Chapter 56 Acute Intracranial Problems Complex 2021

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

Correct answer: a Rationale: The nurse's initial priority in the emergency management of a patient with a severe head injury is to ensure that the patient has a patent airway.

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

Correct answer: d Rationale: Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a. Pulse of 102 beats/min b. Temperature of 101.6° F c. Intracranial pressure of 15 mm Hg d. Mean arterial pressure of 90 mm Hg

ANS: B Infection is a serious complication of ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse only require ongoing monitoring at this time.

Which clinical manifestations would the nurse anticipate identifying in a patient who is comatose? Select all that apply. Patient can cough and swallow. Patient has bowel and bladder control. Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent.

Patient does not respond to painful stimuli. Patient has incontinence of urine and feces. Patient's corneal and pupillary reflexes are absent. A coma is the deepest state of unconsciousness in which the corneal and pupillary reflexes are absent. A comatose patient is also incontinent of urine and feces and does not respond to painful stimuli. The comatose patient is not able to cough and swallow and does not have any bowel and bladder control.

Which method of measurement is the gold standard for obtaining intracranial pressures (ICPs)? Ventriculostomy Fiberoptic catheter Air pouch/pneumatic Transcranial Doppler

Ventriculostomy A ventriculostomy is the gold standard for measurement of ICP. A fiberoptic catheter and air pouch/pneumatic are other measures for monitoring ICP, but they are not considered the gold standard. A transcranial Doppler evaluates blood flow in the brain.

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and BP of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number. _______ mm Hg

39 The CPP is calculated by subtracting the ICP from the MAP; 64 - 25 = 39.Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As CPP decreases, autoregulation fails and cerebral blood flow is decreased.

When assessing a patient's level of consciousness, which potential Glasgow Coma Scale (GCS) scores indicate the patient is in a comatose state? Select all that apply. 4 5 6 9 11

4 5 6 A GCS score of 8 or less generally indicates coma. Scores of 9 or 11 are greater than 8, and do not indicate coma.

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mmHg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

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

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response? a. Flexion withdrawal b. Localization of pain c. Decorticate posturing d. Decerebrate posturing

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

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

ANS: C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

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

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

ANS: D Antibiotic therapy should be started quickly in bacterial meningitis, but cultures must be done before antibiotics are started. After the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture? a. A b. B c. C d. D

ANS: D Battle's sign (postauricular ecchymosis) and periorbital ecchymoses are associated with basilar skull fracture.

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first? a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b. A 30-yr-old patient who lost consciousness for 10 seconds after a fall c. A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13 d. A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

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

For the patient who sustained a head injury in a motor vehicle crash, which primary injury interventions would the nurse include in the patient's plan of care? Select all that apply. Anticipate intubation. Administer oxygen. Maintain neck alignment. Maintain normothermia. Administer fluids cautiously. Establish/maintain IV access.

Administer oxygen. Maintain neck alignment. Establish/maintain IV access. Administration of oxygen, assuming neck injury with head injury, and establishing IV access are priority interventions to ensure the health and safety of the patient. Maintaining normothermia, anticipating intubation, and administering fluids cautiously are part of ongoing monitoring to help to prevent secondary injury; these interventions can take place after the priority interventions have been administered.

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

BP changes Dexmedetomidine is an α2-adrenergic agonist used for continuous IV sedation of intubated and mechanically ventilated patients. It activates the receptors in the brain and spinal cord and inhibits neuronal firing, which can cause both hypotension and hypertension. Dexmedetomidine does not cause insomnia, hyperanxiety, or sedation. It is used in neurologic assessment because of its anxiolytic activities.

Which cranial nerve (CN) irritation, secondary to bacterial meningitis, resulted in the patient's loss of corneal reflexes? CN II CN V CN IV CN VII

CN V CN V is the trigeminal nerve; irritation of this nerve will lead to the loss of the corneal reflex. CN II (optic nerve) irritation leads to blindness. CN IV (trochlear nerve) irritation affects ocular movements. CN VII (facial nerve) irritation causes facial paresis.

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

Cerebral herniation A lumbar puncture involves removal of cerebrospinal fluid from the lumbar region. This can raise the intracranial pressure, resulting in cerebral herniation. Cerebral edema is associated with radiation therapy. Myelosuppression is associated with temozolomide drug therapy. Total body collapse is associated with a ventricular shunt.

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

Loss of the corneal reflex Loss of the corneal reflex may cause corneal abrasions. Taping of the eyes is necessary to protect them. Use an eye patch in patients with diplopia. Use a loose collection pad over the ears for patients with otorrhea. Use cold and warm compresses for patients with periorbital ecchymosis.

For the patient who developed hydrocephalus, which pathophysiologic event would the nurse associate with the diagnosis? Select all that apply. Overproduction of cerebrospinal fluid (CSF) Underproduction of CSF Defective reabsorption of CSF Obstruction of CSF flow in the brain Rupture of cerebral blood vessels added to CSF volume

Overproduction of cerebrospinal fluid (CSF) Defective reabsorption of CSF Obstruction of CSF flow in the brain Hydrocephalus is the accumulation of CSF, which can be caused due to obstruction to flow of CSF and defective reabsorption and overproduction of CSF. Rupture of blood vessels causes intracranial bleeding. Underproduction of CSF is not a cause of hydrocephalus.

Of the four assigned patients in the intensive care unit (ICU), which patient with an infection has the highest risk for developing cerebral edema? The patient diagnosed with encephalitis The patient experiencing cerebral thrombosis The patient who sustained a contusion from a fall The patient with hydrocephalus from a malfunctioning shunt

The patient diagnosed with encephalitis Encephalitis is a cerebral viral infection that can cause cerebral edema. Hydrocephalus is the buildup of cerebrospinal fluid (CSF) in the brain. A contusion is bruising. A thrombosis is a blood clot in the circulatory system.

After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy? "I will have an internal transducer inserted into my head." "I won't be able to have drugs instilled through this procedure." "It will directly measure the pressure within the ventricles of my brain." "The health care provider won't be able to get samples of my cerebrospinal fluid."

"It will directly measure the pressure within the ventricles of my brain." Ventriculostomy is a gold standard procedure for monitoring the intracranial pressure (ICP). In this procedure, the health care provider positions the catheter to measure the pressure within the ventricles. The ventriculostomy transducer is external and facilitates sampling of cerebrospinal fluid. The procedure permits intraventricular drug administration.

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

ANS: 74 Calculate the CPP: (CPP = Mean arterial pressure [MAP] ?2- ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] ?2- Diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Palpate the head for injuries. c. Assess pupil reaction to light. d. Verify Glasgow Coma Scale (GCS) score.

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

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. 1 b. 2 c. 3 d. 4

ANS: A With decorticate posturing, the patient exhibits internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

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

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

ANS: B The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

ANS: C Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

Which outcome would the nurse anticipate after administering a high dose of prescribed barbiturates to the patient with an increased intracranial pressure (ICP)? The medication reduces the vasogenic edema. Barbiturates decrease the level of cerebral metabolism. The drug facilitates plasma expansion and an osmotic effect. The therapy promotes massive movement of water out of brain cells.

Barbiturates decrease the level of cerebral metabolism. High doses of barbiturates decrease cerebral metabolism levels in patients with increased ICP and helps to reduce ICP. Use corticosteroids to reduce vasogenic edema. Mannitol (Osmitrol) 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.

Which clinical manifestations would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt? 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.

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

Bradycardia Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. The triad consists of increasing systolic pressure (not hypotension) with a widening pulse pressure (not narrowing), bradycardia with a full and bounding pulse, and irregular respirations (not tachypnea).

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply. Bradycardia Weak pulse Irregular respirations Increasing systolic BP Decreasing systolic BP

Bradycardia Irregular respirations Increasing systolic BP Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The systolic BP increases, not decreases.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

Correct answer: b Rationale: Vasogenic cerebral edema occurs mainly in the white matter. It is caused by changes in the endothelial lining of cerebral capillaries.

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

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

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

Impaired blood flow to the brain A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the ICP from the mean arterial pressure (MAP).MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm Hg + 2[60 mm Hg])/3 = 120 mm Hg + 120 mm Hg = 240 mm Hg; 240/3 = 80 mm Hg.MAP-ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg.The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is elevated, preventing perfusion of the brain, and requires treatment.

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

Monitor fluid and electrolyte disturbances carefully. Monitor fluid and electrolyte disturbances vigilantly because they can have an adverse effect on ICP. Keep the head of the patient's bed at 30 degrees in most circumstances. Physical restraints are not applied unless necessary because agitation increases ICP. Do not administer vasoconstrictors, typically, in the treatment of ICP.

While monitoring a patient's intracranial pressure (ICP) via an intracranial device in the neurologic intensive care unit, which aspect of care requires collaborative actions by the nurse? Using aseptic technique for intracranial device care Monitoring the intracranial device for greater than five days Assessing the intracranial device insertion site routinely Monitoring the cerebrospinal fluid (CSF) for a change in colo

Monitoring the intracranial device for greater than five days Use of the intracranial device for monitoring ICP should not occur 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 prevent complications; therefore all are appropriate aspects of patient care that do not require follow-up by the nurse.

