Neurologic Disorders and Therapeutic Management

A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? a. Usually arterial in nature b. Worse mortality rate than subdural hematomas c. Associated with a permanent loss of consciousness d. Signs and symptoms include bilateral pupil dilation

ANS: A Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two thirds of patients). A blow to the head that causes a linear skull fracture on the lateral surface of the head may tear the middle meningeal artery. \ As the artery bleeds, it pulls the dura away from the skull, creating a pouch that expands into the intracranial space. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 772 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

The extrusion of cerebral tissue through the cranium is what type of herniation? a. Transcalvarial b. Uncal c. Cingulate d. Transtentorial

ANS: A Transcalvarial herniation is the extrusion of cerebral tissue through the cranium. In the presence of severe cerebral edema, transcalvarial herniation occurs through an opening from a skull fracture or craniotomy site. These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 603 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.

ANS: A Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out. PTS: 1 DIF: Cognitive Level: Applying REF: p. 766 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)? a. Occurrence is greater in men than women younger than the age of 40 years old. b. Occurrence is greater in men than women older than the age of 40 years old. c. 90% of SAHs are caused by traumatic injury. d. Patients with SAHs have a better survival rate than patients with arteriovenous

ANS: A Among people younger than 40 years, more men than women are likely to have subarachnoid hemorrhages (SAHs); among those older than 40 years, more women have SAHs. Hemorrhage from arteriovenous malformation rupture has a better chance of survival and is associated with an overall mortality rate of 10% to 15%. Ninety percent of aneurysms are congenital, the cause of which is unknown. The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial vessel) or infectious material. PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 578-579 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm

ANS: A Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 787 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and symptoms might the patient exhibit? a. Right-sided hemiplegia and receptive aphasia b. Left-sided hemiplegia and tactile agnosia c. Decorticate posturing and unequal pupils d. Unilateral neglect and dressing apraxia

ANS: A Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 585-586 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient has had an ischemic stroke and now having difficulty with speech. The nurse knows the patient is experiencing what problem? a. Expressive aphasia b. Global aphasia c. Receptive aphasia d. Apraxia

ANS: A Expressive aphasia, also known as motor, Broca, or nonfluent aphasia, is primarily a deficit in language output or speech production. Global aphasia results when a massive lesion affects the motor and sensory speech areas. The patient cannot transform sounds into words and cannot comprehend spoken words. Receptive aphasia, also referred to as sensory, Wernicke, or fluent aphasia, occurs when the connection between the primary auditory cortex in the temporal lobe and the angular gyrus in the parietal lobe is destroyed. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 587 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next? a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intraabdominal pressure monitoring

ANS: A Hemodynamically unstable patients with a positive Focused Assessment with Sonography for Trauma (FAST) scan generally undergo emergency surgery to achieve homeostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. Computed tomography (CT) scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intraabdominal hypertension. PTS: 1 DIF: Cognitive Level: Applying REF: p. 790 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown? a. 2 hours b. 4 hours c. 8 hours d. 12 hours

ANS: A Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 591 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient with a Le Fort III facial fracture has been admitted to the critical care unit. Which statements is true regarding this type of facial fracture? a. It is frequently associated with cerebrospinal fluid leaks. b. It is not as severe as Le Forte I and II injuries. c. The patient's airway is not usually compromised. d. It is associated with a low risk for hemorrhagic shock.

ANS: A Le Fort III fractures are associated with craniofacial disruption. Cerebrospinal fluid frequently leaks with Le Fort II and III fractures because there is frequently communication between the cranial base and the cribriform plate. Patients are at risk of airway occlusion from the tongue, hemorrhage, broken teeth, emesis, or bone fragments. Significant blood loss can occur with these injuries because of the extensive soft tissue and vascular damage that results. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 784 OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiologic Integrity

Which medication is a fast-acting, short-duration agent used for breakthrough seizures? a. Lorazepam b. Phenytoin c. Phenobarbital d. Midazolam

