2022 CCRN Review: Musculoskeletal/Neurological/ Psychosocial (14%) Review Date: 8/23

You are caring for a 63-year-old patient with a left-side intracerebral hemorrhage. The next day, his level of conciousness deteriorates secondary to intracranial hypertension, which requires endotracheal intubation and mechanical ventilation. You initiate a mannitol infusion and notice a 2-cm area of blanched skin and edema that is cool to the touch at the IV site. Nursing interventions for this patient include all the following EXCEPT: A. Apply a warm pack to the site B. Aspirating the residual medication from the IV with a 3-cc syringe C. Elevate the extremity to prevent edema D. Remove the IV catheter with minimal pressure applied for hemostasis

A) A warm pack should not be used for vesicant extravasation. A cold pack will provide a stimulus for vasoconstriction and extravasated drug reabsorption. Cold application is recommended for use with hyperosmolar fluids, such as mannitol. Cold packs should be applied for 15 to 20 minutes every 4 hours for 24 to 48 hours after the extravasation.

During the neurologic assessment of a patient who was the driver involved in a head-on collision, the critical care nurse finds no evidence of motor function or ability to sense pain or temperature lower than the nipple line. These neurologic findings suggest that this patient will require nursing management for A. Anterior cord syndrome B. Central cord syndrome C. Brown-Sequard Syndrome D. Posterior cord syndrome

A) Anterior cord syndrome Anterior cord syndrome is commonly caused by flexion injuries as seen in head-on collision or by acute herniation of an intervertebral disk. It is associated with injury to the anterior gray horn (motor) cells, the spinothalamic tracts (pain), the anterior spinothalamic tract (light touch), and the corticospinal tracts (temperature). This type of injury results in a loss of motor function and the ability to sense pain and temperature with intact position sense and sensation to pressure and vibration lower than the level of the injury. Central cord syndrome produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Brown-Sequard syndrome presents as loss of voluntary motor movement on the same side as the injury with loss of pain, temperature, and sensation on the opposite side. Posterior cord syndrome results in loss of position sense, pressure, and vibration lower than the level of injury with intact motor function and sensation of pain and temperature.

Your patient is in the ICU for treatment of a ruptured cerebral aneurysm. He was stable yesterday but has progressed overnight to critical condition after developing hydrocephalus. The patient's wife is an obstetric nurse. She is tearful at the bedside and asks you to explain why her husband has developed hydrocephalus. Which of these explanations should be provided? A. Blood in the subarachnoid space blocks reabsorption of cerebrospinal fluid (CSF) in the arachnoid villi B. A thrombus may form and obstruct flow of CSF out of the ventricles C. Cerebral edema may lead to effect that blocks CSF flow D. Vasospasm may limit the flow of CSF

A) Blood in the subarachnoid space blocks reabsorption of cerebrospinal fluid (CSF) in the arachnoid villi After surviving aneurysmal SAH, patients are primarily at risk for developing any or all these three problems: 1) rebleed of the aneurysm if unsecured 2) hydrocephalus because of problems with reabsorption of CSF 3) vasospasm -- blood in the subarachnoid space can block reabsorption of CSF by the arachnoid villi. This is a type of communicating hydrocephalus.

What would be the physiologic benefit of optimal patient positioning post frontal craniotomy? A. Maximizes jugular venous outflow B. Decreases CPP C. Facilitates the flow of CSF D. Immobilizes the surgical site

A) Maximizes jugular venous outflow. Postoperative care basics are universal and include optimizing airway, breathing, circulation, pain management, wound care, and intake and output. In a neurosurgical patient, these universals also need to incorporate monitoring and optimizing cerebral perfusion and blood flow. Brain, blood, and CSF are the contents of the cranium. If blood flow- either arterial inflow or venous outflow- is altered, cerebral perfusion may be compromised. If jugular venous outflow is obstructed, cerebral blood volume increases. That volume directly corresponds to pressure, particularly because the cranium is fixed in size and cannot accommodate varying volumes or pressures. Not only would this affect intracranial pressure, but it may also influence postoperative bleeding. The usual goal CPP in monitored patients with intracranial processes is 60 to 70 mm Hg.