When the patient experiences visual impairment and hallucinations, in which lobe of the brain would a CT scan indicate the presence of an abscess? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Occipital lobe An abscess in the occipital lobe may lead to visual impairment and hallucinations. Abscesses in the frontal and parietal lobe may result in a local or systemic infection. A temporal lobe abscess can cause psychomotor seizures.

When a patient's clinical manifestations include visual disturbances and seizures, which area of the brain would the nurse identify as the most likely location of the diagnosed brain tumor? 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), dystopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures and dysphagia.

Which intracranial pressure waveform supports the nurse's assessment of a compromise occurring with the patient's intracranial compliance? P3 wave is lower than P1 wave P2 wave is higher than P1 wave P2 wave is higher than P3 wave P1, P2, and P3 resemble a staircase

P2 wave is higher than P1 wave The P2 wave represents the intracranial compliance, and the P2 wave should be lower than the P1 wave. The presence of a higher P2 wave than the P1 wave indicates increased intracranial pressure and compromised intracranial compliance. During normal conditions, the P3 wave is the lowest wave; the P2 wave is higher than the P3 wave; and P1, P2, and P3 waves are in order and resemble a staircase.

Which factors would the nurse associate with influencing a patient's intracranial pressure (ICP) readings? Select all that apply. Posture Swallowing Drowsiness Temperature Carbon dioxide levels Intraabdominal pressure

Posture Temperature Carbon dioxide levels Intraabdominal pressure Posture, temperature, intraabdominal pressure, and carbon dioxide levels all influence ICP. Swallowing does not affect ICP. Drowsiness may be a sign of increased ICP, but it does not influence it.

Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating? Presence of fixed unresponsive pupils Sluggish reaction of pupil in response to light Brisk constriction of pupil in response to light Slight constriction in the opposite pupil in response to light

Presence of fixed unresponsive pupils A penlight is used to test the papillary reaction. Fixed pupils that are unresponsive to light indicate ICP. An increase in the ICP causes suppression of nerves, which leads to fixed unresponsive pupils. Sluggish reaction of the pupil indicates an early pressure. Brisk constriction of the pupils is a normal reaction. Slight constriction in the opposite pupil is a consensual response, which is a normal finding.

Which expected outcome would the nurse anticipate after administering phenytoin (Dilantin) for a patient with an increased intracranial pressure (ICP)? Lowered ICP readings Prevention of seizures Decreased systolic pressures Prevention of gastrointestinal (GI) ulcers

Prevention of seizures Use phenytoin to control seizures for which this patient is at risk. Use histamine (H 2 receptor antagonists), not phenytoin, to prevent GI ulcers. Phenytoin will not affect systolic pressure. Use mannitol to help to decrease ICP.

The nurse would instruct the patient recovering from a head injury and his or her caregiver to report the development of which symptoms immediately to the health care provider? 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.

Which assessments would the nurse include when documenting an evaluation of a patient's central nervous system (CNS)? Select all that apply. Speech Seizures Contusions Oxygen saturation Bowel and bladder incontinence Decerebrate or decorticate posturing

Speech Seizures Bowel and bladder incontinence Decerebrate or decorticate posturing Decerebrate or decorticate posturing, speech, bowel and bladder incontinence, and seizures are all elements that the nurse observes when assessing the CNS. Oxygen saturation is reflective of respiratory status, not the CNS, and contusions are a body surface assessment unrelated to the CNS.

Which initial interventions would the nurse implement as emergency management of a patient who fell and presented with scalp lacerations and a depressed skull? Select all that apply. Stabilize the cervical spine. Wrap the patient in tight clothing. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing. Avoid intubation if the Glasgow Coma Scale (GCS) score is less than

Stabilize the cervical spine. Administer oxygen via a non-rebreather mask. Control external bleeding with a sterile pressure dressing. Manage the patient with scalp lacerations and skull depression by stabilizing the cervical spine, administering oxygen via a non-rebreather mask, and controlling external bleeding with a sterile pressure dressing. Wrapping the patient in tight clothing is not appropriate. Instead, removing the patient's clothes can help. Intubation is required only if the GCS is less than 8 (comatose).

Which response occurs in the brain when a patient's systemic arterial pressure begins to deviate from the normal range? The intracranial pressures decrease. The intracranial pressures increase. There is an increase in brain compliance. The brain begins autoregulation functions.

The brain begins autoregulation functions. Autoregulation is a normal response occurring in the brain when systemic arterial pressures alter. Intracranial pressure alterations, decreasing or increasing, are not an initial response to systemic pressure changes. Compliance is the expandability of the brain and is not an initial response to systemic arterial pressure change.

Which interpretation would the nurse associate with a positive Dextrostix test of the clear nasal discharge obtained from the patient who sustained head trauma? 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.

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect? a. Expressive aphasia b. Impaired judgment c. Right-sided weakness d. Difficulty swallowing

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

Which information would the nurse provide a patient and the caregiver as discharge instructions related to care during the first three days after sustaining a head injury? You may resume driving. Restrict the sodium in your diet. Abstain from alcohol during this time. Wear a helmet when riding your bike.

Abstain from alcohol during this time. Wear a helmet when riding your bike. Alcohol is a central nervous system depressant and may mask important neurologic changes related to a head injury. The patient should refrain from driving because of potential neurologic changes from the head injury. A dietary sodium restriction is not necessary unless it is related to another medical condition. Wearing a helmet is a preventive measure not specific to patients with head injuries.

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

BP, brain tissue, and cerebrospinal fluid Normal ICP involves a balance of BP, 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 with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse give first? Codeine Phenytoin Ceftriaxone Acetaminophen

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

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg? Normal intracranial pressure (ICP) Increased ICP Decreased cerebral blood flow (CBF) Increased cerebral perfusion pressure (CPP)

Decreased cerebral blood flow (CBF) A MAP below 70 mm Hg results in a decreased CBF. The decreased MAP does not indicate an increased or normal ICP. The CPP decreases as a result of the diminished MAP. A MAP below 70 mm Hg does not necessarily guarantee a normal ICP. The normal range of a MAP is between 70 and 100 mm Hg. A MAP of at least 60 mm Hg is vital to provide enough blood to the coronary arteries, kidneys, and brain.

Which type of waveform would the nurse document for a patient receiving intracranial pressure (ICP) monitoring and the waveform represents venous pulsations? Tidal wave Dicrotic wave Rebound wave Percussion wave

Dicrotic wave The dicrotic wave follows the dicrotic notch and represents venous pulsations. Tidal wave and rebound waves represent relative brain volume. A percussion wave represents arterial pulsations.

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

Elevate the head of the patient's bed to 30 degrees. Assess CSF rhinorrhea by the presence of a halo or ring sign. Coalescence of blood in the center of the gauze with an outer yellowish ring indicates the leakage of CSF from the patient's nose. The first action by the nurse should be to elevate the head of the bed to decrease the CSF pressure so that the tear can heal. Do not request the patient to blow the nose. Do not insert packing, but place a loose collection dressing under the nose to catch the drainage. Do not insert a nasogastric tube, especially if suspecting a basilar skull fracture.

Upon hearing a patient with an increased intracranial pressure (ICP) begin to snore, the nurse relates the sound to which potential finding upon assessment? Obstruction Oversedation Normal finding Decreasing ICP

Obstruction Snoring sounds in a patient who has increased ICP is indicative of an obstruction, and this is an emergency. The ICP will not decrease with snoring, and snoring is not a normal finding with increased ICP. Snoring in a patient with increased ICP is not an indication of oversedation.

Of the four assigned patients with skull fractures, which type of skull fracture would the nurse associate with a low-velocity injury? Patient A Patient B Patient C Patient D

Patient A A low-velocity injury, seen in Patient A, is the most common cause of a linear fracture of the skull bone. A powerful blow that creates an inward indentation of the skull is the cause of depressed-type skull fractures, seen in Patient B. Patient C has a comminuted type of skull fracture caused by a direct high momentum impact and multiple linear fractures with fragmentation of the bone. Patient D has a compound-type of skull fracture, which is associated with a depressed skull fracture and scalp laceration caused by a severe head injury.

Which intervention would the nurse implement to prevent cranial nerve (CN) III palsy in a patient with meningitis? Provide low lighting. Administer antibiotics. Elevate the head of the bed. Perform cooling techniques.

Perform cooling techniques. Fever may increase cerebral edema, which may cause CN III palsy. Therefore, any fever should be treated vigorously by performing cooling techniques. Low lighting should be provided if the patient develops hallucinations and delirium. Administration of antibiotics is to treat the infection, not prevention of CN III palsy. Elevation of the head of the bed provides relief from head and neck pain.

When hydrocephalus develops, for which surgical procedure would the nurse begin preparing the patient? 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.

