Module 10 & 11 ICP/Altered Cerebral Function/Traumatic Brain Injury/Brain Tumors

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 Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

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 An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy 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.

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 Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed But are not indications of post concussion syndrome

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 Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.

What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically used in the treatment of ICP.

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 Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

The patient's MRI showed the presence of a brain tumor. The nurse anticipates which treatment modality? A. Surgery B. Chemotherapy C. Radiation therapy D. Biologic drug therapy

A Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

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 Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushings triad. These findings indicate that the intracranial pressure (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.

Which 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 A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not usually indicated in a patient with a concussion.

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 patients 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 Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.

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 Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) A. Judgment B. Eye opening C. Abstract reasoning D. Best motor response E. Best verbal response F. Cranial nerve function

BDE The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS

A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse give first? A. Codeine B. Phenytoin C. Ceftriaxone D. Acetaminophen

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

A nurse is caring for a client who has a benign brain tumor. The client asked the nurse if this is same type of tumor can occur in other areas of the body. Which of the following responses to the nurse make? a. it can spread to breasts and kidneys b. it can develop in your gastrointestinal tract c. it is limited to brain tissue d. it probably started in another area of your body and spread to your brain

C Benign brain tumors develop from the meninges or cranial nerves and do not metastasize.

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 Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN)level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A. Seizures will develop within weeks or months. B. The family will be unable to cope with role reversals. C. There are often residual changes in personality and cognition. D. Referrals will be made to eliminate residual deficits from the damage.

C In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

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 The patients low sodium indicates that hyponatremia may be causing the cerebral edema. The nurses 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 intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

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 patients 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 The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

Which conditions predispose the patient to the development of a brain abscess? (Select all that apply.) A. Endocarditis B. Ear infection C. Tooth abscess D. Skull fracture E. Sinus infection F. Scalp laceration

ABCDE Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for? (Select all that apply.) A. Seizures B. Vision loss C. Cerebral edema D. Pituitary dysfunction E. Parathyroid dysfunction F. Focal neurologic deficitS

ABCDF Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? SATA a. disoriented to time and place b. restlessness and irritability c. unequal pupils d. ICP 15 mm Hg e. headache

ABCE Changes in LOC are an early indicator of increased ICP. Increased ICP can cause behavior changes, such as restlessness and irritability. Unequal pupils indicates pressure on the oculomotor nerve secondary to increased ICP. A headache is a manifestation of increased ice.

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statement by the nurse? SATA a. it is given to reduce swelling of the brain b. you will need to monitor for low blood sugar c. you might notice weight gain d. tumor growth will be delayed e. it can cause you to retain fluids

ACE Dexamethasone is a common steroid prescribed to reduce cerebral edema. weight gain is an adverse effect of dexamethasone. Fluid retention is an adverse effect of dexamethasone.

A nurse is caring for a client who is having surgery for the removal of encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? SATA a. increased intracranial pressure b. hemorrhagic shock c. hydrocephalus d. hypoglycemia e. seizures

ACE a client who has had a craniotomy should be monitored postoperatively for ICP and hydrocephalus. Seizures are a postoperative complication that should be monitored following a craniotomy.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

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 patients record b. Report the BP and ICP to the HCP c. Elevate the head of the patients bed to 60 degrees d. Continue to monitor the patients vital signs and ICP

B Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patients therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. Place packing in the patient's nares. B. Apply a loose gauze pad under the patient's nose. C. Place the patient in a modified Trendelenburg position. D. Ask the patient to gently blow the nose to clear the drainage.

B Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the provider immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and the patient should not sneeze or blow the nose

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 Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

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 Following a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache

After evacuation of an epidural hematoma, a patients 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/min b. Temperature 101.6 F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

B 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.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients 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 Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

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 Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members anxiety.

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 frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

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 The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patients spouse and teenage children stay at the patients 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 familys pastor or spiritual advisor to take them to the chapel while care is given.

B The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

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 patients Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

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 The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

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 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 nurse is caring for a client who has just undergone a craniotomy for a supertentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider? a. dexamethasone 30 mg IV bolus BID b. Morphine sulfate 2 mg IV blus PRN every 2 hr for pain c. Ondansentron 4 mg IV bolus PRN every 4-6 hr for nausea d. phenytoin 100 mg IV bolus TID

B idenyify that if a client following a craniotomy has a respiratory rate of 12, the provider should be notified prior to the administering morphine. Morphine is a narcotic analgesic, which can cause CNS depressant affect such as respiratory depression.

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 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 generalized, it does not indicate localization of pain or flexion withdrawal.

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.

A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. High blood flow to the brain B. Normal intracranial pressure C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow

C Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

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 Suctioning increases intracranial pressure, and should only be done when the patients respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

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 influenzae. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.

C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

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 The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2

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 The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (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 and a slightly irregular apical pulse are not unusual in a patient after a head injury.

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. Document the ICP reading in the chart. B. Determine if the patient has a headache. C. Assess the patient's level of consciousness. D. Position the patient with head elevated 60 degrees.

C The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

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 The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A. Administer IV mannitol as ordered. B. Ventilator use to hyperoxygenate the patient. C. Use strict aseptic technique with dressing changes. D. Be aware of changes in ICP related to cerebrospinal fluid leaks.

C The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.

D A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral nutrition. Excess intravenous fluid administration will also increase cerebral edema.

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 Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? A. Serum sodium of 120 mEq/L B. Urine specific gravity of 1.001 C. Fasting blood glucose of 80 mg/dL D. Serum osmolality of 290 mOsm/kg

D Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood glucose levels occur with diabetes

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 patients room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patients room without a mask.

D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck

D Nuchal rigidity is a manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation

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 Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

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 ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

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 Kernigs sign. c. The patients temperature is 101 F (38.3 C). d. The patients blood pressure is 88/42 mm Hg.

D Shock is a serious complication of meningitis, and the patients low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernigs sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

The nurse prepares to give temozolomide (Temodar) to a patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A. Serum potassium and serum sodium levels B. Urine osmolality and urine specific gravity C. Cerebrospinal fluid pressure and cell count D. Absolute neutrophil count and platelet count

D Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/µL and platelet count greater than 100,000/µL.

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 The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

The health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take test test for this finding? a. stroke the lateral aspect of the sole of the foot b. ask the client to blink both eyes c. observe for facial drooping d. have the client stand erect with eyes closed

D a positive Romberg sign is indicated when a client loses their balance while attempting to stand erect with their eyes closed.