MED/SURG2: Chapter 56

The nurse preceptor is working with the newly licensed registered nurse in caring for a patient with a newly placed ventricular shunt. What statement made by the new nurse requires immediate intervention by the preceptor?

"I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches."

The family of a patient who was admitted 12 hours ago with suspected meningitis approaches the charge nurse stating "We do not understand. We were told the spinal tap looks good. Why is everyone still wearing gowns and masks"? What is the best response by the nurse?

"The policy is that patients remain in isolation for a minimum of 24 hours, which is when the first culture report should be available."

A patient experiences a head injury in a motor vehicle crash. Which priority actions does the nurse anticipate providing when planning the care of the patient? Select all that apply.

-Administering oxygen -Maintain neck alignment -Establish intravenous (IV) access

When performing an assessment on a patient with a head injury, which objective data does the nurse record? Select all that apply.

-Battle's sign -Projectile vomiting -Cranial nerve deficits

A patient presents with a head injury and is suspected to have a temporal fracture. Which manifestations should the nurse assess further? Select all that apply.

-Boggy temporal muscle -Cerebrospinal fluid (CSF) otorrhea -Oval-shaped bruise in the mastoid region

Which are characteristics of Cushing's triad? Select all that apply.

-Bradycardia -Systolic hypertension -Widening pulse pressure

The nurse is caring for a patient who is diagnosed with bacterial meningitis. What are the priority actions by the nurse? Select all that apply.

-Collect specimens for a culture to confirm the diagnosis -Administer a corticosteroid along with the first dose of antibiotics -Initiate antibiotic therapy without waiting for a confirmed diagnosis

The nurse is educating a patient about care after a head injury. Which symptoms should the nurse instruct the patient and caregiver to immediately notify a health care provider about? Select all that apply.

-Seizures -Stiff neck -Increased drowsiness

The nurse is preparing to administer a hypertonic saline infusion to a patient to manage increased intracranial pressure (ICP). Which parameters require frequent monitoring? Select all that apply.

-Serum sodium -Blood pressure

When performing a neurologic assessment, what is the nurse assessing when comparing the pupils? Select all that apply.

-Size -Shape -Reactivity -Movement

The nurse is performing an assessment of the central nervous system (CNS) for a patient. What should the nurse be sure to include when documenting the assessment? Select all that apply.

-Speech -Seizures -Bowel and bladder incontinence -Decerebrate or decorticate posturing

A patient experienced a fall and presented to the emergency department with scalp lacerations and a depressed skull. What initial interventions should the nurse perform as emergency management? Select all that apply.

-Stabilize the cervical spine -Administer oxygen via a non-rebreather mask -Control external bleeding with a sterile pressure dressing

When assessing the outcome of surgery in a patient with a brain tumor, which factors should the nurse consider? Select all that apply.

-Surgery can reduce the tumor mass -Surgery can provide relief of symptoms -Surgery can help to extend survival time

When teaching a patient about home care following meningitis, which instructions should the nurse provide regarding the patient's diet? Select all that apply.

-Take small frequent feedings -Include chicken and lean meat in the diet. -Include whole grains, potatoes, and cereals in the diet.

The nurse is educating a patient that is being discharged with a resolved head injury about prevention of further injury. What measures should the nurse include when discussing this? Select all that apply.

-Use of car seat belts -Use of child car seats -Use of helmets by cyclists

The nurse is caring for a patient admitted for surgical removal of a brain tumor. The nurse will plan interventions for this patient based on the knowledge that brain tumors can lead to which complications? Select all that apply.

-Vision loss -Cerebral edema -Pituitary dysfunction -Focal neurologic deficits

A patient with bacterial meningitis has a severe headache. Which symptoms should be monitored by the nurse to prevent complications? Select all that apply.

-Vomiting -Irritability

What will be the Glasgow Coma Scale score of a patient who has a moderate type of head injury?

10

A patient sustained a concussion after a motor vehicle crash and is fully alert when arriving at the emergency department. What does the nurse document that the Glasgow Coma Scale score is?

15

The nurse is assessing the health status of a patient who is unconscious. While assessing, the nurse finds that the patient is opening the eye in response to pain but not to any other stimulus. The patient is moaning to any verbal communication and is showing flexion withdrawal. What is the Glasgow Coma Scale value for this patient?

8

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak?

