Cognition, Traumatic Brain Injury, Unit 4, Sem 4
A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action in response to the parent's concern? a. Discuss with parents the child's previous experiences with pain. b. Discuss with practitioner what analgesia can be safely administered. c. Explain that analgesia is contraindicated with a head injury. d. Explain that analgesia is unnecessary when child is not fully awake and alert.
ANS: B A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and to promote comfort and relieve anxiety.
Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.
ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.
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.
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.
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 consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse only require ongoing monitoring at this time.
The nurse has received report on four children. Which child should the nurse assess first? a. A school-age child in a coma with stable vital signs. b. A preschool child with a head injury and decreasing level of consciousness. c. An adolescent admitted after a motor vehicle accident who is oriented to person and place. d. A toddler in a persistent vegetative state with a low-grade fever.
ANS: B The nurse should assess the child with a head injury and decreasing level of consciousness (LOC) first. Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status.
A patient who is suspected of having an 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 nurse, closely monitoring a child who is unconscious after a fall, notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as the indication of what occurrence? a. Eye trauma b. Neurosurgical emergency c. Severe brainstem damage d. Indication of brain death
ANS: B The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage.
Which statement is most descriptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient, reversible neuronal dysfunction. d. A slight lesion develops remote from the site of trauma.
ANS: C A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head.
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse? A. The apical pulse is slightly irregular. B. The patient complains of a headache. C. The patient is more difficult to arouse. D. The blood pressure (BP) increases to 140/62 mm Hg.
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.
A 5 year old sustained a concussion when falling out of a tree. In preparation for discharge, the nurse is discussing home care with the mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some difficulty concentrating for a while." d. "If I notice diplopia, I will have my child rest for 1 hour."
ANS: C The parents are advised of probably posttraumatic symptoms that may be expected, including difficulty concentrating, and memory impairment. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.
Clinical manifestations of increased intracranial pressure (ICP) in infants are: (Select all that apply.) a. Low-pitched cry b. Sunken fontanel c. Drowsiness d. Irritability e. Distended scalp veins f. Increased blood pressure
ANS: C, D, E Drowsiness, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? A. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture B. A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 C. A 30-yr-old patient who lost consciousness for a few seconds after a fall D. A 40-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.
While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? A. The patient takes warfarin (Coumadin) daily. B. The patient's blood pressure is 162/94 mm Hg. C. The patient is unable to remember the accident. D. The patient complains of a severe dull headache.
Answer is A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.
The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? A. Judgment B. Eye opening C. Abstract reasoning D. Best verbal response E. Best motor response F. Cranial nerve function
Answer is B, D, E 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 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. Test the drainage for the presence of glucose. B. Apply a loose gauze pad under the patient's nose. C. Place the patient in a modified Trendelenburg position. D. Ask the patient to gently blow the nose to clear the drainage.
Answer: B; Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the physician 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 a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.
The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. Document the ICP reading in the chart. B. Determine if the patient has a headache. C. Assess the patient's level of consciousness. D. Position the patient with head elevated 60 degrees.
Answer: C; The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.
Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.
The answer is B. Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.
A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35
The answer is C. A ventriculostomy is a catheter inserted in the area of the lateral ventricle to assess ICP. It will help drain CSF during increase pressure readings and measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and report it to the doctor.
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning
The answer is C. It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).
According to question 16, the patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)? A. 42 B. 74 C. 102 D. 88
The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102.
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size
The answer is C. Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.
Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
The answer is C. These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.
While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips
The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP.
During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.
The answer is D. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
The answers are A, B, D, and E. These activities can increase ICP.
Select the main structures below that play a role with altering intracranial pressure: (select all that apply) A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater
The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.
Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing
The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.
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.
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.
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
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. Complaint 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.
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness
ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs.
What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.
Answer: A; Fluid and electrolyte disturbances 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 administered in the treatment of ICP.
The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure
Answer: B; Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.
Answer: D; A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema.
