AQ Increased Intracranial Pressure
The nurse is reviewing a patient's imaging studies, which show the presence of lateral displacement of brain tissue beneath the falx cerebri. Which type of herniation does the nurse suspect may be present? Uncal herniation Central herniation Tentorial herniation Cingulate herniation
Cingulate herniation Lateral displacement of brain tissue beneath the falx cerebri results in cingulate herniation. Lateral and downward herniation results in uncal herniation. Forces caused by a mass lesion in the cerebrum cause downward movement of the brain, which results in central herniation or tentorial herniation.
The nurse is caring for a patient that has developed hydrocephalus. Which surgical procedure does the nurse prepare the patient for? Drainage of abscess Excision of malformation Placement of a ventriculoatrial shunt Debridement of fragments and necrotic tissue
Placement of a ventriculoatrial shunt Hydrocephalus occurs due to overproduction of cerebrospinal fluid, which can be treated by placing a ventriculoatrial shunt, allowing excess cerebrospinal fluid to drain. Drainage of abscess is a surgical procedure indicated for brain abscess. Excision of malformation is a surgical procedure indicated for arteriovenous malformation. Debridement of fragments and necrotic tissue is a surgical procedure indicated for skull fractures.
When performing a neurologic assessment on a patient, the nurse notes fixed pupils that are unresponsive to a light stimulus. Which causes of fixed pupils should the nurse consider during this assessment? Select all that apply. Previous eye surgery Administration of diuretics Increased intraocular pressure Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)
Previous eye surgery Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III) A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eye drops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.
The nurse administers mannitol that has been prescribed for a patient with increased intracranial pressure. What outcome does the nurse expect after administration? Increased urine output Decreased blood pressure Reduced intracranial pressure Increased intracranial perfusion
Reduced intracranial pressure Mannitol (Osmitrol) is an osmotic diuretic that increases osmotic pressure in the renal tubules. This increases uptake of water and diuresis, which specifically helps relieve cerebral edema, thereby decreasing intracranial pressure. Increased urine output, decreased blood pressure, and increased intracranial perfusion are secondary outcomes of administration of mannitol (Osmitrol). Of these, increased intracranial perfusion is most desirable because it reduces intracranial pressure. Blood pressure must be monitored closely because an extreme decrease in blood pressure may occur, resulting in decreased intracranial perfusion.
When assessing the outcome of surgery in a patient with a brain tumor, which factors should the nurse consider? Select all that apply. Surgery provides complete cure. Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time. Surgery can increase intracranial pressure (ICP).
Surgery can reduce the tumor mass. Surgery can provide relief of symptoms. Surgery can help to extend survival time. Surgery can reduce the tumor mass, provide relief of symptoms, and can help to extend survival time. These factors should be considered while assessing the outcome of surgery in a patient with a brain tumor. Surgery does not provide a complete cure, or, in most cases, completely remove a tumor. However, surgery helps to decrease the ICP by removing the tumor mass.
The nurse is assessing the clear nasal discharge from a patient that sustained head trauma and notes that it is positive to a Dextrostix test. What does the nurse concur from this finding? The patient has sinusitis. The patient has glaucoma. The patient has allergic rhinitis. The patient has cerebrospinal fluid (CSF) rhinorrhea.
The patient has cerebrospinal fluid (CSF) rhinorrhea. A positive Dextrostix test indicates that CSF is leaking from the nose or ear. The fluid from the nose generally leaks due to a cerebrospinal leak and results in CSF rhinorrhea. A Dextrostix test will not give positive results for sinusitis, glaucoma, or allergic rhinitis.
The nurse is caring for a patient that had a craniotomy. In planning long-term care for the patient, what must the nurse include when teaching the patient, family, and caregiver? Seizure disorders may occur in weeks or months. The family will be unable to cope with role reversals. There are often residual changes in personality and cognition. Referrals will be made to eliminate residual deficits from the damage.
There are often residual changes in personality and cognition. In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition, because these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.
