Neuro
The nurse is assessing a patient who is experiencing altered taste. Which cranial nerve does the nurse assess during the patient's physical examination?
The glossopharyngeal nerve is connected to the medulla and has both sensory and motor functions. Damage to this nerve may result in altered taste.
A patient is diagnosed with viral encephalitis and is hospitalized. What drug does the nurse anticipate administering? 1 Acyclovir 2 Ampicillin 3 Vidarabine 4 Vancomycin
1- Acyclovir is the drug of choice to treat viral encephalitis because it has fewer side effects. Ampicillin and vancomycin are used to treat bacterial meningitis. Vidarabine is used to treat encephalitis, but it has more side effects than acyclovir.
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? 1 Contusion 2 Epidural hematoma 3 Subdural hematoma 4 Intracerebral hematoma
2- An epidural hematoma is bleeding between the dura and the inner surface of the skull. The patient may lose consciousness followed by a period of being awake and alert. A subdural hematoma is bleeding between the dura and the arachnoid layer of the meninges. An intracerebral hematoma is bleeding into the brain tissue. A contusion is bruising of the brain tissue within a focal area.
An intubated and mechanically ventilated patient is ordered dexmedetomidine. Which side effect of the medication would the nurse monitor for in this patient? 1 Insomnia 2 Blood pressure changes 3 Hyperanxiety 4 Sedative effect
2- Dexmedetomidine is an α2-adrenergic agonist used for continuous intravenous 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.
A patient with a head injury has a score of five on the Glasgow Coma Scale. How should the nurse interpret the score? 1 The patient is alert and oriented. 2 The patient is unresponsive and comatose. 3 The patient is awake but lethargic and drowsy. 4 The patient responds appropriately to commands.
2- The Glasgow Coma Scale ranges from 3 to 14. A score of seven 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 seven.
How many doses of meningococcal conjugate vaccine are recommended for prevention of bacterial meningitis? 1 One 2 Two 3 Three 4 Four
2- The meningococcal conjugate vaccine is given in two doses to prevent bacterial meningitis. The first dose is recommended for all 11 to 12 year old, with a booster dose given at age 16.
A patient has a systemic blood pressure of 120/60 and an intracranial pressure (ICP) of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? 1 High blood flow to the brain 2 Normal intracranial pressure 3 Impaired blood flow to the brain 4 Adequate autoregulation of blood flow
3-Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = systolic blood pressure (SBP) + 2 (diastolic blood pressure [DBP])/3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP-ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.
The nurse is 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? 1 Uncal herniation 2 Central herniation 3 Tentorial herniation 4 Cingulate herniation
4- Lateral displacement of brain tissue beneath the falx cerebri results in cingulate herniation. Lateral and downward herniation results in uncal herniation. Forces caused by a mass lesion in the cerebrum cause downward movement of the brain, which results in central herniation or tentorial herniation.
The nurse is caring for a patient who sustained a head injury during a fall. Which factors influence intracranial pressure (ICP)? Select all that apply. 1 Posture 2 Swallowing 3 Drowsiness 4 Temperature 5 Carbon dioxide levels 6 Intraabdominal pressure
1,4,5,6- 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.
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. 1 Sneezing 2 Seizures 3 Stiff neck 4 Constipation 5 Increased drowsiness
2,3,5- 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.
A nurse is caring for a patient with a traumatic brain injury and increased intracranial pressure (ICP). Which symptom would the nurse report to the physician immediately? 1 ICP of 20 mm Hg 2 Urine output of 1000 mL in 1 hr 3 Respiratory rate of 24 4 Pulse of 100 beats/minute
2- 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, and pulse of 100 beats/minute do not indicate a need for the nurse to call the physician.
The nurse is preparing to change the body position of a patient with increased intracranial pressure (ICP). Which factors should the nurse consider prior to changing the position? Select all that apply. 1 Placing the patient in side-lying position 2 Raising the head of bed above 30 degrees 3 Maintaining a head-up position for the patient 4 Taking care to prevent extreme neck flexion of patient 5 Adjusting the patient's body position to decrease intracranial pressure (ICP)
3,4,5- 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. The patient's body position should be adjusted 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 blood pressure (BP). Maintaining a side-lying position may further increase the ICP.