Which interpretation would the nurse associate with a patient's Glasgow Coma Scale score of 5 after sustaining a head injury? The patient is alert and oriented. The patient is unresponsive and comatose. The patient is awake but lethargic and drowsy. The patient responds appropriately to commands.

The patient is unresponsive and comatose. The Glasgow Coma Scale ranges from 3 to 14. A score of 7 or less indicates that a patient is in a coma. The lower the score, the more serious the patient's condition. A patient who is alert and orient, awake but lethargic, or responding appropriately to commands has a Glasgow Coma Scale score higher than 7.

For the patient admitted for surgical removal of a brain tumor, for which potential complications would the nurse integrate assessment interventions into a patient's plan of care? Select all that apply. Vision loss Cerebral edema Pituitary dysfunction Parathyroid dysfunction Focal neurologic deficits Diabetes mellitus

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 and cerebral edema appear. The cerebral cortex or the pituitary gland do not regulate the parathyroid gland. Trauma to the brain, or tumors of the thalamus and sellar tumors, may cause development of diabetes insipidus, not diabetes mellitus.

For the patient with a head injury and suspected temporal fracture, which clinical manifestations would the nurse need to assess further? Select all that apply. Optic nerve injury Periorbital ecchymosis Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region

Boggy temporal muscle Cerebrospinal fluid (CSF) otorrhea Oval-shaped bruise in the mastoid region A temporal fracture may manifest as CSF otorrhea, boggy temporal muscle due to extravasation of blood, and an oval-shaped bruise behind the ear in the mastoid region (Battle's sign). Occipital fractures involve optic nerve injuries and periorbital ecchymosis.

Which objective data would the nurse record when assessing a patient with a head injury? Select all that apply. Headache Battle's sign Projectile vomiting Past health history Mechanism of injury Cranial nerve deficits

Battle's sign Projectile vomiting Cranial nerve deficits Battle's sign, projectile vomiting, and cranial nerve deficits are objective data that the nurse will record when assessing a patient with a head injury. A headache is subjective data. While the mechanism of injury may be helpful information, it is not part of the assessment itself. A patient's past health history is subjective data.

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition? Encephalitis Brain abscess Viral meningitis Bacterial meningitis

Brain abscess The absence of glucose in cerebrospinal fluid indicates a brain abscess. The glucose would be normal in encephalitis, would be normal or low (>40 mg/dL) in viral meningitis, and would be decreased (5 to 40 mg/dL) in bacterial meningitis.

Which position would the nurse expect a patient to display as decerebrate posturing when diagnosed with an elevated intracranial pressure (ICP) causing serious disruption of motor fibers in the midbrain and brain stem?

Decerebrate posture is when all four extremities are in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and is potentially visualized with traumatic brain injury.

Which inflammatory condition would the nurse associate to the common cause of acute nonepidemic encephalitis? St. Louis encephalitis Eastern equine encephalitis Western equine encephalitis Herpes simplex virus encephalitis

Herpes simplex virus encephalitis Herpes simplex virus encephalitis is the most common cause of acute nonepidemic viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western equine cause epidemic encephalitis.p. 1324

For which potential disorder would the nurse monitor the urine output of a patient with an increased intracranial pressure and diabetes insipidus? Hypernatremia Decreased urine output Dilutional hyponatremia Elevated blood glucose level

Hypernatremia Hypernatremia is a symptom of diabetes insipidus, so the nurse must monitor this patient's urine output carefully. Elevated blood glucose levels are not measured via urine output but rather with blood tests. Urine output is increased, not decreased, in the setting of diabetes insipidus because of the decreased antidiuretic hormone. Dilutional hyponatremia is not a symptom of diabetes insipidus; rather, hypernatremia is.

When managing a patient with a brain injury, of which potential secondary intracranial injuries would the nurse monitor development? Select all that apply. Hypoxia Ischemia Hypotension Blunt force trauma Impact of the car accident Increased intracranial pressure

Hypoxia Ischemia Hypotension Increased intracranial pressure Ischemia, increased intracranial pressure, hypoxia, and hypotension are components of a secondary intracranial injury. The impact of a car accident and blunt force trauma are primary components.

For the patient with a head injury, for which complication related to cerebral hemorrhage and edema would the nurse monitor potential development? 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.

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

Insert nasogastric (NG) tube and connect to low, intermittent suction. Patients who need gastric decompression following a basilar skull fracture should have an oral gastric tube inserted. The nurse should collaborate with the health care provider about this intervention because of the risk of meningitis. The recommended intervention is an oral feeding, with placement of either an oral tube or NG tube under fluoroscopy. The use of a soft cervical collar to maintain anatomic alignment, avoiding flexion of hip joints, and elevating the head of the bed are all measures to decrease intracranial pressure by promoting venous return.

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

Loss of the corneal reflex Loss of the corneal reflex may cause corneal abrasions. Taping of the eyes is necessary to protect them. Use an eye patch in patients with diplopia. Use a loose collection pad over the ears for patients with otorrhea. Use cold and warm compresses for patients with periorbital ecchymosis.

For the patient with an increased intracranial pressure, who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcomes indicate an effective intervention? Select all that apply. PaO2 of the patient is 80 mm Hg. PaO2 of the patient is 90 mm Hg. PaO2 of the patient is 110 mm Hg. PaCO2 of the patient is 40 mm Hg. PaCO2 of the patient is 30 mm Hg.

PaO2 of the patient is 110 mm Hg. PaCO2 of the patient is 40 mm Hg. The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO2 of the patient greater than or equal to 100 mm Hg with PaCO2 in the range of 35 to 45 mm Hg. Therefore the PaO2 value of 110 mm Hg and PaCO2 value of 40 mm Hg indicate effective treatment. A PaO2 of less than 100 and PaCO2 of less than 35 mm Hg indicate ineffective treatment.

Which medication has a rapid onset, short half-life, and would the nurse administer to treat a patient's anxiety and agitation secondary to an increased intracranial pressure? Propofol (Diprivan) Lorazepam (Ativan) Morphine sulphate (Duramorph) Cisatracurium besylate (Nimbex)

Propofol (Diprivan) Propofol has a rapid-onset, short half-life, and is used for anxiety and agitation in the intensive care unit (ICU). Use analgesics like opioids, such as morphine sulphate (Duramorph) for pain, not anxiety and agitation. Avoid benzodiazepines such as lorazepam (Ativan) in the patient with increased intracranial pressure, unless used with neuromuscular blocking agents. A nondepolarizing neuromuscular blocking agent is a paralytic, like cisatracurium besylate (Nimbex).

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

Reduced ICP Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules to increase the uptake of water and dieresis by the kidneys, which specifically helps to relieve cerebral edema, thereby decreasing ICP. Increased urine output, decreased BP, and increased intracranial perfusion are secondary outcomes of administration of mannitol. Of these, increased intracranial perfusion is most desirable because it reduces ICP. Monitor BPs closely because an extreme decrease in BP may occur, resulting in decreased intracranial perfusion.

For the patient presenting with watery sanguineous nasal drainage after falling from a first-floor roof, which diagnostic method validates the nurse's suspicion of rhinorrhea? Gram stain The halo test A Dextrostix Slide smear for presence of leukocytes

The halo test The patient may be experiencing rhinorrhea, or leakage of cerebral spinal fluid (CSF) from the nose, which is also sanguineous (bloody). In the presence of blood, the halo test will be the most accurate for determining presence of CSF. A Gram stain is used to identify bacterial presence. If blood is present, the Dextrostix will not be accurate because glucose is present in blood. CSF is sterile in the body and, under normal circumstances, does not contain white cells (leukocytes) or bacteria.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face.

ANS: B Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

Correct answer: c Rationale: An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression in increased ICP. They include decreasing level of consciousness and headache.

Which intervention would the nurse implement to reduce the mental distortion experienced by the patient with meningitis? Provide low lighting. Elevate the head of the bed. Minimize environmental stimuli. Apply a cool cloth over the eyes

Minimize environmental stimuli. A patient with a mental distortion may be frightened and misinterpret the environment. Therefore, minimizing environmental stimuli may help to calm the patient. Provide low lighting if the patient experiences photophobia. Slightly elevate the head of the bed if the patient experiences head and neck pain. Apply a cool cloth over the patient's eyes to decrease photophobia.

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

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

When explaining neurological pathophysiology to a group of nursing students, the nurse describes the progression of increased intracranial pressure in which chronological order? Increased intracranial pressure Tissue edema Decreased cerebral blood flow Decreased oxygen and death of brain cells Compression of ventricles and blood vessels Compression of the brainstem and respiratory center

1. Tissue edema 2.Increased intracranial pressure 3.Compression of ventricles and blood vessels 4.Decreased cerebral blood flow 5.Decreased oxygen and death of brain cells 6.Compression of the brainstem and respiratory center In order, tissue edema occurs and causes reduced blood flow in the cerebellum. The increased cranial pressure leads to decreased oxygen delivery and death of brain cells. The compression of ventricles and blood vessels ultimately causes compression of the brainstem and respiratory center.