The nurse is caring for a patient admitted for surgical removal of a brain tumor. The nurse will plan interventions for this patient based on the knowledge that brain tumors can lead to which complications? Select all that apply. Vision loss Cerebral edema Pituitary dysfunction Parathyroid dysfunction Focal neurologic deficits
Vision loss Cerebral edema Pituitary dysfunction Focal neurologic deficits Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland
The nurse is assessing the breathing patterns of four patients. Which patient does the nurse suspect may have a lesion in the medulla of brain? A patient with cluster breathing A patient with apneustic breathing A patient with Cheyne-Stokes breathing A patient with central neurogenic hyperventilation
A patient with cluster breathing Lesions in the medulla may affect the breathing pattern, resulting in clustered breathing with irregular pauses in between. Lesions on mid or lower pons cause apneustic breathing. Bilateral hemispheric disease causes a Cheyne-Stokes pattern of breathing. Lesions on the brainstem between lower midbrain and upper pons cause central neurogenic hyperventilation.
The nurse is caring for a patient with a brain tumor. Which diagnostic test would the nurse prepare the patient for to further localize and detect blood flow? Angiography Lumbar puncture Endocrine studies Electroencephalogram (EEG)
Angiography For a patient with brain tumor, angiography can be used to localize the tumor and determine blood flow. EEG helps to detect seizures. Lumbar puncture does not detect the blood flow to the tumor and involves additional risk. Endocrine studies are helpful when a pituitary adenoma is suspected.
Which nursing intervention is the priority when caring for a patient who has increased intracranial pressure (ICP)? Continuous ICP monitoring Placing the patient in a supine position Administration of D5W intravenous infusions Withholding opiates to protect respiratory status
Continuous ICP monitoring Because ICP is a dangerous condition, the nurse must monitor it constantly. Patients with ICP need to be in a semi-Fowler's, not supine, position. The administration of D5W IV fluids will decrease serum osmolality and increase, not decrease, intracranial pressure. Opiates such as morphine and fentanyl are rapid acting and have little effect on cerebral perfusion, though the patient's respiratory status must be monitored closely.
A patient is reported to have a brain abscess in the occipital lobe. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. Visual field defects Headache and fever Nausea and vomiting Psychomotor seizures Visual impairment and hallucinations
Headache and fever Nausea and vomiting Visual impairment and hallucinations Headache, fever, and nausea and vomiting are common symptoms of a brain abscess, and visual impairment and hallucinations can be seen in occipital abscess. Visual field defects and psychomotor seizures are seen in abscesses of the temporal lobe.
What will be the Glasgow Coma Scale score of a patient who has a moderate type of head injury? 3 5 10 14
10 The Glasgow Coma Scale range for patients with a moderate type of head injury is 9 to 12. Therefore for the patient with a moderate type of head injury, a score of 10 is suitable. A score of 3 or 5 is given for a patient with a severe type of head injury. A score of 14 is given for a patient who has a minor type of head injury.
The nurse is caring for a patient with increased intracranial pressure (ICP). Why will the nurse question an order for a benzodiazepine prescribed by the health care provider? It may cause sedation. It may increase the pain. It increases anxiety levels. It causes a hypotensive effect.
It causes a hypotensive effect. Benzodiazepine can cause hypotension as a side effect and may worsen the patient's condition by causing a sudden decrease in blood pressure. Benzodiazepines are used as sedatives; however, they are not avoided because of their sedative action. Benzodiazepines do not cause pain and anxiety.
A nurse should assess pupillary response in a patient with a head trauma and suspected intracranial pressure to evaluate the functioning of which cranial nerve? XII X V III
III Cranial nerve III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. Cranial nerve XII controls tongue movement, cranial nerve X is the vagus nerve, and cranial nerve V is the trigeminal nerve.
A patient is brought to the emergency room with a head injury and is at risk of developing increased intracranial pressure. Which is the most reliable indicator that the nurse should use for assessing the patient's neurologic status? Dim vision Papilledema Body temperature Level of consciousness
Level of consciousness The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Dim vision can occur due to dysfunction of cranial nerves. Papilledema, which is an edematous optic disc seen on retinal examination, can be noted and is a nonspecific sign associated with persistent increases in intracranial pressure (ICP). A change in body temperature may also occur because increased ICP affects the hypothalamus.