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? 1- 3 2-6 3-8 4-15
4 -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 to 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.
A nurse should assess pupillary response in a patient with a head trauma and suspected intracranial pressure to evaluate the functioning of which cranial nerve? 1 XII 2 X 3 V 4 III
4- Cranial nerve III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. Cranial nerve XII controls tongue movement, cranial nerve X is the vagus nerve, and cranial nerve V is the trigeminal nerve.
What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces? 1 Linear 2 Depressed 3 Compound 4 Comminuted
4- A comminuted skull fracture has multiple linear fractures with fragmentation of bone into many pieces. A depressed fracture is an inward dentation of the skull. A linear fracture is a break in continuity of the bone, and a compound skull fracture involves a depressed skull fracture and scalp lacerations.
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? 1 A patient with a skull fracture 2 A patient with prior brain trauma 3 A patient with a pulmonary infection 4 A patient with bacterial endocarditis
A patient with a pulmonary infection is at a risk of developing bacterial meningitis. A skull fracture, bacterial endocarditis, and prior brain trauma or surgery places the patient at risk of developing brain abscess.
The nurse is caring for a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient?
Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech.
A patient presents with a shunt malfunction related to increased intracranial pressure (ICP). On examination, which findings would the nurse observe? Select all that apply. 1 Cough 2 Blurred vision 3 Gaseous distention 4 Headache and vomiting 5 Decreased level of consciousness
Blurred vision, headache and vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant.
One of the unlicensed assistive personnel (UAP) reports the following vital signs (VS) obtained from a patient with a suspected brain injury: temperature = 101.6° F orally, heart rate = 58, R = 14, and blood pressure = 162/48. What is the nurse's priority response? 1 Ask the UAP to repeat the blood pressure. 2 Compare the current VS to baseline VS recorded. 3 Validate the VS by repeating the VS measurements. 4 Administer prescribed acetaminophen (Tylenol) for fever.
Change in vital signs is caused by increasing pressure on the thalamus, hypothalamus, pons, and medulla. Manifestations, such as Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations), are often late signs of markedly increased intracranial pressure (ICP). The nurse should compare the vital signs obtained with baseline vital signs recorded. If there is a deviation from baseline, the nurse should assess the patient, including a repeat set of VS to validate findings. More than just the blood pressure can change with increased intracranial pressure; therefore, asking the UAP to repeat the blood pressure only will not provide any further data. An elevated temperature in a patient with a head injury may indicate a hypothalamic response from injury. The nurse should gather all assessment data before administering antipyretic.
A nurse is caring for a patient with a closed head injury and increasing intracranial pressure. Which of the following manifestations does the nurse report to the health care provider that represent Cushing's triad? Select all that apply. 1 Bradycardia 2 Weak pulse 3 Irregular respirations 4 Increasing systolic blood pressure 5 Decreasing systolic blood pressure
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 blood pressure increases, not decreases.
A nurse is assessing the mental function of a patient with a neurologic disorder. What assessment findings would the nurse recognize should be reported to the primary care provider? Select all that apply
Fleeting attention and over talkativeness imply a disturbance in mental status. If the patient is well-groomed and sits comfortably, this indicates that the patient is aware of his or her appearance and behavior. An easy flow of conversation indicates that the patient can communicate well.
The trochlear nerve
Is the only cranial nerve that arises from the back of the brain stem. This nerve controls the superior oblique muscle of the eye. Paralysis of the trochlear nerve results in rotation of the eyeball upward and outward, leading to double vision.
A nurse is educating a patient's family about intracranial pressure (ICP). The nurse explains that normal ICP is a balance of which three components? 1 Blood pressure, brain tissue, body mass index 2 Glucose level, blood pressure, and brain tissue 3 Blood pressure, brain tissue, and cerebrospinal fluid 4 Blood pressure, brain tissue, and ventricles of the brain
Normal ICP involves a balance of blood pressure, brain tissue, and cerebrospinal fluid. The ventricles of the brain, glucose level, and body mass index do not contribute to maintaining normal ICP.