A halo sign on the nasal drip pad

The nurse is caring for a group of patients on the acute care unit. Which patient is at greatest risk for the development of bacterial meningitis?

A patient with a pulmonary infection

The nurse is caring for four patients in the intensive care unit (ICU). Which patient with an infection is at the highest risk for the development of cerebral edema?

A patient with encephalitis

A patient is diagnosed with viral encephalitis and is hospitalized. What drug does the nurse anticipate administering?

Acyclovir

The nurse is monitoring a patient's intracranial pressure (ICP) after a craniotomy. Which finding must be reported immediately to the health care provider?

An ICP of 20 mm Hg

The nurse is performing an assessment of a patient with a closed head injury from a blunt object. What is the most reliable clinical manifestation to determine the patient may be developing increased intracranial pressure (ICP)?

An altered level of consciousness (LOC)

The nurse is caring for a patient with a brain tumor. Which diagnostic test would the nurse prepare the patient for to further localize and detect blood flow?

Angiography

A patient's cerebrospinal fluid (CSF) culture findings showed a white blood cell count of 1200 cells/µL, protein 600 mg/dL, and glucose 25 mg/dL. What could be the diagnosis for the patient?

Bacterial meningitis

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 lumber puncture

A patient with meningitis has a weakness of the left upper limb and lower limb, blurred speech, and reduced vision. The symptoms did not resolve after treatment. What does the nurse infer from these symptoms?

Cerebral abscess

A patient with a head injury is scheduled for a lumbar puncture. What should the nurse closely monitor this patient for?

Cerebral herniation

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

The nurse is reviewing a patient's imaging studies, which show the presence of lateral displacement of brain tissue beneath the falx cerebri. Which type of herniation does the nurse suspect may be present?

Cingulate herniation

What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces?

Comminuted

A patient with meningitis developed loss of the corneal reflex. Which cranial nerve irritation would have led to the loss of the corneal reflex?

Cranial nerve V

A patient sustains a skull fracture and has loose fragments of bone. For which procedure will the nurse prepare the patient?

Craniotomy

The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is suspected to have encephalitis. What type of encephalitis does the nurse anticipate the patient is at risk for?

Cytomegalovirus encephalitis

The nurse is reviewing the laboratory results for a patient with bacterial meningitis. What does the nurse anticipate observing in cerebrospinal fluid analysis?

Decrease in glucose level

The nurse determines that a patient's mean arterial pressure (MAP) is below 70 mm Hg. What outcome of this MAP should be of most concern to the nurse?

Decreased cerebral blood flow (CBF)

The nurse is assessing the waveforms for a patient receiving intracranial pressure (ICP) monitoring and observes a waveform representing venous pulsations. What type of waveform does the nurse document?

Dicrotic wave

A patient sustained head trauma during a skiing accident and lost consciousness but was then awake and alert. What complication of a head trauma might this patient have developed that results in bleeding between the dura and the inner surface of the skull?

Epidural hematoma

A patient with head trauma has a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which action should the nurse perform first?

Evaluate the urine specific gravity

The nurse is caring for a patient with meningitis that has a fever. Which parameter should be monitored to prevent complications for this patient?

Fluid intake

A nurse is caring for a patient who has increased intracranial pressure and diabetes insipidus. When monitoring urine output, for what is the nurse assessing the patient?

Hypernatremia

A patient is intubated and mechanically ventilated and is ordered dexmedetomidine. To what side effect of the medication should the nurse monitor?

Hypotension

The nurse is performing a neurologic assessment for a patient and observes a fixed unilateral dilated pupil. Which cranial nerve does the nurse suspect is being compressed?

III

A patient with a head injury presents to the emergency department. For which potential complication related to cerebral hemorrhage and edema should the nurse evaluate this patient?

Increased intracranial pressure

When a patient's systemic arterial pressure is altered, how does the brain respond?

It autoregulates

A patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). The patient has been maintained on intravenous (IV) fluids for two days. The nurse seeks enteral feeding for this patient based on what rationale?

Malnutrition promotes continued cerebral edema

The nurse is caring for a patient with increased intracranial pressure (ICP). Which osmotic diuretic does the nurse prepare to administer to lower the ICP?

Mannitol

A patient with meningitis is suffering from mental distortion. Which intervention should be performed to reduce mental distortion?

Minimize environmental stimuli

The nurse is monitoring a patient who has undergone a craniotomy. What is the priority action by the nurse?