ANS: A Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 601 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Which patient has the best prognosis based on the cause of coma? a. A 36-year-old man with closed head injury b. A 50-year-old woman with hepatic encephalopathy c. A 46-year-old woman with subarachnoid hemorrhage d. A 72-year-old man with hypertensive intracerebral hemorrhage

ANS: A Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma. PTS: 1 DIF: Cognitive Level: Applying REF: p. 590 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods? a. First 24 hours b. 4 to 12 days c. 3 to 4 weeks d. 3 to 6 months

ANS: A Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 582 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

During assessment of a new trauma patient, the nurse observes perianal ecchymosis. The nurse suspects the patient has what problem? a. Pelvic fracture b. Bladder trauma c. Rectal laceration d. Spleen laceration

ANS: A Signs of pelvic fracture include swelling, tenderness, and/or bruising to the pubis, iliac bones, hips, or sacrum. Perianal ecchymosis (scrotum or vulva), indicating extravasation of urine or blood, may be present. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 793 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before landing on the ground. The patient has an open pelvic fracture. What characteristics of this injury are important for the nurse to understand? a. Aggressive fluid and blood replacement will probably be needed. b. The patient will probably be able to walk as soon as the patient is stable. c. The patient will probably not need surgery to stabilize her fracture. d. There is little likelihood of damage to the genitourinary or gastrointestinal tracts.

ANS: A The mortality rate for these injuries is high because, unlike closed pelvic fractures that bleed into the peritoneum, open pelvic fractures result in external exsanguinations. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 794 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)? a. Mannitol b. Furosemide c. Urea d. Glycerol

ANS: A The most widely used diuretic is mannitol, a large-molecule agent that is retained almost entirely in the extracellular compartment and has little of the rebound effect observed with other osmotic diuretics. Administration of mannitol increases cerebral blood flow and thus induces cerebral vasoconstriction as part of the brain's autoregulatory response to keep blood flow constant. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 602 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient with multi-system trauma has been in the intensive care unit (ICU) for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7° C; and central venous pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock

ANS: A The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 796 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

Downward displacement of the hemispheres, basal ganglia, and diencephalon through the tentorial notch is indicative of what type of herniation? a. Central b. Uncal c. Cingulate d. Infratentorial

ANS: A These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri. The two infratentorial herniation syndromes are upward transtentorial herniation and downward cerebellar herniation. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 603 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side, and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy

ANS: A Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/h for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures. PTS: 1 DIF: Cognitive Level: Applying REF: p. 788 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient with multi-system trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a. Pneumonia b. Infection c. Venous thromboembolism d. Fat embolism syndrome

ANS: B Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 794 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)? a. Decreasing the ventilator rate b. Decreasing noxious stimuli c. Frequent orientation checks d. Administration of loop diuretics

ANS: B A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increased intracranial pressure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 602 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A male patient post right-sided stroke is experiencing hemiagnosia. This is evidenced by which finding? a. The patient only reads the right side of the newspaper. b. The patient refuses to acknowledge the left side of his body. c. The patient is hyperresponsive when approached on the right side. d. The patient attempts to comb his hair with a toothbrush

ANS: B Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. This denial may range from inattention to refusing to acknowledge a paralysis by neglecting the involved side of the body or by denying ownership of the side, attributing the paralyzed arm or leg to someone else. The neglect also may extend to extrapersonal space. This defect most often results from right hemispheric brain damage that causes left hemiplegia. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 586-587 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A trauma patient's condition has deteriorated. The nurse notes changes in patient's condition, including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication? a. Cardiac tamponade b. Hemothorax c. Open pneumothorax d. Ruptured diaphragm

ANS: B Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 787 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient was admitted after a motor vehicle crash (MVC). The nurse knows that this type of injury is the greatest cause of what type of trauma? a. Spinal shock b. Blunt thoracic trauma c. Maxillofacial injuries d. Penetrating thoracic injuries