Which outcomes indicate effective treatment in a patient with increased intracranial pressure who underwent a tracheostomy to help maintain adequate ventilation? Select all that apply. 1 PaO2 of the patient is 80 mm Hg 2 PaO2 of the patient is 90 mm Hg 3 PaO2 of the patient is 110 mm Hg 4 PaCO2 of the patient is 40 mm Hg 5 PaCO2 of the patient is 30 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 and PaCO2 values of 110 and 40 mm Hg indicate effective treatment. A PaO2 of less than 100 and PaCO2 of less than 35 mm Hg indicate ineffective treatment.
The nurse is performing an assessment of the accessory nerve. What should the nurse ask the patient to do?
The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles.
The vagus nerve is
also connected to the medulla and has sensory, motor, and parasympathetic fibers. Damage to this nerve can result in gastroparesis.
The hypoglossal nerve is
connected to the medulla; its motor nerves are connected to the muscles of the tongue. Damage to this nerve can cause paralysis of the tongue.
When evaluating level of consciousness on the basis of the Glasgow Coma Scale (GCS), which possible responses could be scored under best motor response? Select all that apply. 1 Flexion withdrawal 2 Localization of pain 3 Obedience of command 4 Disorganized use of words 5 Opening the eyes in response to sound
1,2,3- Flexion withdrawal, localization of pain, and obedience of command can be recorded under best motor response. Opening of the eyes in response to stimuli and disorganized use of words are not recorded under motor response.
What rate should blood flow in the brain in order to maintain normal function? 1 15 mL/100 g 2 25 mL/100 g 3 55 mL/100 g 4 70 mL/100 g
3- Blood flow must be maintained at 55 mL/100 g for optimal brain functioning. Blood flow of 15 mL/100 g or 25 mL/100 g is not sufficient for optimal brain functioning. Blood flow of 70 mL/100 g indicates an increased rate.
A patient who sustained a stroke is having a severe headache, vomiting, dysphagia, dysarthria, and eye movement disturbances. What type of stroke does the nurse determine to correlate with these clinical manifestations? 1 Embolic stroke 2 Thrombotic stroke 3 Intracerebral hemorrhage 4 Subarachnoid hemorrhage
3- Symptoms such as headaches, vomiting, dysphagia, dysarthria, and eye movement disturbances indicate intracerebral hemorrhage. An embolic stroke is mostly related to heart conditions such as atrial fibrillation, myocardial infarction, and infective endocarditis. A thrombotic stroke has the clinical manifestation of decreased level of consciousness in the first 24 hours. Clinical manifestations such as stiff neck and cranial nerve deficits indicate a subarachnoid hemorrhage.
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? 1 Tonic spasms of the legs 2 Curling in a fetal position 3 Arching of the neck and back 4 Resistance to flexion of the neck
4- Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.
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? 1 Dim vision 2 Papilledema 3 Body temperature 4 Level of consciousness
4- 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.
During shift hand-off, the off-going registered nurse (RN) reports that the patient had a positive Romberg test on earlier examination. What will be the oncoming nurse's priority intervention?
A positive Romberg test indicates that the patient is having difficulty with balance. The nurse will want to inform UAP that the patient is at risk for falls and will need assistance with activity.
A nurse is caring for a patient for whom the health care team suspects cerebral death. Which diagnostic procedure will the nurse prepare the patient for that will confirm this suspicion? Reflex test Myelogram Lumbar puncture Cerebral angiography
Cerebral angiography is a form of angiography that provides images of blood vessels in and around the brain. Lack of cerebral circulation is an important confirmatory test for cerebral death (brain death). A myelogram is an x-ray of the spinal cord and vertebral column performed after an injection of contrast medium into the subarachnoid space. Reflex tests help to assess the integrity of the nerve circuits and are performed to quickly confirm the integrity of the spinal cord or specific nerve root function. Lumbar puncture is done to aspirate cerebrospinal fluid.