A patient in the ICU has been admitted for seizures. The patient is accompanied by his friend who reports that the patient ran out of medication "a while ago" and has not refilled it. The friend does not know the patient's medications, but he reports that he knows the patient has a history of epilepsy and "faint- ing spells" from a low heart rate. The patient is stable now and responded well to IV ben- zodiazepines in the emergency room. His current vital signs are: temperature 37.1°C: HR 58 beats/min; RR 16 breaths/min; blood pressure 110/62 mm Hg. The patient begins to seize after arrival to the ICU. Which of these medications would be contraindicated to treat this patient's seizure? A. Phenytoin (Dilantin) B. Lorazepam (Ativan) C. Valproic acid (Depakote) D. Levetiracetam (Keppra)

A) Phenytoin (Dilantin) (A) Phenytoin can cause bradycardia, heart block, and hypotension. The patient has a history of "fainting spells" and the etiology of the "spells" from a low heart rate is unknown. The "spells" could be secondary to a hypotensive process or Stokes-Adams syndrome (a periodic fainting spell in which there is a periodic onset and offset of blockage of heart due to disorder of heart rhythm that may last for seconds, hours, days, or even weeks before the conduction returns) In addition, the patient already demonstrates asymptomatic bradycardia. Lorazepam, midazolam, and diazepam would be first-line choices followed by valproic acid or levetiracetam if the patient fails to respond to benzodiazepines.

A patient in the ICU is admitted for acute hemorrhagic stroke. He presents with dizziness, vertigo, ataxia, occipital headache, nystagmus, and dysarthria. The critical care nurse anticipates the stroke is located in which cortical structure? A. Cerebellum B. Pons C. Thalamus D. Putamen

A. Cerebellum The symptoms are indicative of hemorrhage in the cerebellum. Hemorrhagic pontine stroke is distinguished by contralateral hemiparesis and with more extensive hemorrhage, quadriparesis and "locked-in" syndrome, impaired lateral eye movement, poorly reactive pupils, and abnormal respiratory patterns. Thalamus hemorrhage causes contralateral hemiparesis and sensory loss equal in the face, arm, and leg or hemisensory loss alone. Hemorrhagic damage to the putamen causes contralateral hemiparesis, sensory loss, and dysarthria.

When caring for a patient with a traumatic brain injury, what intervention should you include to prevent an increase in ICP? A. Keep the patient's head in a neutral midline position B. Keep the head of bed flat at all times C. Keep the patient slightly hyperthermic D. Keep PaCO, between 20 and 30 mm Hg

A. Keep the patient's head in a neutral midline position. A neutral midline position promotes venous drainage thereby preventing or decreasing the ICP.

118. The nurse has expressed concern to the provider that a patient on hospital day two admitted for a left-sided intra- ventricular hemorrhage is experiencing an extension of the initial hemorrhage. Which of the following assessment findings would support this suspicion? A. Left pupil greater than right and non-reactive with noted right upper extremity extensor posturing B. Left hand grasp weakness with numbness and tingling C. Right pupil greater than left and non-reactive with noted left upper extremity extensor posturing D. 8/10 headache pain unrelieved by Tylenol

A. Left pupil greater than right and non-reactive with noted right upper extremity extensor posturing.

A patient admitted to the ICU is suspected to have an ischemic stroke. A CT scan has ruled out intracranial hemorrhage. Which of these assessment findings would alert the nurse to a contraindication for rt-PA? A. NIH stroke scale score of 1 B. History of seizure disorder C. A mild traumatic brain injury from a motor vehicle collision 6 months ago D. INR greater than 1.3

A. NIH stroke scale score of 1

When administering Mannitol to a patient with increased intracranial pressure, which of the following labs should be closely monitored? A. Potassium, sodium and serum osmolality B. Sodium, magnesium and urea nitrogen C. Lactate, hemoglobin and creatinine D. Phosphate, sodium and hemoglobin

A. Potassium, sodium and serum osmolality. Mannitol is an osmotic diuretic that is used to pull water from cells in the brain to reduce cerebral edema and decrease intracranial pressure.

A patient with a diagnosis of hypertensive crisis is admitted to the ICU. He is confused and mildly agitated. When prioritizing care, the critical care nurse's first concern is to prevent which of these complications? A. Stroke B. End-organ failure C.Seizures D. Left ventricular hypertrophy

A. Stroke Prevention of stroke is the primary concern when a patient presents with hypertensive crisis with hypertensive encephalopathy. Neurologic symptoms are frequent and of poor prognosis. Prevention centers on rapid lowering of systolic blood pressure (25% over 8 hours).

