ICP/TBI practice

Confidence: Nailed it Stats Issue with this question? 29.Which intervention would the nurse implement when a patient, admitted with head trauma, has 300 mL/hr of urine output for the each of the last four hours, dry skin, and dry mucous membranes? 1 Evaluate the urine's specific gravity. 2 Prepare the patient for acute hemodialysis. 3 Continue to monitor urine output over the next hour. 4 Slow the IV rate and notify the health care provider.

1

For the patient with a brain tumor, for which diagnostic test would the nurse prepare the patient when needing to localize and detect tumor blood flow? 1 Angiography 2 Lumbar puncture 3 Endocrine studies 4 Electroencephalogram (EEG)

1

For the intubated and mechanically ventilated patient, the development of which potential side effect of dexmedetomidine (Precedex) would the nurse anticipate monitoring? 1 Insomnia 2 BP changes 3 Hyperanxiety 4 Sedative effect

2

When preparing to administer a hypertonic saline infusion to a patient with an increased intracranial pressure (ICP), which parameters would the nurse monitor frequently? Select all that apply. 1 Blood glucose 2 Serum sodium 3 BP 4 Level of sedation 5 Gastrointestinal disturbances

2, 3

Which Glasgow Coma Scale (GCS) score would the nurse anticipate for a patient with a moderate type of head injury? 1. 3 2. 5 3. 10 4. 14

3

Which Glasgow Coma Scale (GCS) score would the nurse assign an unconscious patient who opens the eyes in response to pain but who does not respond to any other stimulus, moans to any verbal communication, and demonstrates flexion withdrawal? 1. 4 2. 6 3. 8 4. 10

3

For the mechanically ventilated patient, which response would the nurse use when family members inquire as to the benefit of maintaining the propofol (Diprivan) drip? 1 Propofol facilitates efficient fluid replacement. 2 The treatment reduces the body's BP. 3 The drug maintains electrolyte balance effectively. 4 The medication has a short half-life and rapid onset of action.

4

When providing care for a patient who sustained a traumatic brain injury, which condition indicates the need to maintain closure of the patient's eyes as a nursing intervention? 1 Diplopia 2 Otorrhea 3 Periorbital ecchymosis 4 Loss of the corneal reflex

4

For the patient with a basilar skull fracture, for which intervention prescribed by the health care provider would the nurse contact the prescriber for clarification? 1 Apply soft cervical collar. 2 Avoid flexion of hip joints. 3 Maintain elevation of the head of bed at 30 degrees. 4 Insert nasogastric (NG) tube and connect to low, intermittent suction.

4

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient? 1 20 mm Hg 2 40 mm Hg 3 60 mm Hg 4 80 mm Hg

4

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data? 1 5 to 15 mm Hg 2 25 to 35 mm Hg 3 45 to 60 mm Hg 4 80 to 120 mm Hg

1

Which intervention would the nurse implement when a patient has cerebrospinal fluid (CSF) rhinorrhea? 1 Elevate the head of the patient's bed to 30 degrees. 2 Have the patient blow the nose on a sterile 4x4 gauze. 3 Pack the nasal cavity with 4x4 gauze to stop the flow of CSF. 4 Insert a nasogastric tube with low, intermittent wall suction.

1

Which intervention would the nurse implement when providing care for a patient experiencing an increased intracranial pressure (ICP)? 1 Monitor fluid and electrolyte disturbances carefully. 2 Position the patient in a high Fowler's position. 3 Administer vasoconstrictors to maintain cerebral perfusion. 4 Maintain physical restraints to prevent episodes of agitation.

1

When developing the plan of care for a patient with an elevated intracranial pressure (ICP), which factors guide the nursing interventions? Select all that apply. 1 Pain and agitation may elevate the patient's ICPs. 2 Elevating the head of the patient's bed increases ICPs. 3 Extreme hip flexion increases intraabdominal pressures. 4 Increased intrathoracic pressures impede venous return. 5 Slow and gentle movements exhausts the patient's energy reserve.