The nurse is educating a patient about care after a head injury. Which symptoms should the nurse instruct the patient and caregiver to immediately notify a health care provider about? Select all that apply. Sneezing Seizures Stiff neck Constipation Increased drowsiness
Seizures Stiff neck Increased drowsiness Seizures, a stiff neck, and increased drowsiness are the important symptoms that the patient and caregivers should immediately relay to the health care provider. Sneezing and constipation are not alarming and can also be due to other reasons.
The nurse is preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF). What surgery should the nurse ensure the consent is signed for? Burr hole Craniotomy Shunt placement Stereotactic procedure
Shunt placement Shunt procedures use a tube or implanted device to provide an alternate pathway to redirect CSF when its absorption is impaired. A burr hole is used to remove localized fluid and blood beneath the dura. Craniotomy is done to remove a lesion or repair a damaged area. Stereotactic procedure is used for biopsy, radiosurgery, or dissection
A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above how many mm Hg to preserve cerebral perfusion? 20 40 60 80
60 Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained above 60 mm Hg to preserve cerebral perfusion.
A patient with increased intracranial pressure (ICP) is prescribed a high dose of barbiturates. What outcome does the nurse anticipate the patient will have after administration of the medication? Reduces vasogenic edema Decreases cerebral metabolism Causes plasma expansion and osmotic effect Brings massive movement of water out of brain cells
Decreases cerebral metabolism High doses of barbiturates are used in patients with increased intracranial pressure. Barbiturates decrease cerebral metabolism, helping to reduce ICP. Corticosteroids are used to reduce vasogenic edema. Mannitol acts to decrease ICP through plasma expansion and osmotic effect. Hypertonic saline solution causes massive movement of water out of the brain cells into the blood vessels.
A patient has a systemic blood pressure of 120/60 and an intracranial pressure (ICP) of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? High blood flow to the brain Normal intracranial pressure Impaired blood flow to the brain Adequate autoregulation of blood flow
Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = systolic blood pressure (SBP) + 2 (diastolic blood pressure [DBP])/3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP-ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.
The nurse is caring for a patient that sustained a traumatic brain injury in a motor vehicle crash. Which condition indicates to the nurse when planning the care of the patient to maintain closure of the eyes? Diplopia Otorrhea Periorbital ecchymosis Loss of the corneal reflex
Loss of the corneal reflex Loss of the corneal reflex may cause abrasion, and taping of the eyes is necessary to protect the eyes. An eye patch is used in patients with diplopia. A loose collection pad is used over the ear in patients with otorrhea. Cold and warm compresses are used in patients with periorbital ecchymosis.
A patient with a brain tumor presents with symptoms of visual disturbances and seizures. When evaluating the patient, the nurse knows that this tumor is most likely located in which area of the brain? Subcortical Parietal lobe Occipital lobe Temporal lobe
Occipital lobe Manifestations of tumors in the occipital lobe include vision disturbances and seizures. Manifestations of tumors in the subcortical region include hemiplegia; other symptoms may depend on area of infiltration. Tumors in the parietal lobe present with speech disturbance (if the tumor is in the dominant hemisphere), dyscopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures, and dysphagia.
A patient is prescribed temozolomide as a treatment for a brain tumor. Which factors should the nurse evaluate prior to administering the medication? Select all that apply. Temozolomide causes photosensitivity. Temozolomide causes myelosuppression. Temozolomide can cross the blood-brain barrier. Temozolomide can convert to an agent that directly interferes with tumor growth. Temozolomide interacts with other drugs usually taken by brain tumor patients.