Following left heart cardiac catheterization, which of the following complications would the nurse be vigilant for? A. Stroke B. Pulmonary embolus C. Flushing and nausea D. Bradycardia and vagal responses

A. stroke Stroke may occur during left heart catheterization as emboli are released from the left heart and travel to the aorta and cerebral arteries. Catheterization of the right heart releases thrombi to the pulmonary artery, causing pulmonary embolus. Right heart catheterization may irritate vagus nerve endings in the SA or AV node, causing vagal stimulation that results in bradycardia or hypotension.

A patient is admitted to the ICU after rupture of a cerebral aneurysm with a subarachnoid hemorrhage (SAH). The critical care nurse knows that the most common site of aneurysm rupture is the -- A. Middle cerebral artery B. Anterior communicating artery C.Posterior communicating artery D. Anterior cerebral artery

B) Anterior communicating artery Aneurysms located at the anterior communicating artery are the most common site of aneurysmal SAH. It is located near the optic nerve. Aneurysm in this area can produce visual symptoms such as visual dimness, l unilateral visual field defect, or unilateral visual loss.

An 80-year-old cachectic woman was found on the floor at home by her family. She has a past medical history of hypertension and atrial fibrillation, and she takes daily warfarin. She presents to the emergency room with left-sided paralysis and decreased level of consciousness. Her INR level is 6.7. and a head CT scan reveals a 2.5 x 2 cm deep, right hemispheric hemorrhage. Which of the following would be the most appropriate course of action? A. Urgent preparation for neurosurgery to evacuate the clot B.Aggressive correction of coagulopathy with vitamin K, fresh-frozen plasma, and recombinant factor VIla C. Urgent brain MRI to rule out other potential etiologies for these findings D. Immediate infusion of EACA (Epsilon- aminocaproic acid) to correct coagulopathy.

B) B.Aggressive correction of coagulopathy with vitamin K, fresh-frozen plasma, and recombinant factor VIla Risk factors for intracerebral hemorrhage (CH) include low weight (lower than 70 kg), hypertension, advanced age (older than 70 years), and thrombolytic therapy. Coagulopathies must be reversed as soon as possible. Warfarin should be reversed with vitamin K (three 10 mg IV doses) and fresh-frozen plasma to normalize prothrombin time. Factor IX concentrate can be used along with vitamin K. IV bolus dosing of recombinant factor Vlla can be administered within the first 3 to 4 hours after symptom onset or in patients at risk of additional bleeding, such as those with warfarin-related coagulopathies. It may limit hematoma enlargement and reduce morbidity and mortality after ICH. Surgery for evacuation of a large deep hemispheric clot has been found ineffectiove in reducing mortality or disability. CT scan is appropriate for diagnostic evaluation in this case. MRI may be considered in cases in which the clot morphology, location, or presentation is inconsistent with typical ICH. However, this patient does not present with any atypical findings. Epsilon-aminocaproic acid (EACA) (Option D) is indicated in patients who recently received a thrombolytic and are deteriorating. EACA can enhance hemostasis when fibrinolysis contributes to bleeding, but it can also cause excessive thrombosis and is generally not indicated in this scenario.

A patient has survived a severe traumatic brain injury with a basilar skull fracture but has now developed an elevated temperature. Although the nurse's plan for managing fever in this patient population will be multifactorial, the most important aspect will center on identifying: A. Deep vein thrombosis, a frequently neglected complication of immobility B. Meningitis, a potential complication of basilar skull fractures C. Hypothalamic dysfunction, or "storming" a potentially lethal febrile syndrome after head trauma D. Foreign bodies still embedded in the skull base, a common source of infection

B) Meningitis is a potential complication of basilar skull fracture, and an elevated temperature is a key examination finding. Deep vein thrombosis may present with an elevated white count and/or elevated temperature. Screening would include venous duplex of the extremities. Hypothalamic dysfunction or "storming" characteristically presents with hypertension, tachycardia, and fever.

A patient with medically refractory seizures is admitted to the unit. He has just arrived postoperatively after resection of a seizure focus. Which of these orders are inappropriate for this patient? A. Neurologic examination hourly B. Lorazepam 1 mg IV prn for seizures lasting longer than 10 minutes C. Phenobarbital 10 to 20 mg/kg IV for refractory seizures D. Postoperative brain MRI upon admission

B) Seizures are defined as a discrete event characterized by an excessive and disorderly discharge of cerebral neurons with associated sensory, motor, and/or behavioral changes. Seizures warrant treatment when they last longer than 3 minutes to avoid the possibility of permanent neurologic injury. High dose phenobarbital may be given if seizures are refractory to other medications.