Monitor the patient for increased intracranial pressure (ICP).

The nurse is caring for a patient in the neurologic intensive care unit that is undergoing intracranial pressure (ICP) monitoring through an intracranial device. What intervention should the nurse ensure that the health care provider is aware of?

Monitoring for more than five days

Using the Glasgow Coma Scale (GCS), the nurse assesses the patient and records a score of 5. What is the nurse's priority action?

Notify the rapid response team.

A patient has visual impairment and hallucinations. Which lobe of the brain would show a presence of an abscess on a computed tomography scan?

Occipital lobe

A patient with a brain tumor presents with symptoms of visual disturbances and seizures. When evaluating the patient, the nurse knows that this tumor is most likely located in which area of the brain?

Occipital lobe

A patient with a brain tumor reports speech disturbances and inability to write. Which part of the cerebral hemisphere may be affected by the tumor?

Parietal lobe

A nurse is assessing four patients with different types of skull fractures. Which patient would have a low-velocity injury as the cause of skull fracture?

Patient A

The nurse is caring for a patient that has developed hydrocephalus. Which surgical procedure does the nurse prepare the patient for?

Placement of a ventriculoatrial shunt

A patient with increased intracranial pressure (ICP) has an order for phenytoin. What does the nurse anticipate the expected outcome of administering phenytoin will be for the patient?

Prevention of seizures

The nurse is reviewing the medical records of a patient with acquired immunodeficiency syndrome (AIDS) that has been diagnosed with a brain tumor. What tumor growth is associated with AIDS?

Primary central nervous system lymphoma

What medication with a rapid onset and a short half-life can be used for anxiety and agitation in a patient with increased intracranial pressure?

Propofol

Which action should the nurse include in the plan of care for a patient who has bacterial meningitis?

Reducing the patient's environmental stimuli as much as possible

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation?

Resistance to flexion of the neck

The nurse is preparing a patient for cranial surgery to provide an alternate pathway to redirect cerebrospinal fluid (CSF). What surgery should the nurse ensure the consent is signed for?

Shunt placement

At which stage of increased intracranial pressure (ICP) does a loss of autoregulation occur?

Stage III

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need to be prepared for which treatment modality?

Surgery

The nurse is caring for a patient with increased intracranial pressure (ICP) resulting from a mass lesion in the brain. About what treatment option does the nurse educate the patient that will have the best outcome?

Surgery

The laboratory reports of a patient with a brain tumor, who reports uncontrolled urination and excessive thirst, show high sodium levels. The nurse also observes involuntary eye movements and suspects which type of brain tumor?

Thalamus and sellar tumor

The nurse notes watery sanguineous drainage from the nares of a patient who is being evaluated after falling from a roof. What is the best method for the nurse to validate suspicion of rhinorrhea?

The halo test

A patient with a head injury has a score of five on the Glasgow Coma Scale. How should the nurse interpret the score?

The patient is unresponsive and comatose

Which population has the highest rate of malignant brain tumors?

White males

The nurse caring for a patient with a diagnosis of acute meningitis. Which actions should the nurse perform? Select all that apply.

-Place the patient in a comfortable position -Position the patient in a curled up position with the head slightly extended -Slightly elevate the head of the bed if permitted after lumbar puncture

The nurse is caring for a patient who sustained a head injury during a fall. Which factors influence intracranial pressure (ICP)? Select all that apply.

-Posture -Temperature -Carbon dioxide levels -Intraabdominal pressure

A patient is diagnosed with a brain abscess. When performing an assessment on this patient, what causes does the nurse determine for the development of this problem? Select all that apply.

-Prior brain trauma or surgeryPrior brain trauma or surgery -Distant spread from a pulmonary infection - Correct 5 Direct extension from an ear or sinus infection

When managing a fever in a patient with acute meningitis, what actions should the nurse perform? Select all that apply.

-Reduce fever with the use of acetaminophen -Use a cooling blanket on the patient to reduce fever -Lower temperature by the use of tepid water sponge baths

When planning the care of a patient with a brain tumor, which goals should the nurse select as primary goals? Select all that apply.

-Removing tumor mass -Identifying the tumor type and location -Managing increased intracranial pressure (ICP)

A patient is admitted with elevated intracranial pressure (ICP). What factors should the nurse be sure are avoided that may create further elevation in intracranial pressure? Select all that apply.