Temozolomide causes myelosuppression. Temozolomide can cross the blood-brain barrier. Temozolomide can convert to an agent that directly interferes with tumor growth .Temozolomide can cross the blood-brain barrier. The drug is also known to cause myelosuppression; therefore, absolute neutrophil counts and platelet counts should be checked before starting the therapy. Temozolomide does not require metabolic activation to exert its effects and therefore can convert to an agent that directly interferes with tumor growth. It is not known to cause photosensitity or interact with other drugs usually taken by brain tumor patients.
The laboratory reports of a patient with a brain tumor, who reports uncontrolled urination and excessive thirst, show high sodium levels. The nurse also observes involuntary eye movements and suspects which type of brain tumor? Subcortical tumors Cerebellopontine tumor Thalamus and sellar tumor Fourth ventricle and cerebellar tumors
Thalamus and sellar tumor Thalamus and sellar tumors may induce diabetes insipidus. This causes symptoms of diabetes insipidus such as excessive urine production, thirst, and elevated sodium and potassium levels. Tumors in the hypothalamic region may cause nystagmus or involuntary eye movements. Subcortical tumors cause hemiplegia. Cerebellopontine tumors cause tinnitus and vertigo. Fourth ventricle and cerebellar tumors cause headache, nausea, and papilledema.
The nurse preceptor is working with the newly licensed registered nurse in caring for a patient with a newly placed ventricular shunt. What statement made by the new nurse requires immediate intervention by the preceptor? "I need to wear sterile gloves whenever I palpate the incision site." "I should be concerned if my patient begins to vomit and has a headache." "I need to compare my assessment findings now with preoperative assessments." "I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches."
"I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches." Rapid decompression of intracranial pressure (ICP) can cause total body collapse, weakness, and headache by rapid position change. To prevent this, the patient should be gradually moved into an upright position. Infection of shunts can occur, so the nurse should use sterile precautions when assessing incision sites. To recognize changes in neurologic status, the nurse should compare postoperative findings with baseline to quickly recognize complications or establish improvement from the surgical intervention. Headache, vomiting, change in level of consciousness (LOC), restlessness, and visual disturbances are all indications of increased ICP from malfunction of the shunt.
A patient who sustained a head injury received initial management and is being discharged. The nurse is teaching measures to be followed by the caregiver. Which statements made by the caregiver indicate the need for further teaching? Select all that apply. "I should maintain a calm environment if the patient is angry." "I should assist with a walker if the patient has difficulty walking." "I should not allow the patient to drive under the influence of morphine." "I should give hot baths if the patient experiences shivering and drowsiness." "I should report to the primary health care provider if the patient has numbness in fingers."
"I should maintain a calm environment if the patient is angry." "I should assist with a walker if the patient has difficulty walking." "I should give hot baths if the patient experiences shivering and drowsiness." The caregiver of a patient with a head injury should immediately report to the primary health care provider if the patient has difficulty walking and seems angry. These manifestations may indicate a deteriorating mental status. Hot baths dilate the blood vessels, bring more blood, and cause more swelling at the injury site, delaying the healing process. Opioid pain medications such as morphine cause drowsiness, and driving should be avoided. The caregiver should report to the primary health care provider if the patient has sensory disturbances such as numbness.
The nurse is calculating the cerebral perfusion pressure (CPP) of an unconscious patient. The patient's blood pressure is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. What is the patient's CPP? Record your answer using a whole number.
58 The nurse calculates the CPP by subtracting the ICP from the mean arterial pressure (MAP). The MAP is [162 + 2(58)]/3 = 193. The nurse subtracts 35 from 93 to determine that the patient's CPP is 58 mm Hg.
A nurse from the acute care unit is reassigned for the shift to the neurologic intermediate care unit. An appropriate assignment would include which patient? A patient just returning from a craniotomy for evacuation of subdural hematoma. A patient with traumatic brain injury who is being transferred to a rehabilitative facility. An alert patient with viral encephalitis who has a scheduled dose of intravenous (IV) acyclovir. An unconscious patient with bacterial meningitis who is needing another lumbar puncture for repeat cultures.