The nurse is planning the care for a patient with increased intracranial pressure (ICP). What actions should the nurse plan to perform to provide the most comfort for the patient? Select all that apply. 1 Minimize procedures that can produce agitation. 2 Observe the patient for signs of agitation or irritation. 3 Teach the patient's family about increasing stimulation. 4 Make the patient remain in a quiet and calm environment. 5 Allow the patient's family to visit the patient more often.
1,2,4- When managing the patient with increased ICP, procedures that can produce agitation should be avoided. The patient should be observed for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. The stimulation levels should be decreased, and patient's family should be instructed to decrease stimulation and reduce noise, including not visiting too frequently.
A patient with 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. 1 Create a routine. 2 Use reality orientation. 3 Provide increased stimuli. 4 Make the patient drive a vehicle. 5 Minimize environmental stimuli.
1,2,5- Creating a routine, using reality orientation, and minimizing environmental stimuli are appropriate actions to comfort the confused patient and to familiarize the confused patient with the environment. Providing increased stimuli and making the patient drive a vehicle are not advisable because they increase the risks for confusion.
The nurse is caring for a patient with increased intracranial pressure. Which actions should the nurse perform to promote optimal outcomes for the patient? Select all that apply. 1 Maintain fluid balance and assess osmolality. 2 Maintain intubation and mechanical ventilation. 3 Lower the head of the bed and turn the patient to one side. 4 Wait for the respiration to improve before beginning with ventilation. 5 Elevate the head of the bed to 30 degrees with the head in a neutral position.
1,2,5- 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.
A patient on the intensive care unit has increased intracranial pressure (ICP) and a decreased level of consciousness. What actions should the nurse perform to prevent injury to the patient? Select all that apply. 1 Consider the use of light sedation agents. 2 Observe the skin area under the restraints. 3 Use a stimulating environment in the room. 4 Keep family members away from the patient. 5 Use effective restraints in an agitated patient.
1,2,5-To prevent the patient from injury, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Skin area under the restraints should be checked for signs of irritation, because it 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. Family members should not be prevented from visiting the patient. Instead allowing a family member to visit may help to calm the patient.
A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment? Select all that apply. 1 Monitor fluid intake and sodium levels regularly. 2 Monitor patient's sleep and diet routine regularly. 3 Perform blood glucose monitoring at least every six hours. 4 Avoid taking any antacids along with corticosteroid treatment. 5 Start concurrent treatment with antacids or proton pump inhibitors.
1,3,5- Patients on corticosteroid treatment should be regularly monitored for fluid intake and sodium levels. Blood glucose monitoring should be performed at least every six hours until hyperglycemia is ruled out. Starting concurrent treatment with antacids or proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding, because complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal bleeding. Regularly monitoring the patient's sleep and diet routine does not contribute to avoiding complications related to corticosteroid therapy. Antacids should be given along with corticosteroids to prevent gastrointestinal complications.
A patient has been diagnosed with a right-sided brain tumor resulting in significant increased intracranial pressure (ICP). The nurse can expect to document which assessment findings? Select all that apply. 1 Ipsilateral pupil dilation 2 Ipsilateral hemiparesis 3 Contralateral hemiparesis 4 Contralateral pupil dilation 5 Altered level of consciousness
1,3,5- 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 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).
The nurse is caring for a patient with increased intracranial pressure (ICP). What seizure precautions should the nurse take to protect the patient? Select all that apply. 1 Keep suction equipment readily available. 2 Provide sufficient stimulation to the patient. 3 Use seizure treatment only after confirming the diagnosis. 4 Use padded side rails and maintain an airway at the bedside. 5 Use prophylactic antiseizure therapy during first seven days after injury.
1,4,5- 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. Prophylactic antiseizure therapy can be used during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate his condition; therefore, the environment should be quiet. Seizure treatment should be used prophylactically; instead of waiting for the confirmation of diagnosis or the seizures to happen, the nurse should administer antiseizure treatment in such a situation.