A patient admitted to the emergency room after a traumatic brain injury has been successfully resuscitated. Which of these studies would be most helpful at this point? A. Magnetic resonance imaging (MRI) of the brain B. CT scan of the head C. Lumbar puncture (LP) D. Cerebral angiography

B. Ct scan of the head --- best imaging study to view most intracranial processes, including trauma, intracerebral hemorrhage, and hydrocephalus. MRI is useful for evaluating tumors, spinal pathology, spinal cord injury, and other processes. It is most helpful for looking at tissue, structures, and perfusion.

Cerebral Perfusion Pressure (CPP) is calculated by assessing: A. Central venous pressure (CVP) & mean arterial pressure (MAP) B. Mean arterial pressure (MAP) & intracranial pressure (ICP) C. Intracranial pressure (ICP) & pulmonary artery occlusive pressure (PAOP) D. Central venous pressure (CVP) & intracranial pressure (ICP)

B. Mean arterial pressure (MAP) & intracranial pressure (ICP). The pressure available to perfuse brain tissue (CPP) equals the pressure coming into the brain (MAP) minus the pressure in the skull that the MAP must work against (ICP). CPP = MAP - ICP

A newly admitted patient with traumatic brain injury (TBI) is experiencing increased intracranial pressure (ICP). At this point in the patient's care, the nurse should maintain the patient's arterial PaCO2 at a level ---- A. Lower than 20 mm HgB. B. Between 25 and 30 mm Hg C. Between 30 and 35 mm Hg D. Higher than 40 mm Hg

C) Between 30 and 35 mm Hg Normal arterial PaCO, is 35 to 45 mmHg. Generally, hyperventilation is avoided in the early hours after head injury in order to prevent ischemia and worsening of related secondary injury. Chronic prophylactic hyperventilation therapy should be avoided during the first 5 days after severe TBI, particularly during the first 24 hours. Mild hyperventilation (arterial PaCO2 30-35 mm Hg) is considered for management of intracranial hypertension when measures such as osmotic therapy (mannitol), cerebrospinal fluid drainage (in patients with an external ventricular drain), sedation, and chemical paralysis are ineffective.

A patient with an elevated ICP is admitted to the ICU. The critical care nurse understands that ICP elevations cause displacement of brain structures. The patient has this herniation description: bilateral cerebral lesions that displace both hemispheres, the diencephalon, and the midbrain downward through the tentorial notch, which causes midbrain compression. Which herniation syndrome was described? A. Cingulate or subfalcine herniation B. Uncal or lateral transtentorial herniation C. Central transtentorial herniation D. Tonsillar herniation

C) Central transtentorial herniation Cingulate or subfalcine herniation is a unilateral cerebral lesion that shifts brain tissue laterally across the midline, which causes distortion of the cingulate gyrus under the falx cerebri. Uncal or lateral transtentorial herniation - the expanding lesion forces the uncus of the medial temporal lobe over the edge of the tentorium. Tonsillar herniation is described by posterior fossa contents particularly the cerebellar tonsils are displaced through the foramen magnum, which causes brainstem distortion.

A patient with supratentorial intracerebral hemorrhage is being transferred to the ICU from the emergency room. Which action would be most appropriate for this patient? A. Aggressive reduction of blood pressure B. STAT completion of cerebral angiography C. Correction of coagulopathy D. Surgical evacuation of the clot

C) Correction of coagulopathy The primary goals of emergency management of intracerebral hemorrhage (ICH) are to prevent subsequent damage from rebleeding, edema, or hypoxia and to identify the cause, site, and extent of the hemorrhage. If coagulopathies are present, these must be corrected in order to prevent further bleeding. Reduction of BP should be gradual and controlled because acute blood pressure normalization may reduce local cerebral perfusion pressure and cerebral blood flow to ischemic levels; in chronically hypertensive patients, it may shift the autoregulatory curve to higher pressures. Patients with a history of significant hypertension, the MAP should initially be maintained in the range of 120 mm Hg. In formerly non- hypertensive patients, lowering SBP to less than 160 mm Hg in the first hours after ICH may prevent additional bleeding. CT scan of the head is the primary imaging modalilty used for these patients.