For the patient who experienced head trauma from a motor vehicle crash, place the progressive pathophysiology steps in order from the injury to severe increased intracranial pressure (ICP) and death. 1. Increased ICP from increased blood volume 2. Compression of ventricles and blood vessels 3. Decreased cerebral blood flow 4. Increased ICP with brainstem compression 5. Tissue edema from initial insult 6. Increased ICP

1. Tissue edema from initial insult 2. Increased ICP 3. Compression of ventricles and blood vessels 4. Decreased cerebral blood flow 5. Increased ICP with brainstem compression 6. Increased ICP from increased blood volume After initial insult to the brain, there is tissue edema, which causes an initial increase in ICP; then compression of ventricles and blood vessels occurs, which decreases cerebral blood flow, thus decreasing O2 and causing death of brain cells. Edema occurs around this necrotic tissue, and increased ICP with compression of the brainstem and respiratory center occurs, leading to accumulation of CO2. Further increases in ICP occur from increased blood volume, which leads to death.

When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid? 1. Close the stopcock to return the ventriculostomy to a closed system. 2. Allow the CSF to drain for two to three minutes into the collection bag. 3. Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 4. Open the ventriculostomy system when ICP is greater than the prescribed pressure.

1.Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 2.Open the ventriculostomy system when ICP is greater than the prescribed pressure. 3.Allow the CSF to drain for two to three minutes into the collection bag. 4.Close the stopcock to return the ventriculostomy to a closed system. The first step is determining that the ICP is above the prescribed/desired level. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. After opening the stopcock, allow CSF to drain for two to three minutes to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step. Always maintain strict aseptic techniques when performing this intervention.

Which Glasgow Coma Scale score would the nurse assign to the patient who sustained a motor-vehicle crash concussion and who is fully alert upon arrival to the emergency department? 3 6 8 15

15 The Glasgow Coma Scale is a quick, practical, and standardized system for assessing the level of consciousness in a patient. According to the Glasgow Coma Scale, the score of a fully alert patient will be 15. This includes 4 for spontaneous response of the patient when approached at the bedside, 5 for appropriate response during verbal questioning, and 6 for obedience of commands. The lowest possible score according to the Glasgow Coma Scale is 3, which indicates severe coma conditions. A score of 6 or 8 indicates coma.

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

80 mm Hg Patients with elevated ICP are at risk for lower CPP during suctioning. When suctioning, maintain the patient's CPP above 60 mm Hg to preserve cerebral perfusion.

Which observation would the nurse associate with a cerebrospinal fluid (CSF) leak when a patient with a suspected traumatic brain injury (TBI) develops a bloody nasal drainage? A halo sign on the nasal-drip pad Decreased BP and urinary output A positive reading for glucose on a test-tape strip Clear nasal drainage along with the bloody discharge

A halo sign on the nasal-drip pad When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased BP and urinary output would not be indicative of a CSF leak.

Which patient condition contraindicates testing the doll's-eye reflex when performing a neurologic assessment? An unconscious patient An uncooperative patient A patient with cervical spine injury A patient who has intracranial lesion

A patient with cervical spine injury A doll's-eye reflex test is performed to determine the oculocephalic reflex. It increases the risk of brainstem injury with a cervical spine problem. A doll's-eye reflex test can be performed in an unconscious and uncooperative patient. This test is used to determine the presence of intracranial lesions due to increased intracranial pressure.

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? a. Pale yellow urine output of 1200 mL over the past 2 hours. b. Ventriculostomy drained 40 mL of fluid in the past 2 hours. c. Intracranial pressure spikes to 16 mm Hg when patient is turned. d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

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

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis b. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury c. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day d. A 55-yr-old patient who is receiving hyperventilation therapy for increased ICP

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

ANS: A Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

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

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg.

ANS: A The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits? a. "Do you have any difficulty in hearing?" b. "Are you experiencing vision problems?" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?"

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

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Arrange to admit the patient to the neurologic unit for observation. d. Transport the patient to radiology for magnetic resonance imaging (MRI).

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

Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go right to bed." c. "I do not even remember being in an accident today." d. "I can take acetaminophen (Tylenol) for my headache."

ANS: B After a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

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

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

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

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? a. "This type of monitoring system is complex, and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for changes in cerebral perfusion pressure." d. "This monitoring system has many benefits, including the ability to drain cerebrospinal fluid."

ANS: B Short, simple, and accurate explanations should be given initially to patients and family members. Explaining that the system is complex, and it is managed by skilled staff or that it has multiple benefits does not address the family question about purpose for this patient. Terminology such as ventriculostomy and cerebral perfusion pressure is too complex for the initial explanation and may increase family members' anxiety.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? a. Emphasize the importance of hand washing before meals. b. Encourage immunization for adolescents and college freshmen. c. Tell adolescents and young adults to avoid crowds in the winter. d. Support serving healthy nutritional options in the college cafeteria.

ANS: B The Neisseria meningitidis vaccination is recommended for children ages 11 and 12 years, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, and good nutrition may increase resistance to infection, but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient reports a severe dull headache. b. The patient takes warfarin (Coumadin) daily. c. The patient's blood pressure is 162/94 mm Hg. d. The patient is unable to remember the accident.

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

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 120 beats/min

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

The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse? a. The patient reports a headache. b. The apical pulse is slightly irregular. c. The patient is more difficult to arouse. d. The blood pressure increases to 140/62 mm Hg.

ANS: C The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take? a. Call the family's pastor or spiritual advisor to take them to the chapel. b. Ask the family to stay in the waiting room until the assessment is completed. c. Allow the family to stay with the patient and briefly explain all procedures to them. d. Refer the family members to the hospital counseling service to deal with their anxiety.

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

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? a. Report of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

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

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care? a. Cluster nursing activities to allow longer rest periods. b. Turn and reposition the patient side to side every 2 hours. c. Position the bed flat and log roll to reposition the patient. d. Perform range-of-motion (ROM) exercises every 4 hours.

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

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)? Steady vital signs Reports of a headache Increased motor function An altered level of consciousness (LOC)

An altered level of consciousness (LOC) Changes in the LOC are a result of impaired cerebral blood flow, which causes oxygen deprivation to the cerebral cortex and reticular activating system, so this is the most sensitive and reliable manifestation of ICP. A decrease (not an increase) in motor function occurs as the ICP increases. A headache could indicate compression but is potentially attributed to other causes. An increased ICP can cause changes in vital signs; however, they will not necessarily remain steady.

Which pathophysiologic processes would the nurse suspect when a patient with a head injury develops a temperature of 103o F (39.4o C)? Select all that apply. The patient's metabolic rate decreased. An increased cerebral blood flow is occurring. The patient's intracranial pressures have decreased. The metabolic wastes are increasing due to the head injury. A decreased blood flow decreased the amount of cerebral blood volume. Hyperthermia occurs when there is an injury or inflammation in the hypothalamus. The body temperature of 103° F (39.4° C) of a patient who has a head injury indicates an injury to the hypothalamus. Injury to the hypothalamus can increase metabolic waste because of increased metabolism secondary to hyperthermia. Hyperthermia causes an increase in cerebral flow because of increased metabolic demands. Hyperthermia associated with a head injury causes increased metabolism and increased intracranial pressure because of increased cerebral blood flow.

An increased cerebral blood flow is occurring. The metabolic wastes are increasing due to the head injury. Hyperthermia occurs when there is an injury or inflammation in the hypothalamus. The body temperature of 103° F (39.4° C) of a patient who has a head injury indicates an injury to the hypothalamus. Injury to the hypothalamus can increase metabolic waste because of increased metabolism secondary to hyperthermia. Hyperthermia causes an increase in cerebral flow because of increased metabolic demands. Hyperthermia associated with a head injury causes increased metabolism and increased intracranial pressure because of increased cerebral blood flow.

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

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

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

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

The initial assessment of a patient in the postanesthesia care unit recovering from a brain tumor resection included a temperature of 100°F (37.7°C), BP of 130/76 mm Hg, pulse 64 beats/min, a urinary catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One hour later, which assessment finding would the nurse immediately report to the surgeon? Presence of a gag reflex Urine output of 50 mL during the past hour BP of 148/58 mm Hg and pulse 48 beats/min Temperature of 99.8°F (37.6°C) and pulse of 96 beats/min

BP of 148/58 mm Hg and pulse 48 beats/min Associate a BP with a widening pulse pressure, bradycardia, and irregular respirations with an increasing intracranial pressure (ICP) known as the Cushing's triad, which should be reported immediately. Presence of a gag reflex, urine output of 50 mL over an hour, and temperature of 99.8°F (37.6°C) and pulse of 96 beats/min are acceptable assessment findings in a postoperative patient.