ANS: B Blunt trauma to the chest most often is caused by motor vehicle crashes (MVCs) or falls. Spinal shock is a condition that can occur shortly after traumatic injury to the spinal cord. Maxillofacial injury results from blunt or penetrating trauma. Blunt trauma may occur from motor vehicle, industrial, or athletic injuries; violent blows to the head; or falls. The penetrating object involved determines the damage sustained from penetrating thoracic trauma. Low-velocity weapons (eg, 22-caliber gun, knife) usually damage only what is in the weapon's direct path. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 785 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient becomes flaccid with fixed and dilated pupils. The patient's intracranial pressure (ICP) falls from 65 to 12 mm Hg. What should the nurse suspect is happening? a. The patient is having a seizure. b. The patient's brain has herniated. c. The patient's cerebral edema is resolving. d. The patient is excessively dehydrated from the mannitol

ANS: B Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs and symptoms of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward. PTS: 1 DIF: Cognitive Level: Applying REF: p. 602 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

The patient has uncontrolled intracranial pressure and now is receiving high-dose barbiturate therapy. The nursing management plan for this patient should include monitoring the patient for what complication? a. Hypothermia b. Hypotension c. Myocardial depression d. Dehydration

ANS: B Hypotension, the most common complication in barbiturate therapy, results from peripheral vasodilation and can be compounded in an already dehydrated patient who has received large doses of an osmotic diuretic in an attempt to control intracranial pressure. Myocardial depression results from cardiac muscle suppression and can be avoided by frequent monitoring of fluid status, cardiac output, and serum drug levels. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 602 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract computed tomography (CT) findings are negative. The patient is being prepared for a lumbar puncture. What appearance does the nurse anticipate that the cerebrospinal fluid (CSF) would look? a. Cloudy b. Bloody c. Xanthochromic d. Clear

ANS: B If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH. PTS: 1 DIF: Cognitive Level: Applying REF: p. 581|Box 23-7 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A female right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. While assisting with personal care, the nurse notes that the patient is unable to comb her hair with her left hand. The nurse suspects the patient may be experiencing which complication? a. Agnosia b. Apraxia c. Broca aphasia d. Wernicke aphasia

ANS: B Lesions in the parietal lobe, as well as in other cortical structures, can result in apraxia, an inability to perform a learned movement voluntarily. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 587 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient's ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Given that the practitioner has left appropriate orders, which action should the nurse take next? a. No action is required. b. Administer mannitol 1 to 2 g/kg IV. c. Place the patient supine and flat in bed. d. Suction the patient.

ANS: B Mannitol is an osmotic diuretic and will pull swelling out of edematous brain tissue, thereby decreasing intracranial pressure (ICP). Having the patient lie flat in bed will impair venous drainage from the head and worsen ICP. Suctioning will cause increased intrathoracic pressure, which will also worsen the already elevated ICP. PTS: 1 DIF: Cognitive Level: Applying REF: p. 602|p. 604|Table 23-5 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival? a. Decorticate posturing b. Absent pupillary light reflexes c. Decerebrate posturing d. Central hyperventilation

ANS: B Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy. PTS: 1 DIF: Cognitive Level: Applying REF: p. 590 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms? a. 1 b. 3 c. 6 d. 10

ANS: B National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and Stroke rtPA Stroke Study. This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours of onset of the stroke was an effective and safe therapy for ischemic stroke. This time frame has now been expanded from 3 to 4.5 hours with additional excursion criteria. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 577 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Which nursing intervention will help prevent spikes in intracranial pressure in the post-neurosurgical patient? a. Keep the head of the bed elevated 45 to 90 degrees. b. Administer an antiemetic to prevent vomiting. c. Provide fluid restriction. d. Help with turn, cough, and deep breathe exercises

ANS: B Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP) in the postoperative neurosurgical patient. Antiemetics are administered as soon as nausea is apparent. Fluid restriction may be ordered as a routine measure to lessen the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of inappropriate antidiuretic hormone secretion. Most craniotomy patients can be turned from side to side within these restrictions, using pillows for support, except in some cases of extensive tumor removal, cranioplasty, and when the bone flap is not replaced. Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications. To prevent dangerous elevations in ICP, this care measure must be performed using proper technique and at time intervals that are adequately spaced from other patient care activities. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 597 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient is admitted to the intensive care unit (ICU) for observation of his grade II splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. Blood pressure (BP), 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/h; skin that is pink, warm, and dry, with a capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/h; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/h; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/h; flushed, warm, diaphoretic skin; agitated and confused