After thoracic aortic repair, a motor vehicle crash victim is on continuous cardiac and hemodynamic pressure monitoring, as well as CSF pressure monitoring. Which of these interventions is contraindicated in the care of this patient? A. Administration of 200 mL/hr of normal saline B. Administration of nitroglycerine to maintain SBP less than 170 mm Hg C. Drainage of 100 ml CSF to maintain CSF pressure less than 10 mmHg D. Administration of fresh frozen plasma (FFP) and platelets at 75 ml/hr

C) Drainage of 100 ml CSF to maintain CSF pressure less than 10 mmHg Although it is common to maintain CSF pressure at 10 mm Hg after thoracic aortic aneurysm repair, there is only about 150 mL of CSF in the system at one time. If CSF is drained too rapidly or in too large a volume, the patient is at risk of subdural hemorrhage.

A postoperative patient has experienced nerve damage secondary to endotracheal intubation. In the cranial nervous system, which of the following nerves is most likely damaged? A. Abducens nerve B. Trochlear nerve C. Hypoglossal nerve D. Oculomotor nerve

C) Hypoglossal nerve Hypoglossal neurapraxia caused by damage to the hypoglossal nerve during intubation is a rare but serious finding. The hypoglossal nerve innervates the muscles of the tongue. This nerve is involved in controlling tongue movements required for speech and swallowing. The abducens nerve, trochlear nerve, and oculomotor nerves all have sensory or motor functions that involve the eyes.

An ICU patient has become confused and lethargic 5 days after aneurysmal subarachnoid hemorrhage and aneurysm coil embolization. Which of these approaches should the nurse anticipate discussing with the acute care nurse practitioner managing this patient's care? A. Discontinue nimodipine therapy B. Reduce the volume of IV fluids to prevent hyperemia and risk of rebleed C. Perform CT angiography to evaluate for evidence of vasospasm D. Prepare for lumbar puncture to evaluate for evidence of meningitis

C) Perform CT angiography to evaluate for evidence of vasospasm Cerebral arterial vasospasm is the most common cause of neurologic deterioration 4 to 7 days after SAH in both operated and nonoperated patients. It is diagnosed with either CT or traditional angiography as well as by clinical examination and transcranial Doppler ultrasonography. Nimodipine (calcium channel blocker) is the only medication shown to prevent vasospasm and improve patient outcome after aneurysmal SAH because of the vasodilator effect, BP should be carefully monitored. Triple-H therapy (hypertensive- hypervolemic-hemodilution[HHH]) increases cardiac output and BP with aggressive intravascular volume loading and vasopressor medications. Fluid load- ing usually leads to hemodilution. Vasoactive drugs are administered to increase BP if intravascular volume expansion alone is inadequate. Filling pressures (CVP or PCWP) are also monitored to guide volume dosing.

During an initial neurologic assessment, the nurse finds that the patient has a positive Brudzinski sign and a positive Kernig sign. Otherwise, the patient's examination is nonfocal. Because the lumbar puncture performed earlier showed high protein and low glucose in the CSF, the nurse's most appropriate action at this time is to --- A. Prepare for brain MRI to rule out mass lesion B. Arrange for initiation of plasmapheresis C. Prepare to administer intravenous anti- biotics D. Prepare the patient for a repeat LP to withdraw accumulating CSF

C) Prepare to administer intravenous anti- biotics The patient is exhibiting signs of meningitis, which include headache, chills, fever, nausea, vomiting, photophobia, back pain, and generalized seizures. Signs of mengeal irritation may include stiff neck (nuchal rigidity), Brudzinski sign (adduc- tion/flexion of legs as examiner flexes neck), and Kernig sign (after examiner adducts thigh against abdomen, exam- iner's attempts to extend the leg are met with resistance). Common CSF findings in meningitis include high protein, low glucose, and an elevated white blood cell count. Bacterial meningitis is most commonly caused by Staphylococcus and is most appropriately treated with antibiotics. Meningitis is diagnosed with lumbar puncture for CSF evaluation after head CT scan is obtained. MRI to rule out any intracranial pathology such as a mass lesion (e.g., brain tumor) is not indicated. Plasmapheresis is indicated for patients with Guillain- Barré syndrome when IV immune globulin (IVIG). is not used. It is generally used every other day for 10 to 15 days and works by removing detrimental immune factors. There is also meningeal irritation subarachnoid hemorrhage (SAH). LP is typically done only if SAH is suspected but head CT is negative. LP in SAH commonly includes elevated cell count (particularly RBCs) and xanthochromia but neither elevated protein nor low glucose.