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

Begin parenteral nutrition if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Evaluate the patient's urine output, fluid loss, and electrolyte balance. For a patient with increased ICP, begin parenteral nutrition or enteral feedings if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Monitor the patient's urine output, fluid loss, and electrolyte balance to evaluate the effectiveness of nutritional therapy. Do not keep the patient in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, the desired treatment is to reach full nutritional replacement within seven days after injury. Do not confuse reducing brain edema with mannitol (Osmitrol) with the overall fluid balance in the body.

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

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

For the patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression? CN V CN IV CN III CN VIII

CN III Compression of CN III, the oculomotor nerve, is a result of the brain shifting from midline, compressing the trunk of the CN III, and paralyzing the muscles controlling pupillary size and shape. CN IV is the trochlear nerve, which moves the eye inward, down, and laterally. CN V (trigeminal nerve) is responsible for sensation in the face and motor functions such as biting and chewing. CN VIII is the vestibulocochlear nerve, which is responsible for hearing and balance.

For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response? CN X CN V CN III CNXII

CNIII CN III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. CN XII controls tongue movement, CN X is the vagus nerve, and CN V is the trigeminal nerve.

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual changes, weakness of right upper and lower extremities, and personality changes. The nurse determines that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.

Correct answer: a Rationale: A unilateral frontal lobe tumor may result in unilateral hemiplegia, seizures, memory deficit, personality and judgment changes, and visual changes. A bilateral frontal lobe tumor may cause symptoms associated with a unilateral frontal lobe tumor and an ataxic gait.

A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. maintaining strict bed rest with the head of the bed slightly elevated. d. keeping the room dark and quiet to minimize environmental stimulation.

Correct answer: b Rationale: Fever must be vigorously managed because it increases cerebral edema and the frequency of seizures. Neurologic damage may result from an extremely high temperature over a prolonged period. Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or tepid sponge baths with water, may be effective in lowering the temperature.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

Correct answer: b Rationale: The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevation in ICP. Elevating the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the venous system and jugular veins, and decreases the vascular congestion that can cause cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic BP. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. An older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0- to 10 scale d. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting

Correct answer: c Rationale: The patient with meningitis should be seen first. Patients with meningitis must be observed closely for manifestations of increased ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second. Although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nosebleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

Correct answers: c, e Rationale: Nursing interventions should be based on a realistic appraisal of the patient's condition and prognosis after cranial surgery. The nurse should provide support and education to the caregiver and family about the patient's behavioral changes. The nurse should be prepared to manage seizures and teach the caregiver and family about antiseizure drugs and how to manage a seizure. An overall goal is to foster the patient's independence for as long as possible and to the highest degree possible. The nurse should decrease stimuli in the patient's environment to prevent increases in intracranial pressure.

Which clinical manifestations would the nurse anticipate identifying in a patient suspected of having a disruption of motor fibers in the midbrain after sustaining a head injury? Projectile vomiting Tentorial herniation Decorticate posturing Decerebrate posturing

Decerebrate posturing Decerebrate posturing is an expected clinical finding resulting from the disruption of motor fibers in the midbrain. Projectile vomiting is related to increased intracranial pressure (ICP). Tentorial herniation is a complication of increased ICP. Decorticate posturing is a result of the interruption of voluntary motor tracts in the cerebral cortex.

Which response would the nurse document when a patient with a brain injury experiences the motor function changes depicted in the image? Decorticate posturing Decerebrate posturing Sinusoidal posturing Opisthotonic posturing

Decorticate posturing Decorticate posture involves internal rotation and adduction of the arms with extension of the elbows, wrists, and fingers, as illustrated in the image. This results from interruption of voluntary motor tracts in the cerebral cortex. The patient may also demonstrate an extension of the legs. A decerebrate posture may indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar extension of the feet. Sinusoidal posturing does not exist. Opisthotonic posturing consists of the head, neck, and spinal column in an arching position.

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? 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 indicate damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The described assessment findings do not specifically relate to describing a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. A nurse would describe decerebrate posturing as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing results from disruption of motor fibers in the midbrain and brainstem and indicates serious tissue damage.

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis? Decrease in neutrophils Decrease in lymphocytes Decrease in glucose level Decrease in protein level

Decrease in glucose level There is a decrease in glucose levels in the cerebrospinal fluid in a patient with bacterial meningitis. An increase in neutrophils, lymphocytes, and protein levels would be relative to bacterial meningitis.

Which tests would the nurse utilize to detect cerebral spinal fluid (CSF) in a patient suspected of otorrhea after sustaining head trauma? Select all that apply. Dextrostix Litmus test Guaiac test Tes-Tape strip Imaging scans Quantitative human chorionic gonadotropin (hCG)

Dextrostix Tes-Tape strip Image scans Use a Dextrostix or Tes-Tape strip to detect glucose, which is present in CSF. The appearance of a halo around blood in imaging studies may also be indicative of CSF. The litmus test analyzes the pH of the fluid, which does not provide information about CSF. The guaiac test is used to test stools for occult blood. Quantitative hCG is a test that measures the hormone hCG, which does not provide information about CSF.

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

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

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

Evaluate the urine's specific gravity. The patient is experiencing manifestations of diabetes insipidus related to a decrease in the pituitary gland production of antidiuretic hormone (ADH) secondary to the 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. Notify the health care provider 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 health care provider. If the patient has diabetes insipidus, then the IV rate should not be slowed and will likely have to be increased to prevent dehydration.

For the patient recovering from cranial surgery involving a bone flap, which interventions would the nurse implement to prevent an increased intracranial pressure (ICP)? Select all that apply. Assess the patient's weight loss after surgery. Frequently assess the patient's neurologic status. Monitor the patient's serum creatinine and lipid profile. Do not position the patient's surgical site in a dependent position. Closely monitor fluid and electrolyte levels and serum osmolality

Frequently assess the patient's neurologic status. Do not position the patient's surgical site in a dependent position. Closely monitor fluid and electrolyte levels and serum osmolality. The patient should be turned and positioned appropriately and carefully to prevent increase in ICP. Frequent assessment of the patient's neurologic status is essential during the first 48 hours after the cranial surgery. Closely monitor fluid and electrolyte levels, and monitor serum osmolality to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia. Assessing the patient's weight loss after surgery and monitoring the patient's serum creatinine and lipid profile are not the prime interventions after any cranial surgery because they do not affect the ICP.

A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? 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 Rationale: Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

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

Inform the patient that headaches can occur after recovery. Inform the patient that headaches might occur postrecovery, even though they are a rare manifestation. Treat the patient symptomatically based on the reason for developing the headache. A complete recovery is expected. A severe headache might be a major complication.

When assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first? 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.

Which interventions would the nurse implement to promote optimal outcomes for the patient with an increased intracranial pressure (ICP)? 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 respirations 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.

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

Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious and with increased intracranial pressure (ICP). This patient is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within three days after injury. Neither IV fluids nor enteral nutrition is categorized as free water. Electrolytes and fluid volume can be managed with both IV fluid and enteral nutrition administration. Enteral feeding is not a treatment for dehydration; enteral nutrition can actually lead to dehydration due to the high concentration of solute in the feed.

Which medication is an osmotic diuretic that the nurse would prepare to administer when needing to lower a patient's intracranial pressure (ICP)? Mannitol Cimetidine Dexamethasone Hypertonic saline

Mannitol Mannitol is an osmotic diuretic given via IV to decrease ICP. Hypertonic saline is an IV solution used to help to reduce cerebral swelling. Dexamethasone is a corticosteroid used to treat vasogenic edema. Cimetidine is a histamine (H2) receptor blocker given to a patient receiving corticosteroids to prevent gastrointestinal ulcers and bleeding.

Which interventions would the nurse implement to promote positive outcomes for the patient experiencing increased intracranial pressures (ICPs) in the neurologic intensive care unit? Select all that apply. Monitor ICP. Perform a cerebral angiography. Elevate the head of the bed to 30 degrees. Maintain PaO2 of 90 mm Hg or greater. Obtain a patient history and physical examination. Maintain systolic arterial pressure of 100 to 160 mm Hg.

Monitor ICP. Elevate the head of the bed to 30 degrees. Maintain systolic arterial pressure of 100 to 160 mm Hg. Elevating the head of the bed 30 degrees, ICP monitoring, and maintaining a systolic arterial pressure of 100 to 60 mm Hg are components of the expected management for a patient with increased ICP. Cerebral angiography, history, and a physical are diagnostic assessment tools rather than interventions. The PaO2 should be maintained at 100 mm Hg or greater.

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? 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. Initiate concurrent treatment with antacids or proton pump inhibitors.

Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Initiate concurrent treatment with antacids or proton pump inhibitors. Regularly monitor patients on corticosteroid treatment for fluid intake and sodium levels. Perform blood glucose monitoring at least every six hours until ruling out hyperglycemia from the steroids. 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. Administer antacids along with corticosteroids to prevent gastrointestinal complications.

Which factors would the nurse consider when preparing to administer the pharmacologic therapy for a patient with an increased intracranial pressure (ICP)? Select all that apply. Use benzodiazepines as a standalone treatment for sedation. Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous IV 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 IV 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 IV 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; providers use these agents in combination with sedatives, analgesics, or benzodiazepines.