An alert patient with viral encephalitis who has a scheduled dose of intravenous (IV) acyclovir. The nurse from a medical-surgical unit would have the skills to perform an IV piggyback medication, as well as basic neurologic assessment skills. A patient just returning from surgery for a neurologic problem will need a staff member who is experienced with assessment of potential complications. A patient with an altered level of consciousness is more acute then one who is alert. Although the medical-surgical nurse may be familiar with assisting with a lumbar puncture, the fact the patient is unconscious requires a more experienced nurse. A patient being transferred to a rehabilitative facility is more involved, requiring appropriate documentation, nurse-to-nurse report, and instructions to the patient and family, with which the medical-surgical nurse may not be familiar.
A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute. Two hours later the nurse assesses the patient. Which finding indicates deterioration in the patient's condition? The patient does not remember what happened. The patient is sleeping but awakens in response to painful stimuli. Blood pressure is 110/80 mm Hg, pulse is 78 beats/minute, and respirations are 20 breaths/minute. Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.
Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute. Late signs of increased intracranial pressure include an increased systolic blood pressure and decreasing diastolic blood pressure (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a blood pressure of 110/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute do not necessarily indicate deterioration in the patient's condition.
A nurse is educating a patient's family about intracranial pressure (ICP). The nurse explains that normal ICP is a balance of which three components? Blood pressure, brain tissue, body mass index Glucose level, blood pressure, and brain tissue Blood pressure, brain tissue, and cerebrospinal fluid Blood pressure, brain tissue, and ventricles of the brain
Blood pressure, brain tissue, and cerebrospinal fluid Normal ICP involves a balance of blood pressure, brain tissue, and cerebrospinal fluid. The ventricles of the brain, glucose level, and body mass index do not contribute to maintaining normal ICP.
A patient presents with a shunt malfunction related to increased intracranial pressure (ICP). On examination, which findings would the nurse observe? Select all that apply. Cough Blurred vision Gaseous distention Headache and vomiting Decreased level of consciousness
Blurred vision Headache and vomiting Decreased level of consciousness Blurred vision, headache and vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant.
One of the unlicensed assistive personnel (UAP) reports the following vital signs (VS) obtained from a patient with a suspected brain injury: temperature = 101.6° F orally, heart rate = 58, R = 14, and blood pressure = 162/48. What is the nurse's priority response? Ask the UAP to repeat the blood pressure. Compare the current VS to baseline VS recorded. Validate the VS by repeating the VS measurements. Administer prescribed acetaminophen (Tylenol) for fever.
Compare the current VS to baseline VS recorded. Change in vital signs is caused by increasing pressure on the thalamus, hypothalamus, pons, and medulla. Manifestations, such as Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations), are often late signs of markedly increased intracranial pressure (ICP). The nurse should compare the vital signs obtained with baseline vital signs recorded. If there is a deviation from baseline, the nurse should assess the patient, including a repeat set of VS to validate findings. More than just the blood pressure can change with increased intracranial pressure; therefore, asking the UAP to repeat the blood pressure only will not provide any further data. An elevated temperature in a patient with a head injury may indicate a hypothalamic response from injury. The nurse should gather all assessment data before administering antipyretic.
The nurse assesses a comatose head-injured patient and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. How can the findings be described? Stroke Epileptic seizure Decorticate posturing Decerebrate posturing
Decorticate posturing Decorticate posturing, described as flexion of the arms, wrists, and fingers and adduction of the upper extremities, indicates damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The assessment findings described are not specifically related to a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. Decerebrate posturing is described as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing, which may indicate more serious damage, results from disruption of motor fibers in the midbrain and brainstem.
A patient with head trauma has a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which action should the nurse perform first? Evaluate the urine specific gravity. Prepare the patient for acute hemodialysis. Continue to monitor urine output over the next hour. Slow the IV rate and notify the primary health care provider.