A patient with suspected meningitis had a lumbar puncture performed 2 hours ago. The patient is complaining of a headache, and the nurse is concerned about a cerebrospinal fluid leak. The critical care nurse understands that the functions of cerebrospinal fluid are all of the following EXCEPT: A. Enables the diffusion of water-soluble metabolites B. Serves as a channel for neurochemical communication C. Provide ATP for impulse formation D. Provides cushioning from injury

C) Provide ATP for impulse formation Adenosine triphosphate (ATP) is a nucleoside triphosphate, a small molecule used in cells as a coenzyme. It is often referred to as the "molecular unit of currency of intracellular energy transfer. ATP transports chemical energy within cells for metabolism. Cerebrospinal fluid provides all the listed functions for the brain. In addition, it provides support and buoyancy for the brain, decreasing the weight on the skull; cerebrospinal fluid also compensates for increases in intracranial volume and pressure.

A patient is admitted for elective craniotomy and clipping of a posterior communicating artery aneurysm. On the initial ICU assessment, the nurse notes that the patient's Glasgow Coma Scale (GCS) score is 15 with no focal weakness. The patient has a large, nonreactive pupil as well as ptosis in the left eye. The nurse's best course of action at this point would be to: A. Call the neurosurgeon immediately because the aneurysm may have ruptured B. Prepare the patient for an anticipated STAT head CT scan to evaluate for expansion of the aneurysm C. Review the medical record to identify the patient's presenting symptoms and examination before admission D. Call anesthesia STAT for emergent intubation in response to the altered neuro assessment

C) Review the medical record to identify the patient's presenting symptoms and examination before admission. The patient may have initially presented with the large nonreactive pupil and ptosis. A little bit of detective work through review- ing the patient's medical record can help the nurse distinguish whether the examination findings are old or new.

A patient presents with flu-like symptoms, lymphadenopathy, a diffuse erythematous rash, and severe muscle weakness. The nurse admits the patient for close monitoring and further diagnostic workup to identify the cause of these findings. The patient suddenly loses consciousness followed by a brief period of muscle rigidity and then rhythmic muscle jerking. The best immediate course of action for the nurse is to: A. Obtain a serum laboratory specimen for STAT identification of a disease- specific antigen or antibody causing this syndrome B. Observe, record, and report all details of these clinical events to the physician as soon as these muscular movements have subsided C. Administer benzodiazepine per stand- ing order to stop the seizure activity D. Quickly apply soft restraints to prevent injury

C) The patient is exhibiting findings characteristic of arthropod-borne encephalitis. Prolonged seizure is life-threatening. If there is a standing order for a benzodiazepine, the nurse should be quick to provide treatment to stop the seizure activity. Padded side rails would be most appropriate (not soft restraints) CSF culture is important to identify the causative organism but the nurse and physician have to wait until seizure activity has stopped.

The critical care nurse is caring for a patient with a diagnosis of meningococcal meningitis. The nurse is diligently monitoring for the development of a serious complication of meningitis that can lead to sepsis and shock. Which of the following is a potential complications of meningitis that can lead to shock and increased mortality? A. Korsakoff Syndrome B. Brudzinski Sign C. Water-House Friderichsen Syndrome D. Brown-Sequard Syndrome

C) Water-House Friderichsen Syndrome Waterhouse-Frideichsen syndrome involves adrenal hemorrhage. It may be seen in fulminating meningococcal meningitis. It results in adrenal insufficiency, subsequent hypotension, respiratory distress, DIC, and circulatory collapse. Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B,). Korsakoff syndrome is most commonly caused by alcohol misuse, but certain other conditions also can cause the syndrome. Brudzinski sign is one of the physically demonstrable symptoms of meningitis. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed. Patients with Brown-Séquard syndrome have ipsilateral upper motor neuron paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensation. A zone of partial preservation or segmental ipsilateral lower motor neuron weakness and analgesia may be noted.

When providing nursing care for a patient with suspected stroke, the most important factor related to the use of fibrinolytic therapy is to A. Begin the therapy within 90 minutes of the patient's arrival B. Obtain a detailed history of the patient's allergies C. Establish the nature and time of symptom commencement D. Start a large-bore central IV line

C. Establish the nature and time of symptom commencement Patients with sudden-onset neurologic deficiencies and persistent focal neurologic deficits should be considered for rt-PA therapy. Patients with persistent symptoms after 1 hour have an 85% risk of stroke with only a 15% chance of full recovery.

Elevated P2 waves in an ICP waveform are a sign of: A.Increased intracranial compliance B. Systemic hypertension C. Increased intracranial pressure D. Brain death

C. Increased intracranial pressure The P2 wave of an ICP occurs just after systole and indicates the compliance of the brain, or its ability to respond to pressure. P2 should be lower than P1; elevation indicates decreased compliance due to increased ICP.