ANS: B The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse pressure and oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused. Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs. Progressive deterioration may indicate the need for operative management. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 768 OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new-onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications, as they are ineffective

ANS: B The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. The use of biomarkers, such as troponin, offers very little diagnostic help for blunt cardiac injury (BCI). Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 789 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

After neurosurgery, the patient is at risk of developing what problem? a. Aspiration b. Diabetes mellitus c. Seizures d. Corneal abrasions

ANS: C After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery, patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 597 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

When an object is placed in the hand of a patient with neurologic impairment during assessment, the patient is unable to recognize the placement. What is this complication called? a. Homonymous hemianopsia b. Aphasia c. Agnosia d. Apraxia

ANS: C Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. Tactile agnosia is a perceptual disorder in which a patient is unable to recognize an object that has been placed in his or her hand by touch alone. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily. Optic radiations extend back to the occipital lobes. Visual defects restricted to a single field, right or left, are called homonymous hemianopsia. Aphasia is a loss of language abilities caused by brain injury, usually to the dominant hemisphere. PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 586-587 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Which intervention should be considered LAST in treating uncontrolled intracranial hypertension? a. Sedatives b. Analgesics c. Barbiturates d. Hyperventilation

ANS: C Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not responded to the conventional treatments previously described. The two most commonly used drugs in high-dose barbiturate therapy are pentobarbital and thiopental. The goal with either of these drugs is a reduction of intracranial the pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 602 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

What is one cause of metabolic coma? a. Trauma b. Ischemic stroke c. Drug overdose d. Intracerebral hemorrhage

ANS: C Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 589|Box 23-9 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

The nurse understands that certain trauma patients are at risk of developing fat embolism syndrome. Which group of patients is a high risk for this complication? a. Patients with liver trauma b. Patients with burns c. Patients with orthopedic trauma d. Patients with spleen trauma

ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 795 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention? a. Administering osmotic diuretics and vasodilator agents b. Providing the patient with a quiet environment c. Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg d. Keeping the patient's central venous pressure at 5 to 8 mm Hg

ANS: C Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures. PTS: 1 DIF: Cognitive Level: Applying REF: p. 583 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Which medication is prescribed to decrease cerebral vasospasm? a. Phenytoin b. Phenobarbital c. Nimodipine d. Vecuronium

ANS: C Nimodipine is used to decrease cerebral vasospasm. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 604|Box 23-5 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

The nurse is working on an organization-wide falls prevention project. The nurse understands that the majority of falls accounting for traumatic injury occur in what population? a. Construction workers b. Adolescents c. Older adults d. Young adults

ANS: C Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (eg, syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall. PTS: 1 DIF: Cognitive Level: Applying REF: p. 796 OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiologic Integrity 18. A patient with multisystem trauma has been

What is one of the earliest signs of increased intracranial pressure (ICP)? a. Cushing triad b. Decerebrate posturing (abnormal extension) c. Change in level of consciousness d. Increase in pupillary size

ANS: C One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 577 OBJ: Nursing Process Step: Assessment TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5° C.

ANS: C Severe diffuse axonal injury (DAI) usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive sweating. Treatment of DAI includes support of vital functions. The outcome after severe DAI is poor because of the extensive dysfunction of cerebral pathways. Neurologic assessment is performed every hour. DAI may not be visible on computed tomography (CT) scan. Warming measures are generally not needed, but the cooling measures may be needed. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 774 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

Which patient position is optimal to prevent elevated intracranial (ICP) pressures? a. The head of the bed elevated 30 to 40 degrees b. Supine with the patient's neck in a neutral alignment c. Individualized head position to minimize ICP measurements d. The head of the bed elevated with flexion of the hips

ANS: C The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 596|Box 23-20 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient has been admitted with a flail chest. What findings would the nurse expect to note supporting this diagnosis? a. Tracheal deviation toward the unaffected side b. Jugular venous distention c. Paradoxical respiratory movement d. Respiratory alkalosis

ANS: C Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out. PTS: 1 DIF: Cognitive Level: Applying REF: p. 786 OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient has been admitted with a flail chest and pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing

ANS: D A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration. PTS: 1 DIF: Cognitive Level: Applying REF: p. 786 OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiologic Integrity

What is a pathologic consequence of an unruptured cerebral aneurysm? a. It shunts blood away from the surrounding tissues. b. It leaks blood into the subarachnoid space. c. It causes damage the middle layer of the arterial wall. d. It places pressure on the surrounding tissues.