Evaluate the urine specific gravity. The patient is experiencing manifestations of diabetes insipidus related to a decrease in the pituitary gland production of ADH (antidiuretic hormone) as a result of a head injury. Without an adequate amount of ADH, the kidneys are unable to conserve water and therefore large fluid losses occur. The patient's problem is not related to renal failure, so there is no indication for hemodialysis. The primary health care provider should be notified of the increased urine output and results of the urine specific gravity, which will be low because of the diluted urine. After evaluation of the urine specific gravity, the patient requires continued close monitoring of the urine output until seen by the primary health care provider. If the patient is found to have diabetes insipidus, the IV rate should not be slowed and will likely have to be increased to prevent dehydration.
When evaluating level of consciousness on the basis of the Glasgow Coma Scale (GCS), which possible responses could be scored under best motor response? Select all that apply. Flexion withdrawal Localization of pain Obedience of command Disorganized use of words Opening the eyes in response to sound
Flexion withdrawal Localization of pain Obedience of command Flexion withdrawal, localization of pain, and obedience of command can be recorded under best motor response. Opening of the eyes in response to stimuli and disorganized use of words are not recorded under motor response.
Which findings will the nurse suspect in a patient who reports a headache and disturbed consciousness and whose imaging studies indicate cerebral edema in the white matter? Decreased oxygen supply to brain Presence of intact blood-brain barrier Increase in the extracellular fluid volume Abnormal accumulation of cerebrospinal fluid in brain
Increase in the extracellular fluid volume Vasogenic cerebral edema mainly occurs in the white matter of the brain. In this type of cerebral edema, there is an increase in the permeability of the blood-brain barrier, which causes increase in the extracellular fluid (ECF) volume. Cerebral hypoxia or decreased oxygen supply is seen in cytotoxic cerebral edema. An intact blood-brain barrier is seen in cytotoxic cerebral edema. Hydrocephalus or abnormal accumulation of cerebrospinal fluid in brain is seen in interstitial cerebral edema.
A patient with a head injury presents to the emergency department. For which potential complication related to cerebral hemorrhage and edema should the nurse evaluate this patient? Anxiety Hyperthermia Impaired physical mobility Increased intracranial pressure
Increased intracranial pressure Increased intracranial pressure can occur as a potential complication related to cerebral hemorrhage and edema. Anxiety can result from an abrupt change in health status, being in a hospital environment, and having an uncertain future. Hyperthermia can occur due to increased metabolism, infection, and hypothalamic injury. Impaired physical mobility is related to a decreased level of consciousness.
A nurse in the neurologic intensive care unit is caring for a patient with intracranial pressure (ICP) monitoring through an intracranial device. Which aspect of the patient's care requires follow-up by the nurse? Using aseptic technique for intracranial device care Intracranial device monitoring for greater than 5 days Assessing the intracranial device insertion site routinely Monitoring the cerebrospinal fluid (CSF) for a change in color
Intracranial device monitoring for greater than 5 days The intracranial device used for monitoring ICP should not be used for more than five days because it can lead to severe infection. Using aseptic technique, routinely assessing the insertion site, and monitoring the CSF for a change in drainage color prevents complications while monitoring ICP, and so are all appropriate aspects of patient care that do not require follow-up by the nurse.
The nurse is caring for a patient with increased intracranial pressure. Which actions should the nurse perform to promote optimal outcomes for the patient? Select all that apply. Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Lower the head of the bed and turn the patient to one side. Wait for the respiration to improve before beginning with ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position
Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position Intubation and mechanical ventilation, maintenance of fluid balance and assessment of osmolality, and elevation of head of bed to 30 degrees with head in a neutral position are the appropriate actions to be performed when managing a patient with increased intracranial pressure (ICP). Waiting for the respiration to improve may be life-threatening. Lowering of the head of the bed and turning the patient to one side may further increase the intracranial pressure.
The nurse is planning the care for a patient with increased intracranial pressure (ICP). What actions should the nurse plan to perform to provide the most comfort for the patient? Select all that apply. Minimize procedures that can produce agitation. Observe the patient for signs of agitation or irritation. Teach the patient's family about increasing stimulation. Make the patient remain in a quiet and calm environment. Allow the patient's family to visit the patient more often.