A rapid response is activated on a patient post-operative day 3 from a subdural hematoma (SDH) evacuation. The patient is transferred to the ICU. Which of the following would the nurse expect to assess with a concern for a new left-sided subdural hematoma? A. Bilateral pinpoint non-reactive pupils B. Right pupil greater than left and minimally reactive C.Left pupil greater than right and minimally reactive D. Bilateral pupils 6 cm with brisk reaction

C. Left pupil greater than right and minimally reactive. Assessment manifestations for cerebral insults including head bleeds and ischemic events include ipsilateral pupil changes and contralateral motor extremity changes.

Which assessment score should be completed within one hour of presentation of stroke, evaluates the severity of ischemic stroke and is a predictor of patient outcome? A. Hunt & Hess Scale B. Miami Emergency Neurologic Deficit Scale (MEND) C. National Institute of Health Stroke Scale (NIHSS) D. Cincinnati Pre-hospital Stroke Scale (CPSS)

C. National Institute of Health Stroke Scale (NIHSS)

A 25-year-old male patient was admitted to the ICU yesterday with a diagnosis of closed head injury. During bedside handoff, the off-going nurse reported the patient was awake, alert, and oriented to person, place, time, and situation. During visiting time, the family reports the patient "seems sleepier than yesterday". What is the appropriate next nursing action? A. Ask the family members not to overstimulate the patient B. Notify the physician of the neurologic change C. Perform a focused neurologic exam D. Reassure the family this is a normal finding in the first 24 to 48 hours

C. Perform a focused neurologic exam.

The critical care nurse is caring for a patient who is recuperating from a stroke. The patient continues to demonstrate intermittent lethargy and expressive aphasia. As a result, the patient is being closely monitored for difficulty with coughing or swallowing. This patient is at high risk for aspiration. Which of these findings is an early indication that the patient may have aspirated? A. Increased PaCO2 B. Chest x-ray demonstrating bilateral infiltrates C. Tachypnea and tachycardia D. Coughing and positive sputum cultures

C. Tachypnea and tachycardia Dysphagia is a frequent occurrence after stroke. Swallowing problems are reported in 37% to 78 % of stroke patients. Findings of aspiration maybe : dyspnea, tachypnea, low oxygen saturation (O, sat), putrid expectoration, malaise, and frequent coughing.

81. An unresponsive 82-year old patient was admitted to the ICU after a fall at their skilled nursing facility. An emergent CT scan was performed, which revealed a large intraparenchymal hemorrhage. The patient has a known history of atrial fibrillation, for which she takes warfarin 5 mg PO daily. Her INR is currently 7.5. The nurse should anticipate initial orders for: A. Oral phytonadione × 3 doses B. Protamine 50 mg IV C. Vitamin K 10 mg IV slowly D. One unit of packed red blood cells

C. Vitamin K 10 mg IV slowly Warfarin inhibits the activation of the vitamin K-dependent clotting factors (II, VII, IX, X, protein S & C) thereby resulting in increased anticoagulant effect. Vit K reverses coagulation completely. Intracranial hemorrhage (ICH) is considered an emergency requiring immediate reversal of anticoagulation. Fresh-frozen plasma Activated prothrombin complex concentrates (PCC) Oral phytonadione is recommended for an INR>10 with no evidence of acute bleeding. ******Protamine is used to reverse Heparin in the setting of an elevated aPTT.

A patient with a traumatic brain injury is admitted to the ICU. An ICP monitor is placed, and the critical care nurse is at the bedside. Which of these findings must be reported to the physician? A. A rise to 15 mm Hg while the patient is suctioned that returns to 8 mm Hg after suctioning is completed B. A rise to 18 mm Hg that is sustained for greater than 15 minutes C. A rise to 20 mm Hg that immediately decreases to 10 mm Hg D. A rise to 25 mm Hg that is sustained for 10 minutes

D) A rise to 25 mm Hg that is sustained for 10 minutes Normal ICP range is 0 to 15 mm Hg. Thresholds for treating sustained ICP elevations vary, but 20 mm Hg is the upper limit beyond which intervention is recommended in patients with traumatic brain injury. ICP will rise in response to stimuli (coughing, turning, suctioning) but should return to baseline after the stimuli is removed. A failure to return to baseline after stimuli would require immediate phy- sician notification.