ANS: D An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 579 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury? a. Posterior cord syndrome b. Brown-Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome

ANS: D Central cord syndrome is associated with cervical hyper-extension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 777-778 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient has been admitted post craniotomy for a brain tumor. The nursing management plan should include monitoring the patient for what complication? a. Diabetes mellitus b. Fluid retention c. Intracranial hypotension d. Surgical hemorrhage

ANS: D Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, and deep venous thrombosis. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 595 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? a. Check circulatory status. b. Check the electrolyte profile. c. Insert a urinary catheter. d. Obtain patient history.

ANS: D During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey. PTS: 1 DIF: Cognitive Level: Applying REF: p. 768 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient has been told he has a nonencapsulated tumor that has infiltrated the brain tissue. Why type of tumor does the nurse suspect the patient has? a. Angioma b. Pituitary adenoma c. Meningioma d. Glioma

ANS: D Gliomas are nonencapsulated; tend to infiltrate brain tissue; arise in any part of brain connective tissue; infiltrate primarily cerebral hemisphere tissue; are not well outlined, so they are difficult to excise completely; and grow rapidly. Angiomas arise from vascular structures and are usually difficult to resect. Pituitary adenomas arise from various tissues. Meningiomas arise from meningeal coverings of brain and are usually encapsulated. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 594|Table 23-3 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) of the patient's head reveals a large left parietal area bleed. Patient assessment includes temperature (T), 98.7° F; pulse (P), 98 beats/min and thread; respirations (R), 8 breaths/min; and blood pressure (BP), 168/100 mm Hg. Initial management of the patient includes which intervention? a. Placing the patient in the Trendelenburg position b. Administering an antihypertensive agent c. Initiating induced hypertensive therapy d. Intubating and ventilating the patient

ANS: D Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg. PTS: 1 DIF: Cognitive Level: Applying REF: p. 585 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a. Hemorrhagic stroke b. Intracerebral hemorrhages c. Subarachnoid hemorrhages d. Ischemic stroke

ANS: D Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages. PTS: 1 DIF: Cognitive Level: Applying REF: p. 575 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit? a. The demyelination process of the peripheral nerves is irreversible. b. The demyelination process is limited to the peripheral nervous system only. c. The paralysis associated with the syndrome occurs in a descending pattern. d. The most common cause of death is respiratory arrest.

ANS: D Most patients with Guillain-Barré syndrome (GBS) do not require admission to the critical care unit. However, the prototype of GBS, known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), involves a rapidly progressive, ascending peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure. Because of the need for ventilatory support, AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 591 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve

ANS: D Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 797|Box 31.14 OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiologic Integrity

A patient with a severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. c. Maintain the patient's body temperature more than 37.5° C. d. Administer fluids to keep the systolic blood pressure greater than 90 mm Hg.

ANS: D Secondary injury can be caused by ischemia, hypercapnia, hypotension, cerebral edema, sustained hypertension, calcium toxicity, or metabolic derangement. Hypoxia or hypotension, the best-known culprits for secondary injury, typically are the result of extra-cranial trauma. Extreme vasodilation of the cerebral vasculature occurs in an attempt to supply oxygen to the cerebral tissue. This increase in blood volume increases intracranial volume and raises intracranial pressure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 770 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? a. Used to assess respiratory status b. Used to assess circulatory status c. Used to assess pain status d. Used to assess level of consciousness

ANS: D The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: response to painful stimuli, and U: unresponsive. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 767 OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiologic Integrity 21. A patient was admitted after a motor vehicle c