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy? Monitor the patient for pain. Monitor the patient for an infection. Monitor the patient for excessive bleeding or hemorrhage. Monitor the patient for increased intracranial pressure (ICP).

Monitor the patient for increased intracranial pressure (ICP). The priority action of the nurse caring for a patient following a craniotomy is to monitor for increased ICP, which can have serious life-threatening implications. Manage the patient's pain, but pain is not an emergency. Monitor the patient for development of an infection, but the infection will not be immediately apparent. A hemorrhage will cause an increase in ICP if it is cerebral.

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings? When flexing the neck, eye movement is in the upward direction. Movement of the eye is in the opposite direction of the turned head. When extending the neck, eye movement is in the downward direction. Movement of the eye in the sideward direction occurs, with neck extension.

Movement of the eye in the sideward direction occurs, with neck extension. Test the oculocephalic reflex 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 extending the neck. 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 when flexing the neck is normal and does not indicate any abnormality. When extending the neck, movement of the eye in the downward direction indicates a normal finding.

Which rationale would the nurse use to explain to family members why older adult patients who fall have a high risk for developing a chronic subdural hematoma? Older adult patients have larger subdural spaces. Changes in vasculature occurs with older adult patients. Older adult patients experience a decrease in sensing their pain. There is a decreased level of consciousness in the older adult patient.

Older adult patients have larger subdural spaces. Chronic subdural hematomas are more common in older adults because of the potentially larger subdural space because of brain atrophy. With aging, a reduction in sensing pain sensation may occur, but this is not the physiologic cause for the risk of a chronic subdural hematoma. Changes in vasculature occur in the elderly as well but do not put the patient at risk for a subdural hematoma from a fall. The older adult patient does not normally experience a decreased level of consciousness; this is an alteration in mental status and is a pathologic symptom unrelated to the risk for chronic subdural hematoma.

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

Pain and agitation may elevate the patient's ICPs. Extreme hip flexion increases intraabdominal pressures. Increased intrathoracic pressures impede venous return. Pain and agitation cause rapid movements, which may increase the ICP. Extreme hip flexion may raise the intraabdominal pressure, which increases the ICP. Increased intrathoracic pressure may increase ICP by impeding the venous return. Slow and gentle movements will provide comfort to the patient and will not increase the ICP. Elevation of the head of the bed promotes drainage from the head, decreases the vascular congestion, and therefore decreases ICP.

Which type of brain injury would the nurse associate with the patient who sustained a subdural hematoma from a motor vehicle crash? Anoxia Primary Cerebral Secondary

Primary Primary injuries are those that occur at the time of the injury (e.g., blunt force trauma, car accident); the subdural hematoma is itself an example of this. Secondary injuries are those injuries resulting from the primary injury; for instance, increased intracranial pressure may result from the hematoma. A cerebral injury is damage to the cerebrum, and an anoxia injury results from a lack of oxygen to the brain.

For the patient diagnosed with a brain abscess, which events would the nurse associate with the development of the abscess? Select all that apply. Acne or skin abscess Prior brain trauma or surgery Prior leg fracture or ligament tears Distant spread from a pulmonary infection Direct extension from an ear or sinus infection

Prior brain trauma or surgery Distant spread from a pulmonary infection Direct extension from an ear or sinus infection Prior brain trauma or surgery can result in a brain abscess. A distant spread from a pulmonary infection and direct extension from an ear or sinus infection are primary causes of a brain abscess. Acne or skin abscess and a prior leg fracture or ligament tears do not cause brain abscess.

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. Provide the patient a quiet and calm environment. Minimize procedures that potentially produce agitation. Facilitate an increased number of family visits to the patient. Encourage the patient's family to increase patient interactions. Observe the patient for signs of agitation or irritation and intervene.

Provide the patient a quiet and calm environment. Minimize procedures that potentially produce agitation. Observe the patient for signs of agitation or irritation and intervene. When managing the patient with increased ICP, avoid procedures that can produce agitation. Observe the patient for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. Decrease the stimulation levels and instruct patient's family to decrease stimulation and reduce noise, including not visiting too frequently.

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? Sims' Prone Trendelenburg Semi-Fowler's

Semi-Fowler's Position a patient with an increased ICP with his or her head elevated, as in semi-Fowler's position (typically at 30 degrees). Sims' position is side-lying with one leg flexed, which may elevate intracranial pressure. A prone position is flat with the face down, and the Trendelenburg position is supine with the feet higher than the head. The head is not elevated in these positions, which is dangerous for someone with ICP.

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

Serum osmolality of 290 mOsm/kg Rationale: Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood glucose levels occur with diabetes.

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

Serum sodium BP Use hypertonic saline solutions to treat increased ICP. Hypertonic saline infusions increase the intravascular fluid volume, which may alter the serum sodium levels and BP in the body. If administering corticosteroids to a patient, monitoring includes blood glucose levels. Monitor sedation levels if administering barbiturates to the patient. Monitor gastrointestinal disturbances if administering corticosteroids to the patient.

When preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF), which surgical consent would the nurse obtain from the patient or immediate family member? 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 removes localized fluid and blood beneath the dura. Craniotomy removes a lesion or repairs a damaged area. Use of the stereotactic procedure is for biopsy, radiosurgery, or dissection.

Which rationale supports the nurse contacting the prescribing health care provider regarding an order of benzodiazepine for a patient with an increased intracranial pressure (ICP)? The medication may cause sedation. The patient's pain scores may increase. Anxiety levels increase as a side effect. Side effects include a hypotensive effect.

Side effects include a hypotensive effect. Benzodiazepine can cause hypotension as a side effect and may worsen the patient's condition by causing a sudden decrease in BP. Benzodiazepines are used as sedatives; however, they are not avoided because of their sedative action. Benzodiazepines do not cause pain and anxiety.

Which pupil comparisons would the nurse perform when completing a neurologic assessment of the eyes? Select all that apply. Size Shape Reactivity Movement Visual acuity Corneal reflex

Size Shape Reactivity Movement When performing a neurologic assessment, compare the pupils for reactivity, size, shape, and movement. Eliciting a corneal reflex provides information about cranial nerves V and VII, not neurologic functioning. A visual acuity assessment determines the smallest letters viewed by the patient, but this does not provide information about neurologic functioning.

When providing a community safety presentation, which disorder would the nurse include as a possible cause for a patient's increased intracranial pressure? Sinusitis Cor pulmonale Diabetes insipidus Subdural hematoma

Subdural hematoma A subdural hematoma is a collection of blood between the brain and its covering, which can cause intracranial pressure. Sinusitis is a respiratory disorder, which would not cause increased intracranial pressure. Cor pulmonale is a cardiorespiratory disorder, which would not affect intracranial pressure. Diabetes insipidus is an endocrine disorder affecting glucose regulation, not intracranial pressure.

After assessing the breathing patterns of four assigned patients, which patient would the nurse suspect of having a lesion in the medulla of the brain? The patient with cluster breathing The patient with apneustic breathing The patient with Cheyne-Stokes breathing The patient with central neurogenic hyperventilation

The 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.

When teaching the patient, family, and caregiver about long-term care of the patient who had a craniotomy, which instruction would the nurse include? Seizure disorders may occur within weeks or months. The family will be unable to cope with role reversals. There are often residual changes in personality and cognition. We initiate a referral 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 elimination of residual deficits will not occur with a referral, improvement may happen.

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

Urine output of 1000 mL in one hour An increased urine output of 1000 mL in one hour could cause critical fluid and electrolyte imbalance issues and needs prompt attention; this indicates a decline in the patient's condition. An ICP of 20 mm Hg, respiratory rate of 24 breaths/minute, and pulse of 100 beats/minute do not indicate a need for the nurse to call the health care provider.

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intracranial pressures (ICP) caused by a brain tumor? Administer IV mannitol (Osmitrol). Maintain hyperoxygenation through use of a ventilator. Use strict aseptic technique with all procedural dressing changes. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

Use strict aseptic technique with all procedural dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. Administer IV mannitol or hypertonic saline as prescribed. Potential ventilator use is to maintain oxygenation, not hyperoxygenation. CSF leaks may cause inaccurate ICP readings, or staff may drain CSF to decrease the patient's ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

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

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

Which type of cerebral edema would the nurse associate with a diagnostic report indicating edema of the white matter and characterized by leakage of large molecules from the capillaries into the surrounding space? Interstitial cerebral edema Vasogenic cerebral edema Hypoxic cerebral edema Cytotoxic cerebral edema

Vasogenic cerebral edema Vasogenic cerebral edema occurs mainly in the white matter and is the most common type. It is characterized by leakage of large molecules from the capillaries into the surrounding space. Interstitial cerebral edema is usually a result of hydrocephalus. Hypoxia is a lack of oxygen to the brain and does not cause cerebral edema, though the edema may cause the hypoxia. Cytotoxic cerebral edema results from disruption of the integrity of the cell membranes from lesions or trauma.