A 26-year-old female is admitted to the ICU after a motor vehicle accident. She experienced a transient loss of consciousness at the scene of the accident but is currently alert and oriented. She is diagnosed with a linear left temporal skull fracture. Two hours after admission, the patient's neurologic status deteriorates. Which of these interventions would the critical care nurse anticipate? A. Cerebral angiography and coil embolization B. Ventriculostomy and cerebrospinal fluid drainage C. Osmotic diuretic and corticosteroid therapy D. Burr holes and clot evacuation

D) Burr hole & clot evacuation Linear fracture of the temporal bone leading to laceration of the middle meningeal artery is the most common cause of epidural hematoma. Classically, these patients present with a history of a brief loss of consciousness immediately after the injury with a subsequent period of lucidity. Subsequently, these patients often deteriorate because of the expanding arterial bleed. Epidural hematoma is a neurosurgical emergency.

A 75-year-old patient was struck by a motor vehicle, sustaining a head injury. The patient is sedated, intubated, and on mechanical ventilation. Vital signs are mean arterial pressure 65 mm Hg; HR 84/min; RR 18/min; ICP 14 mm Hg. Which of the following is indicated at this time? A. Consult with the neurosurgeon regard- ing draining some fluid to decrease ICP . B. Speak with the attending physician regarding administering a fluid bolus to increase MAP C. Call respiratory therapy to initiate hyper- ventilation to a PaCO of 30 mm Hg D. No action is needed; these are accept- able values

D) No action is needed for this patient because all the parameters are within accept able range. Cerebral perfusion pressure (CPP) is defined as the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). The target cerebral perfusion pressure is 50 to 70 mm Hg. Normal intracranial pressure is up to 15 mm Hg. Option C is incorrect because, even if ICP were elevated, hyperventilation to achieve a PaCO2 of 30 mm Hg is no longer recommended based on research findings. CPP = MAP - ICP 65 - 14 = 51 mmHg

An 89-year-old patient is in the ICU for 1 week with maximal medical therapy for a hemorrhagic stroke after warfarin overdose. Her Glasgow Coma Scale score is 3 since her admission to the hospital. Her pupils are equally nonreactive. She is being evaluated for brain death. Which of these neurologic deficits would the nurse correctly interpret as supporting a determination of brain death? A. Loss of vascular tone B. Loss of response to barbiturate infusion C. Loss of spinal arc response D. Loss of spontaneous respiratory effort

D) Signs of brain death include fixed pupils; no motor response to deep central pain, absent corneal reflexes; absent oculocephalic (doll's eyes) reflex; absent oculovestibular reflex (cold water calorics); positive apnea result (no spontaneous breaths with PaCO2 greater than 60 mm Hg and despite 100% FiO2 ventilation 15 minutes prior).

An elderly woman is diagnosed with normoprogressive hydrocephalus and receives a ventricular-peritoneal shunt. During the postoperative period, she has a perietal`` stroke that leaves her with some blurred vision and expressive aphasia, which have impeded her recovery and caused her considerable frustration and anger. Her husband tells the nurse that he knows that she understands him, but he is distressed to see her get so upset every time she attempts to respond to his statements. He wonders if some type of activity would help his wife cope better. With which member of the health care team should the nurse consult for this problem? A. Occupational therapist B. Psychiatric social worker C. Physical therapist D. Speech therapist

D) Speech therapist The immediate need of this patient is to alleviate her frustration by consulting a speech therapist who can assist the patient in regaining and improving her speech expression and help to alleviate patient's vexation with her current limitations.

A patient is admitted to the neuro trauma unit with an epidural hematoma after a motorcycle collision. This type of intracranial bleeding is: A. Venous in origin and is associated with a compound skull fracture B. Venous in origin and is associated with a basilar skull fracture C. Arterial in origin and is associated with a depressed skull fracture D. Arterial in origin and is associated with a linear skull fracture

D. Arterial in origin and is associated with a linear skull fracture.

A patient is admitted with an acute ischemic stroke. After a head CT scan & assessment, there is high suspicion for embolic stroke. Recombinant PA is ordered. The patient's BP is 220/160. Your initial priority is: A. Preparing for STAT administration of the rtPA B. Preparing for STAT cerebral angiogram C. Administer Mannitol IV to decrease cerebral edema D. Lowering the patient's BP to less than 185/110

D. Lowering the patient's BP to less than 185/110

What does the Glasgow coma scale assess? A. Motor response, eye opening, hearing B. Eye opening, sensory response, motor response C. Sensory response, verbal response, motor response D. Motor response, verbal response, eye opening

D. Motor response, verbal response, eye opening