During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing
B. Decerebrate posturing
A patient is brought to the ED with a head injury and is at risk of developing increased intracranial pressue. Which is the most reliable indicator that the nurse should use for assessing the patient's neurologic status?
LOC
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 alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."
b. "The monitoring system helps show whether blood flow to the brain is adequate."
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.
b. elevate the head of the bed to 30 degrees.
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. 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 who had a craniotomy for a brain tumor and who is now 3 days postoperative and has had continued vomiting
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale
The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal
The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The patient's CPP is 90 and this is normal. A normal CPP is 60-100 mmHg.
Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications
The answer is A. LPs are avoided in patients with ICP because they can lead to possible brain herniation.
You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg
The answer is A. Normal ICP should be 5 to 15 mmHg.
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.
You're collecting vital signs on a patient with ICP. The patient has a Glasgow Coma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary
The answer is A. This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.
A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? A. Check oxygen saturation. B. Assess pupil reaction to light. C. Palpate the head for injuries 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.
You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg
The answer is B. 60-100 mmHg is a normal CPP. Option A (5-15 mmHg) represents a normal intracranial pressure.
What is the appropriate action by the nurse if an assessment of a patient scheduled for a lumbar puncture reveals increased intracranial pressure? (ICP)
Cancel the lumbar puncture
A pt. with a head injury presents to the ED. For which potential complication r/t cerebral hemorrhage and edema should the nurse evaluate this patient?
Increased Intracranial Pressure
External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle
The answer is B. External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle.
The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier
The answers are B and D. These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).
A patient with a head injury has a score of 5 on the GCS. How should the nurse interpret the score?
The patient is unresponsive and comatose Rationale; GCS ranges from 3 to 14, a score of 7 or less indicates patient is in a coma.
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.
a. patency of airway.
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
b. altering the endothelial lining of cerebral capillaries.
A nursing measure that is indicated to 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. keeping the room dark and quiet to minimize environmental stimulation. d. maintaining the patient on strict bed rest with the head of the bed slightly elevated.
b. controlling fever with prescribed drugs and cooling techniques.
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.
c. develops decreased level of consciousness and a headache within 48 hours of a head injury.
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.
A toddler, who fell out of a second-story window, had brief loss of consciousness and vomited 4 times. Since admission, the child has been alert and oriented. The mother asks why a computed tomography (CT) scan is required when the child "seems fine." The nurse should base the response on the need to monitor for what possible complication? a. A brain injury b. Coma c. Seizures d. Skull fracture
ANS: A The child's history of the fall, brief loss of consciousness, and vomiting 4 times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. All the remaining options are a result of varying degrees of brain injury.
Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, 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 of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min B. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min C. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min D. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 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.
Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol b. Epinephrine hydrochloride c. Atropine sulfate d. Sodium bicarbonate
ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction.
What is the priority nursing intervention when a child is unconscious after a fall? a. Establish an adequate airway b. Perform neurologic assessment c. Monitor intracranial pressure d. Determine whether a neck injury is present
ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority.
An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem b. Skull fracture c. Subdural hemorrhage d. Epidural hemorrhage
ANS: A Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.
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/minute
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.
A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.
The answer is B. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.
What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst
The answer is B. Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.
An older adult patient fell and hit their head on a coffee table 2 weeks previously. What type of hematoma should the nurse suspect may have occurred in this patient?
chronic subdural hematoma Rationale: chronic subdural hematoma is most commonly seen in older adults due to the presence of a potentially larger subdural space caused by brain atrophy.
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 between brain tissue, blood, and cerebrospinal fluid.
d. a normal balance between brain tissue, blood, and cerebrospinal fluid.
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP
The answer is C. An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis
The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant? (Select all that apply.) a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations
ANS: B, D, E Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.
The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema b. Delirium c. Doll's head maneuver d. Periodic and irregular breathing
ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Delirium is a state of mental confusion and excitement marked by disorientation to time and place. The doll's head maneuver is a test for brainstem or oculomotor nerve dysfunction.
