient developed SIADH? A) Fluid restriction B) Fluid replacement C) Electrolyte replacement D) Electrolyte restriction

ANS: A The nurse also assesses for complications of increased ICP, including diabetes insipidus and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. You do not "restrict" electrolytes with patients, you monitor them. Diabetes insipidus requires fluid and electrolyte replacement.

What diagnostic test is contraindicated in a patient exhibiting clinical manifestations of increased intracranial pressure? A) CT scan B) Lumbar puncture C) MRI D) Venous Doppler studies

ANS: B A lumbar puncture in a client with increased intracranial pressure (ICP) may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. A CT scan, MRI, and venous Doppler are considered noninvasive procedures and would not affect the intracranial pressure itself.

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the emergency department. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The priority nursing evaluations, when assessing level of consciousness in this patient, would be based on what? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status exam

ANS: B Level of consciousness (LOC), a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Refer to Chart 63-4. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status exam would be part of the neurologic examination for this patient, but would not be the priority in evaluating level of consciousness.

You have admitted a patient to the Neurolog Intensive Care Unit with a brainstem herniation. The patient is now exhibiting an altered level of consciousness. The nurse has determined that the patient's mean arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values? A) Normal B) High C) Low D) Compensating

ANS: C The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion.

A patient is being admitted to the Neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medications to reduce cerebral edema? A) Hydrochlorothiazide (HydroDIURIL) B) Lasix (Furosemide) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

ANS: C The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reduces the volume of brain and extracellular fluid. Spirolactone, Lasix, and Hydrochorothiazide are used in the treatment of CHF and hypertension.

A patient is considered terminal after being involved in a motor vehicle accident in which they received massive trauma to the head. As the patient's ICP increases and condition worsens, the family asks you what indications of approaching death will there be. What would be your best response? A) "There is a change in the pattern of their respirations." B) "Projectile vomiting and hemiplegia usually occur just before death." C) "Posturing may develop as pressure on the brainstem increases." D) "Loss of brainstem reflexes is a sign of approaching death."

ANS: D As ICP increases, the patient's condition worsens, as manifested by the following signs and symptoms: the LOC continues to deteriorate until the patient is comatose. The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne-Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brainstem increases. Bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death.

What should the nurse suspect when hourly assessment of urine output on a postcraniotomy patient exhibits a urine output from a catheter of 1500 mL for 2 consecutive hours? A) Cushing's syndrome. B) Syndrome of inappropriate antidiuretic hormone C) Adrenal crisis. D) Diabetes insipidus.

ANS: D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

During the examination of an unconscious patient, the nurse notices that the patient's pupils are fixed and dilated. What is the clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.

ANS: D Pupils that are fixed and dilated indicate injury at the midbrain level.

A 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. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

ANS: D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.

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

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 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

Which assessment finding would be most indicative of increased ICP in a patient admitted with a basilar skull fracture? A. Vomiting B. Headache C. Dizziness D. Papilledema

D. Correct Papilledema Papilledema is a hallmark sign of increased ICP.

The nurse suspects that a 36-year-old patient recovering from a hypophysectomy (removal of the pituitary gland) has developed diabetes insipidus (DI). What sign or symptom is most indicative of diabetes insipidus? A. Hyperkalemia. B. Hypertension. C. Polyphagia. D. Polyuria.

D. Correct Polyuria. DI results from lack of antidiuretic hormone (ADH), which is to be expected in this situation. The combination of polyuria and polyphagia could indicate onset of diabetes mellitus under other circumstances, however.

A client with a confirmed acute ischemic stroke is admitted to the medical unit after evaluation in the ED. What is the nurse's priority action on admission? A. Ask the nursing technician to weigh the client and record it. B. Consult with the physical therapist about the client's rehab care. C. Keep client NPO until the swallowing assessment is complete. D. Give warfarin and check activated thromboplastin levels.

c

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon eyes and Battle sign. A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.