When performing an initial baseline assessment and subsequent assessments, which actions would the nurse implement specific to the patient's neurologic status? Select all that apply. Perform temperature and pulse rate assessments. When performing daily activities, assess the patient. Assess patient's integrated function and balance. Determine the patient's weight, height, and waist-to-hip ratio. Monitor level of consciousness and motor abilities.

When performing daily activities, assess the patient. Assess patient's integrated function and balance. Monitor level of consciousness and motor abilities. A neurologic assessment includes assessment of the patient when performing daily activities, assessment of integrated function and balance, and assessment of the level of consciousness and motor abilities. Assessing the patient's temperature, pulse rate, and weight, height, and waist-to-hip ratio are general measurements and are not included for neurologic status measurement.

Which assessments would the nurse perform when utilizing the Glasgow Coma Scale (GCS) to assess a patient admitted with a head injury and requiring regular neurologic and vital sign assessments? Select all that apply. Judgment Eye opening Abstract reasoning Best verbal response Best motor response Cranial nerve function

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

Which potential factors would the nurse associate with explaining a patient's pupils becoming fixed and unresponsive to light stimulus? 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 eyedrops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.

For the patient with a resolved head injury, which prevention interventions would the nurse include when providing discharge instructions? Select all that apply. Use of carpooling Use of car seat belts Use of tinted glasses Use of child car seats Use of helmets by cyclists

Use of car seat belts Use of child car seats Use of helmets by cyclists Using car seat belts, using child car seats, and using helmets by cyclists can help to prevent head injuries. Use of carpooling and use of tinted glasses do not help to reduce the rate of head injuries.

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

5 to 15 mm Hg A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention.

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

10 The GCS 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. Patients with a severe type of head injury have a GCS score between 3 to 5. Patients who has a minor type of head injury have a GCS score of 14.

Which patient would the charge nurse assign to the nurse floating from the acute care medical-surgical unit to the neurologic intermediate care unit? A patient just returning from a craniotomy for evacuation of subdural hematoma The patient scheduled to transfer to a rehabilitative facility with a traumatic brain injury in two hours An alert patient with viral encephalitis who needs an IV access for a scheduled acyclovir An unconscious patient with bacterial meningitis who needs another lumbar puncture for repeat cultures

An alert patient with viral encephalitis who needs an IV access for a scheduled acyclovir The nurse from a medical-surgical unit would have the skills to initiate an IV access and administer an IV piggyback medication, as well as basic neurologic assessment skills. A patient just returning from surgery for a neurologic problem will need a neurologic staff member experienced with assessment of potential complications. A patient with an altered level of consciousness is more acute than one who is alert. Although the medical-surgical nurse may be familiar with assisting with a lumbar puncture, the fact that the patient is unconscious requires a more experienced nurse. A patient pending a transfer 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.

While utilizing the Glasgow Coma Scale (GCS) to assess a patient's level of consciousness, which potential responses would the nurse document 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 Utilize flexion withdrawal, localization of pain, and obedience of command to record a patient's best motor response. Do not use opening of the eyes in response to stimuli and disorganized use of words under the scale's motor response.

Which clinical manifestations would the nurse expect to identify when assessing a patient with a brain abscess within the occipital lobe? 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 An occipital abscess commonly presents with the clinical manifestations of headache and fever, as well as nausea and vomiting. Visual impairment and hallucinations may accompany an occipital abscess. Abscesses of the temporal lobe present with visual field defects and psychomotor seizures.

Which assessment findings would the nurse document regarding a patient diagnosed with a right-sided brain tumor resulting in a significantly increased intracranial pressure (ICP)? Select all that apply. Ipsilateral pupil dilation Ipsilateral hemiparesis Contralateral hemiparesis Contralateral pupil dilation Altered level of consciousness

Ipsilateral pupil dilation Contralateral hemiparesis Altered level of consciousness The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Patients experiencing increased intracranial pressure will present with varying degrees of altered levels of consciousness, depending on the degree of pressure. Compression of cranial nerve (CN) II (optic) results in dilation of the pupil on the same side (ipsilateral), not the opposite side (contralateral). As ICP continues to rise, the patient will experience changes in motor response on the opposite side of the lesion (contralateral), not the same side (ipsilateral).

Which intervention would the nurse implement when providing care for a patient with an increased intracranial pressure (ICP)? Place the patient in a supine position. Monitor ICP continuously. Administer D5W IV infusions. Withhold opiates to protect respiratory status.

Monitor ICP continuously. Because ICP is a dangerous condition, the nurse must monitor 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, ICP. Opiates such as morphine and fentanyl are rapid acting and have little effect on cerebral perfusion; however, there is a need to monitor the patient's respiratory status closely.

The nurse suspects that a patient with bacterial meningitis is experiencing cranial nerve II irritation based on which assessment finding? Facial paresis Papilledema and blindness Ptosis, unequal pupils, and diplopia Sensory loss and loss of corneal reflex

Papilledema and blindness Irritation of cranial nerve II can cause papilledema and blindness. Facial paresis would result from irritation of cranial nerve VII. Ptosis, unequal pupils, and diplopia can indicate involvement of cranial nerves III, IV, and VI. Sensory loss and loss of corneal reflex can occur with irritation of cranial nerve V.

When experiencing speech disturbances and an inability to write, which part of the patient's cerebral hemisphere would the nurse associate with the patient's brain tumor? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Parietal lobe Parietal lobe tumors cause spatial orientation problems resulting in speech disturbances and an inability to write. Frontal lobe tumors cause visual disturbances and unilateral hemiplegia. Occipital lobe tumors cause vision disturbances and seizures. Temporal lobe tumors cause seizures and dysphagia.

Which interpretation would the nurse associate with a positive Dextrostix test of the clear nasal discharge obtained from the patient who sustained head trauma? 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.

Which statement by the novice nurse demonstrates understanding of the care required for a patient admitted earlier today with a diagnosis of post-head injury concussion? "I can expect the pupils to be unequal in size and sluggish to respond to my pen light." "I will delegate keeping the patient awake for the next eight hours to my unlicensed assistive personnel (UAP)." "To help with post-head injury headaches, I will contact the health care provider about prescribing morphine IV." "I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

"I need to assess the patient's level of consciousness frequently because changes are the first indication of complications." The first indication of increased intracranial pressure (ICP) is a change in the patient's level of consciousness. Pupil changes are not an immediate assessment finding following a concussion; in fact, pupil changes are often a late sign of neurologic complications. Keeping the patient awake following a head injury is not necessary. Arousing the patient frequently to assess arousal and level of consciousness is an appropriate plan of care following a head injury. Although headache can be common following a head injury, avoid narcotics for pain management because they can mask the signs of impending complications, particularly alteration in level of consciousness.

Which statements made by the caregiver of a patient who sustained a head injury indicate understanding of the patient's needs? Select all that apply. "I should maintain a calm environment if the patient becomes angry." "I should assist with a walker if the patient experiences difficulty walking." "I should not allow the patient to drive when under the influence of morphine." "I should provide hot baths if the patient experiences shivering and drowsiness." "I should notify the health care provider if the patient develops finger numbness."

"I should not allow the patient to drive when under the influence of morphine." "I should notify the health care provider if the patient develops finger numbness." The caregiver of a patient with a head injury should immediately report to the 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 should be avoided when driving. The caregiver should report to the health care provider if the patient has sensory disturbances such as numbness.

Which disorder would the nurse associate with a patient who has meningitis with seizures, cranial nerve (CN) III palsy, and bradycardia? Cerebral abscess Subdural effusion Acute cerebral edema Increased intracranial pressure

Acute cerebral edema Acute cerebral edema is a complication of meningitis that causes seizures, CN III palsy, and bradycardia. Cerebral abscess, subdural effusion, and increased intracranial pressure are complications of meningitis, but they do not cause the aforementioned symptoms.

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/minute, and respirations 24 breaths/minute, which subsequent vital signs would the nurse report immediately to the health care provider? BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute BP 136/84 mm Hg, pulse 88 beats/minute, respirations 26 breaths/minute BP 112/56 mm Hg, pulse 98 beats/minute, respirations 28 breaths/minute BP 126/68 mm Hg, pulse 110 beats/minute, respirations 32 breaths/minute

BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute Fluctuations in vital signs are expected. The nurse will report a BP of 172/54 mm Hg, pulse of 58 beats/minute, and respiration rate of 10 breaths/minute because these values may indicate Cushing's triad or systolic hypertension with a widening pulse pressure, bradycardia, and irregular or low respirations. These values are indicative of an increased intracranial pressure. BPs of 136/84, 126/68, and 112/56; pulses of 88, 110, and 98; and respiration rates of 26, 32, and 28 are not values linked to ICP when compared to the patient's initial vital signs.