What is the target range for PaCO2 in the patient with intracranial hypertension? a. 25 to 30 mm Hg b. 25 to 35 mm Hg c. 35 to 40 mm Hg d. 33 to 37 mm Hg

ANS: D The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 599 OBJ: Nursing Process Step: Evaluation TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents? a. Epinephrine, hydrocortisone, and Benadryl b. Dopamine, 10% dextrose in distilled water, and calcium chloride c. Mannitol, dexamethasone, and sodium bicarbonate d. Thiamine, glucose, and opioid antagonist

ANS: D The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known. PTS: 1 DIF: Cognitive Level: Applying REF: p. 590 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

What are the most common medications used in high-dose barbiturate therapy? a. Phenytoin and fosphenytoin b. Mannitol and nimodipine c. Lidocaine and phenobarbital d. Pentobarbital and thiopental

ANS: D The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained. Phenytoin and fosphenytoin are anticonvulsants. Mannitol is an osmotic diuretic, lidocaine is a local anesthetic, and nimodipine is a calcium channel blocker. PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 602-603|Table 23-5 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome? a. Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients or increased metabolic demand b. Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c. Risk for aspiration d. Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment

ANS: D The most common cause of death of patients with Guillain-Barré syndrome (GBS) is respiratory arrest; thus, the highest nursing priority for a patient with GBS is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 591-592|Box 23-12 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The provider requests the drainage be tested for the presence of glucose. Why did the physician order this test? a. To assess for an infection b. To check for a shift in osmolality c. To check for occult blood d. To assess for a cerebrospinal fluid leak

ANS: D To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater. PTS: 1 DIF: Cognitive Level: Applying REF: p. 596 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A ventriculoperitoneal shunt may be placed in a post-stroke patient to treat which complication? a. Hyponatremia b. Intracerebral hemorrhage c. Spontaneous intracerebral hemorrhage d. Hydrocephalus

ANS: D Treatment for hydrocephalus consists of placing a drain to remove cerebrospinal fluid. This can be accomplished temporarily by inserting a ventriculostomy or permanently by placing a ventriculoperitoneal shunt. Treatment for hyponatremia is sodium replenishment with isotonic fluids. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 584 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing care for the patient includes which intervention? a. Keep the room cool, dark, and quiet. b. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg. c. Elevate the head of the bed 45 degrees. d. Resuscitate low blood pressure by only using intravenous fluid.

B Management of acute cervical spinal cord injury (SCI) involves close hemodynamic monitoring. Current guidelines for the management of acute cervical SCI cite that hypotension (systolic blood pressure less than 90 mm Hg) should be avoided or corrected as soon as possible after acute SCI. It is also considered an option to maintain the mean arterial pressure (MAP) at 85 to 90 mm Hg for the first 5 to 7 days after acute SCI to improve spinal cord perfusion. The room should be kept warm to avoid hypothermia. Elevating the head of the bed will often cause hypotension and is contraindicated until additional spinal cord injuries have been ruled out. Because of the profound vasodilation found with neurogenic shock, patients should be resuscitated with both intravenous fluids and vasopressors to restore intravascular volume as well as vascular tone. PTS: 1 DIF: Cognitive Level: Applying REF: p. 782 OBJ: Nursing Process Step: Intervention TOP: Trauma MSC: NCLEX: Physiologic Integrity

Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study? a. Magnetic resonance imaging b. Noncontrast computed tomography c. Contrast computed tomography d. Lumbar puncture

Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. In addition to excluding intracranial hemorrhage, CT can assist in identifying early neurologic complications and the cause of the insult. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 577 OBJ: Nursing Process Step: Diagnosis TOP: Neurologic MSC: NCLEX: Physiologic Integrity

A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy? a. Instillation of mannitol b. Drainage of subdural hematoma c. Brain tissue sampling d. Cerebrospinal fluid drainage

a. Instillation of mannitol b. Drainage of subdural hematoma c. Brain tissue sampling d. Cerebrospinal fluid drainage ANS: D Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 596 OBJ: Nursing Process Step: Intervention TOP: Neurologic MSC: NCLEX: Physiologic Integrity