-Pain and agitation -Extreme hip flexion -Increased intrathoracic pressure

The nurse is assessing a comatose patient. Which findings does the nurse anticipate observing? Select all that apply.

-Patient does not respond to painful stimuli -Patient has incontinence of urine and feces -Patient's corneal and pupillary reflexes are absent

A patient with bacterial meningitis develops seizures. What are the appropriate nursing actions for this patient? Select all that apply.

-Convey an attitude of caring -Administer antiseizure medications -Keep a familiar person at the patient's bedside.

A patient with a tumor of the frontal lobe is reported to have disorientation and confusion due to perceptual problems. What actions should the nurse perform to comfort the patient? Select all that apply.

-Create a routine -Use reality orientation. -Minimize environmental stimuli.

A patient is diagnosed with a brainstem tumor. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply.

-Crossed eyes -Facial muscle weakness -Headache on awakening

A patient with a brain tumor reports inability to eat. What appropriate actions should the nurse perform? Select all that apply.

-Encourage the patient to eat -Ensure adequate nutritional intake -Assess the patient's nutritional status

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS)? Select all that apply.

-Eye opening -Best verbal response -Best motor response

A patient reports a headache, which is worse in the morning and aggravated with movements, as well as vomiting without any preceding nausea. When assessing the patient, which common causes should the nurse consider when suspecting increased intracranial pressure? Select all that apply.

-Hematoma -Head injury -Brain tumor

Which are components of a secondary intracranial injury? Select all that apply.

-Hypoxia -Ischemia -Hypotension -Increased intracranial pressure

The nurse is performing an assessment for a patient that has been comatose for seven hours and then awakens. Which manifestations does the nurse anticipate finding while performing the assessment? Select all that apply.

-Loss of concentration -Loss of social restraint -Euphoria and mood swings

When evaluating the diagnostic studies for a patient with bacterial meningitis, which factors should the nurse consider regarding lumbar puncture? Select all that apply.

-Lumbar puncture is done after ruling out an obstruction in the foramen magnum. -Lumbar puncture is usually helpful in confirming the diagnosis of bacterial meningitis. -Lumbar puncture is done to analyze cerebrospinal fluid (CSF) in case of bacterial meningitis

What is the gold standard for measuring intracranial pressure (ICP)?

Ventriculosotomy

The nurse is providing discharge instructions for a patient and a caregiver for the first three days after a head injury. Which information is important for the nurse to include?

Abstain from alcohol.

The nurse reviews the x-ray reports of a patient who has a skull fracture, which reveals multiple linear fractures and the presence of a fragmented bone. Which type of skull fracture does the nurse suspect?

Comminuted type

A patient is brought to the emergency room with a head injury and is at risk of developing increased intracranial pressure. Which is the most reliable indicator that the nurse should use for assessing the patient's neurologic status?

Level of consciousness

The nurse is caring for a patient that sustained a traumatic brain injury in a motor vehicle crash. Which condition indicates to the nurse when planning the care of the patient to maintain closure of the eyes?

Loss of the corneal reflex

A patient with meningococcal meningitis is suspected to have Waterhouse-Friderichsen syndrome. Which possible findings would the nurse observe regarding this complication? Select all that apply.

-Petechiae -Adrenal hemorrhage -Disseminated intravascular coagulation (DIC)

The nurse is assessing the clear nasal discharge from a patient that sustained head trauma and notes that it is positive to a Dextrostix test. What does the nurse concur from this finding?

The patient has cerebrospinal fluid (CSF) rhinorrhea

A patient with bacterial meningitis is given antibiotic therapy and symptomatic treatment. What is the expected treatment outcome?

The patient may return to maximal neurologic function

The nurse is caring for a patient that had a craniotomy. In planning long-term care for the patient, what must the nurse include when teaching the patient, family, and caregiver?

There are often residual changes in personality and cognition.

The nurse is preparing to administer temozolomide to a patient with a brain tumor and assesses the patient's neutrophil count to verify it is greater than 1500/µL. What is the rationale behind this nursing intervention?

To prevent immune-related complications

How many meningococcal polysaccharide vaccine doses are recommended for the vaccination of bacterial meningitis?

Two

Which type of cerebral edema occurs mainly in the white matter and is characterized by leakage of large molecules from the capillaries into the surrounding space?

Vasogenic cerebral edema