Minimize procedures that can produce agitation. Observe the patient for signs of agitation or irritation. Make the patient remain in a quiet and calm environment. When managing the patient with increased ICP, procedures that can produce agitation should be avoided. The patient should be observed for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. The stimulation levels should be decreased, and patient's family should be instructed to decrease stimulation and reduce noise, including not visiting too frequently.
A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment? Select all that apply. Monitor fluid intake and sodium levels regularly. Monitor patient's sleep and diet routine regularly. Perform blood glucose monitoring at least every six hours. Avoid taking any antacids along with corticosteroid treatment. Start concurrent treatment with antacids or proton pump inhibitors.
Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Start concurrent treatment with antacids or proton pump inhibitors. Patients on corticosteroid treatment should be regularly monitored for fluid intake and sodium levels. Blood glucose monitoring should be performed at least every six hours until hyperglycemia is ruled out. Starting concurrent treatment with antacids or proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding, because complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal bleeding. Regularly monitoring the patient's sleep and diet routine does not contribute to avoiding complications related to corticosteroid therapy. Antacids should be given along with corticosteroids to prevent gastrointestinal complications.
The nurse is planning to administer pharmacologic therapy for a patient with increased intracranial pressure (ICP). Which factors should the nurse consider? Select all that apply. Use benzodiazepines as a standalone treatment for sedation. Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous intravenous sedatives. Use nondepolarizing neuromuscular blocking agents alone for better outcomes. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.
Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous intravenous sedatives. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents. The appropriate factors to evaluate include monitoring for hypotension when using opioids to manage anxiety and monitoring for hypotension when using continuous intravenous sedatives, because hypotension is a side effect. Using sedatives or analgesics with nondepolarizing neuromuscular blocking agents is important because these agents paralyze muscles without blocking pain or noxious stimuli. Using benzodiazepines as a standalone treatment for sedation is not advisable due to their hypotensive effects and long half-life. Nondepolarizing neuromuscular blocking agents paralyze muscles without blocking pain or noxious stimuli; they are used in combination with sedatives, analgesics, or benzodiazepines.
Following an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which behavior of the patient supports the nurse's conclusion? Movement of the eye in the opposite direction to the turning head Movement of the eye in the upward direction when the neck is flexed Movement of the eye in the sideward direction when the neck is extended Movement of the eye in the downward direction when the neck is extended
Movement of the eye in the sideward direction when the neck is extended The oculocephalic reflex is tested by having the patient turn his or her head briskly to the left or right while holding the eyelids open. The eye movement should be in the opposite direction and not in the sideward direction if the neck is extended. The sideward eye movement indicates an intracranial lesion. Movement of the eye in the opposite direction to the turning head is a normal response. Movement of eye in the upward direction if the neck is flexed is normal and does not indicate any abnormality. Movement of the eye in the downward direction if the neck is extended indicates a normal finding.
The nurse is reviewing the medical records of a patient with acquired immunodeficiency syndrome (AIDS) that has been diagnosed with a brain tumor. What tumor growth is associated with AIDS? Metastatic tumor Acoustic neuroma Pituitary adenoma Primary central nervous system lymphoma
Primary central nervous system lymphoma Lymphocyte production is affected in patients with AIDS. Primary central nervous system lymphoma originates from lymphocytes and, therefore, is seen in patients with AIDS. Metastatic tumors are malignant types that originate in the lungs and breasts. Acoustic neuroma is a low-grade malignancy, which originates from cells that form myelin sheath. Pituitary adenoma is usually benign and originates from the pituitary gland.
When planning the care of a patient with a brain tumor, which goals should the nurse select as primary goals? Select all that apply. Making patient walk Removing tumor mass Managing patient's family Identifying the tumor type and location Managing increased intracranial pressure (ICP)
Removing tumor mass Identifying the tumor type and location Managing increased intracranial pressure (ICP) Removing tumor mass, identifying the tumor type and location, and managing the ICP are the primary goals of treatment of a patient with brain tumor. Assisting the patient with walking and managing the patient's family are not appropriate primary goals.