1, 3, 4

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? Select all that apply. 1 Keep suction equipment readily available at the patient's bedside. 2 Provide sufficient stimulation of the patient to avoid comatose behaviors. 3 Implement seizure treatment only after confirming the seizure diagnosis. 4 Pad side rails and maintain an airway at the bedside per facility protocol. 5 Use prophylactic antiseizure therapy during first seven days after injury.

1, 4, 5

For the patient admitted with a subdural hematoma following a motor vehicle accident, which vital sign change would the nurse interpret as a clinical manifestation of an increasing intracranial pressure (ICP)? 1 Tachypnea 2 Bradycardia 3 Hypotension 4 Narrowing pulse pressure

2

Which clinical manifestation would the nurse report immediately to the health care provider when providing care for a patient with a traumatic brain injury and an increased intracranial pressure (ICP)? 1 ICP of 20 mm Hg 2 Urine output of 1000 mL in one hour 3 Respiratory rate of 24 breaths/minute 4 Pulse of 100 beats/minute

2

Which intervention would the nurse implement when a patient, receiving treatment for viral meningitis since last week, arrives at the hospital reporting a persistent severe headache? 1 Instruct the patient to use analgesics for the headache. 2 Inform the patient that headaches can occur after recovery. 3 Teach the patient that a headache is not a major complication. 4 Notify the patient that a full recovery from viral meningitis is not possible.

2

Which factors would the nurse associate with the use of hypertonic saline as a treatment for the patient with an increased intracranial pressure (ICP)? Select all that apply. 1 The nurse would closely monitor the patient's blood sugar levels. 2 The nurse would frequently monitor the BP and sodium levels. 3 Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. 4 Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. 5 The nurse should ensure administration of an antacid prior to administration to prevent gastrointestinal complications.

2, 3, 4

Which factors would the nurse consider when preparing to administer the pharmacologic therapy for a patient with an increased intracranial pressure (ICP)? Select all that apply. 1 Use benzodiazepines as a standalone treatment for sedation. 2 Monitor for hypotension when using opioids to manage anxiety. 3 Monitor for hypotension when using continuous IV sedatives. 4 Use nondepolarizing neuromuscular blocking agents alone for better outcomes. 5 Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

2, 3, 5

Which interventions would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply. 1 Keep the patient in a hypovolemic fluid state. 2 Begin parenteral nutrition if oral intake is not adequate. 3 Initiate nutritional replacement within three days after injury. 4 If comatose, wait at least seven days to begin nutritional replacement. 5 Evaluate the patient's urine output, fluid loss, and electrolyte balance.

2, 3, 5

A patient's systemic BP is 120/60 mm Hg and the intracranial pressure (ICP) is 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? 1 High blood flow to the brain 2 Normal ICP 3 Impaired blood flow to the brain 4 Adequate autoregulation of blood flow

3

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include? 1 BP, brain tissue, body mass index 2 Glucose level, BP, and brain tissue 3 BP, brain tissue, and cerebrospinal fluid 4 BP, brain tissue, and ventricles of the brain

3

Which outcome would the nurse expect after administration of IV mannitol (Osmitrol) prescribed for a patient experiencing an increased intracranial pressure (ICP)? 1 Increased urine output 2 Decreased BP 3 Reduced ICP 4 Increased intracranial perfusion

3

For the patient with an increased intracranial pressure, who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcomes indicate an effective intervention? 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.

3, 4

Which common causes would the nurse consider when assessing the patient reporting a headache that is worse in the morning and aggravated with movement, results in vomiting without preceding nausea, and is suspected of having an increased intracranial pressure? Select all that apply. 1 Sinusitis 2 Glaucoma 3 Hematoma 4 Head injury 5 Brain tumor

3, 4, 5

After 72 hours of intravenous (IV) fluid therapy for a patient who suffered a diffuse axonal traumatic brain injury (TBI), which rationale supports the nurse seeking an enteral feeding prescription? 1 Administration of free water is avoided in the setting of TBI. 2 Electrolytes and fluids can be managed more efficiently. 3 Enteral feedings assist with avoiding dehydration. 4 Malnutrition promotes continued cerebral edema.

4

After sustaining a head injury, for which clinical manifestation would the nurse monitor potential development in a patient scheduled for a lumbar puncture? 1 Cerebral edema 2 Myelosuppression 3 Total body collapse 4 Cerebral herniation

4