The patient admitted with a closed head injury is awake but lethargic, and the baseline vital signs include a BP of 120/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min. Which findings indicate deterioration of the patient's condition two hours later? The patient is sleeping but awakens in response to painful stimuli. The patient does not remember what happened during the six hours prior to the injury. BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are 20 breaths/min. BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min.

BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min. Late signs of increased intracranial pressure include an increased systolic BP and decreasing diastolic BP (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 BP of 110/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min do not necessarily indicate deterioration in the patient's condition.

Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled? Prepare the patient and assist with the lumbar puncture. Reschedule the lumbar puncture for the next business day. Administer IV fluids before the lumbar puncture. Cancel the lumbar puncture and contact the prescribing provider.

Cancel the lumbar puncture and contact the prescribing provider. Lumbar puncture may cause cerebral herniation due to the sudden release of pressure in the skull from the area above the punctured site and is contraindicated in a patient with increased ICP, so cancel the procedure and contact the prescribing provider. Rescheduling the lumbar puncture for the next day may not reduce the risk of cerebral herniation. Performing the lumbar puncture immediately may cause cerebral herniation. Administering IV fluids does not reduce the risk of cerebral herniation.

Which type of hematoma would the nurse suspect when an older adult patient fell and hit their head on the coffee table two weeks ago? Epidural hematoma Intracerebral hematoma Acute subdural hematoma Chronic subdural hematoma

Chronic subdural hematoma In older adults, due to the presence of a potentially larger subdural space caused by brain atrophy, chronic subdural hematomas are the most commonly seen hematoma. Atrophy increases the tension in the brain; even though supportive structures attach to the brain, tearing of the brain tissues is a potential because of the increased tension. Epidural hematoma, intracerebral hematoma, and acute subdural hematoma are common in all age groups.

Which type of skull fracture would the nurse associate with an x-ray report indicating multiple linear fractures and the presence of a fragmented bone? Linear type Depressed type Compound type Comminuted type

Comminuted type Skull fractures associated with multiple linear fractures along with fragmented bone indicate a comminuted type of skull fracture. A linear fracture is a break in continuity of the bone without alteration of other parts. A powerful blow or inward indentation of the skull is known as a depressed type of skull fracture. A severe head injury causes a compound type of skull fracture and is associated with a depressed skull fracture and scalp laceration.

When the unlicensed assistive personnel (UAP) reports the vital signs (VS) of a patient with a suspected brain injury as temperature = 101.6° F (38.7° C) orally, heart rate = 58 beats/minute, respiratory rate = 14 breaths/minute, and BP = 162/48 mm Hg, which action would the nurse implement first? Ask the UAP to repeat the BP. Validate the VS by repeating the measurements. Compare the current VS to recorded baseline VS. Administer prescribed acetaminophen (Tylenol) for fever.

Compare the current VS to recorded baseline VS. Increasing pressure on the thalamus, hypothalamus, pons, and medulla changes a patient's VS. 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 BP can change with increased intracranial pressure; therefore asking the UAP to repeat the BP 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 acetaminophen.

Which interventions would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? Select all that apply. Consider administering light sedation agents. Observe the skin area under the restraints. Use a stimulating environment in the room. Keep family members away from the patient. Use effective restraints in an agitated patient.

Consider administering light sedation agents. Observe the skin area under the restraints. Use effective restraints in an agitated patient. To prevent injury to the patient, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Check skin area under the restraints for signs of irritation because the irritation can increase the patient's agitation. Using effective restraints in an agitated patient is advisable to ensure a secure outcome. The room should not have a stimulating environment; a calm, nonstimulating environment will help. Do not prevent family members from visiting the patient; instead, allow a family member to visit to assist in calming the patient.

Which assessment would the nurse perform to determine whether the mannitol (Osmitrol) IV treatment had the desired outcome for a patient with a head injury? Increased BP Decrease in body temperature Decreased intracranial pressure Decreased serum blood glucose

Decreased intracranial pressure Administering mannitol decreases intracranial pressure, so measuring this will determine the effectiveness of the drug. Measurements of serum blood glucose, BP, and body temperature occur, but these will not determine the effectiveness of the mannitol.

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

Hematoma Head injury Brain tumor Common causes of increased intracranial pressure include a mass-like hematoma or tumor and cerebral edema due to brain tumors or hydrocephalus, head injury, or brain inflammation. Sinusitis and glaucoma do not cause an increase in intracranial pressure.

Which characteristic would the nurse assess when performing a palmar drift (pronator drift) test during a neurologic assessment? Eye movements Pupillary reaction Strength of the legs Strength of the hands

Strength of the hands A palmar or pronator drift test is an excellent measure of the strength in the upper extremities. In this test, the patient extends their arms up in front of the body with eyes closed. Eye movements are tested by examining the cranial nerve functioning. Test the patient's pupillary reactions with a penlight. Test strength by asking the patient to pull the knees up in bed.

After performing a patient's assessment, which condition supports the nurse's intervention to decline IV administration of mannitol (Osmitrol) to the patient? Cerebral edema Cerebral tissue swelling Increased serum osmolality Increased intracranial pressure (ICP)

Increased serum osmolality Mannitol increases the osmotic effect and may cause neurologic complications; contraindications include administering to a patient with an increased serum osmolality. Use mannitol to treat cerebral edema, cerebral tissue swelling, and increased ICP because of its diuretic effect.

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14? Increased systolic BP, increased pulse, GCS score of 12 Decreased diastolic BP, decreased pulse, and GCS score of 13 Increased systolic and diastolic BP, increased pulse, GCS score of 9 Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4

Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4 One classic sign of increasing intracranial pressure and neurologic deterioration is an increased systolic BP and decreased diastolic BP (resulting in a widening pulse pressure) accompanied by bradycardia. Cushing's triad includes hypertension (elevated systolic pressure and widening pulse pressure), bradycardia, and bradypnea. Increased systolic BP, increased pulse, and GCS of 12 and decreased diastolic BP, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic BP, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the BP and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score, reflecting a fully awake, alert, and oriented patient. Any patient scoring less than 8 on the GCS is comatose.

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

Keep suction equipment readily available at the patient's bedside. Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first seven days after injury. Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Utilize prophylactic antiseizure therapy during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate the condition; therefore the environment should be quiet. Seizure treatment should be used prophylactically. Implement seizure treatment instead of waiting for the confirmation of diagnosis or the seizures to occur. The nurse should administer antiseizure treatment in this situation.

For which complication would the nurse monitor potential development while providing care for a patient with meningitis and ventricle adhesions that prevent the normal flow of cerebrospinal fluid? Cerebral abscess Acute cerebral edema Cranial nerve irritation Noncommunicating hydrocephalus

Noncommunicating hydrocephalus Adhesions preventing the normal flow of cerebrospinal fluid lead to an obstruction of the foramen magnum, which causes noncommunicating hydrocephalus. Cerebral abscess is an accumulation of pus within the brain tissue. An acute cerebral edema is an abnormal increase in water content within the extracellular fluid of the brain. The condition occurs due to hydrocephalus. Cranial nerve irritation is caused by neurologic dysfunctions because of increased intracranial pressure.

Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply. Raise the head of bed above 30 degrees Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Rotate the patient to a side-lying position to prevent skin breakdown. Follow protocol standards to maintain a head-up position for the patient.

Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Follow protocol standards to maintain a head-up position for the patient. Maintaining a head-up position for the patient is important because elevation of the head of the bed promotes drainage and decreases the vascular congestion that can produce cerebral edema. The nurse should take care to prevent extreme neck flexion of the patient because it can cause venous obstruction and contribute to elevated ICP. Position the patient's body to decrease ICP and improve the cerebral perfusion pressure (CPP). Raising the head of the bed above 30 degrees is not advisable because it may decrease the CPP by lowering systemic BP. Rotating the patient to a side-lying position may further increase the ICP. Special air beds can alternate skin pressures to prevent tissue damage.

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

The medication has a short half-life and rapid onset of action. The IV anesthetic propofol gained popularity in management of anxiety and agitation because of the short half-life, which facilitates faster therapeutic action of the drug in the body. The side effect of propofol is hypotension, which limits the use of propofol in hypotensive patients. Propofol does not have an effect on fluid replacement or electrolyte balance in the body.

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

The nurse would frequently monitor the BP and sodium levels. Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. Hypertonic saline provides massive movement of water out of swollen brain cells and into blood vessels. When the patient is on this treatment, frequent monitoring of BP and sodium levels is required because intravascular fluid volume excess can occur. Hypertonic saline is as effective as mannitol in treating increased ICP. The treatment does not require monitoring of blood sugar levels and does not require administration of antacids. IV medications may be administered to prevent gastric ulcers, but not because of the use of mannitol.

For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? Select all that apply. The patient is alert and oriented. The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient has a regular respiratory rate of 14 breaths/min. The patient is vomiting without preceding nausea.

The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient is vomiting without preceding nausea. Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. A patient with increased intracranial pressure would likely have an impaired level of consciousness rather than being alert and oriented. He or she would also have an irregular, not regular, respiratory rate.