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? 1 Decreased cerebral blood flow (CBF) 2 Increased intracranial pressure (ICP) 3 Increased cerebral perfusion pressure (CPP) 4 Normal intracranial pressure (ICP)
1- A MAP below 70 mm Hg results in a decreased CBF. It will not result in an increased or normal ICP. The cerebral perfusion pressure will be decreased. A MAP below 70 mm Hg does not necessarily guarantee a normal ICP.
The nurse is caring for a patient in the neurologic intensive care unit with increased intracranial pressure (ICP). What assessment data obtained by the nurse indicates a worsening of the patient's condition? 1 Presence of fixed unresponsive pupils 2 Sluggish reaction of pupil in response to light 3 Brisk constriction of pupil in response to light 4 Slight constriction in the opposite pupil in response to light
1- 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.
The nurse is caring for a patient experiencing increased intracranial pressure (ICP). What is the priority nursing action in the care of this patient? 1 Monitor fluid and electrolyte status carefully. 2 Position the patient in a high Fowler's position. 3 Administer vasoconstrictors to maintain cerebral perfusion. 4 Maintain physical restraints to prevent episodes of agitation.
1-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 typically are not administered in the treatment of ICP.
When considering the use of hypertonic saline treatment in a patient with increased intracranial pressure (ICP), which factors should the nurse consider? Select all that apply. 1 The nurse should closely monitor blood sugar levels in the patient. 2 The nurse should frequently monitor the blood pressure and sodium levels. 3 Hypertonic saline treatment works similarly to mannitol in treating increased ICP. 4 Hypertonic saline treatment provides massive movement of water out of swollen brain cells. 5 The nurse should ensure that antacid is given to prevent gastrointestinal complications.
2,3,4- 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 blood pressure 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 antacids are not required to be given.
The nurse is caring for a patient with increased intracranial pressure (ICP). What actions should the nurse perform as a part of nutritional therapy? Select all that apply. 1 Keep the patient in a hypovolemic fluid state. 2 Begin parenteral nutrition if oral intake is not adequate. 3 Begin nutritional replacement within three days after injury. 4 Wait for at least seven days to begin nutritional replacement. 5 Evaluate the patient's urine output, fluid loss, and electrolyte balance.
2,3,5- For a patient with increased ICP, parenteral nutrition should be started if oral intake is not adequate. Nutritional replacement should begin within three days after injury. The patient's urine output, fluid loss, and electrolyte balance should be monitored to evaluate the effectiveness of nutritional therapy. The patient should not be kept in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, full nutritional replacement should be reached within seven days after injury.
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. 1 Blood glucose 2 Serum sodium 3 Blood pressure 4 Level of sedation 5 Gastrointestinal disturbances
2,3- Hypertonic saline solutions are used to treat increased ICP. Hypertonic saline infusions increase the intravascular fluid volume, which may alter the serum sodium levels and blood pressure in the body. Blood glucose monitoring is required if the patient is given corticosteroids. Sedation is monitored if the patient is administered barbiturates. Gastrointestinal disturbances are monitored if the patient is administered corticosteroids.
A patient being treated for viral meningitis arrives at the hospital reporting a persistent severe headache. Which nursing intervention is most appropriate for the patient? 1 Telling the patient to use analgesics 2 Informing the patient that headaches can occur after recovery 3 Informing the patient that a headache is not a major complication 4 Informing the patient that a full recovery from viral meningitis is not possible
2- The patient should be informed that headaches will occur post recovery, even though they are a rare manifestation. The patient should be treated symptomatically, based on the reason for developing the headache. A complete recovery is expected. A severe headache might be a major complication.
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? 1 Tachypnea 2 Bradycardia 3 Hypotension 4 Narrowing pulse pressure
2-Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist 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).
A nurse is using the Glasgow Coma Scale (GCS) to assess a patient who fell out of a tree and sustained a head injury and developed increased intracranial pressure. Which components will the nurse assess? 1 Swallowing, speaking, and following verbal commands 2 Swallowing, pupillary response, and following verbal commands 3 Speaking, responding to stimuli, and following verbal commands 4 Responding to stimuli, swallowing, and following verbal commands
3- The GSC assesses a patient's ability to respond to stimuli, speak, and follow verbal commands. Swallowing and pupillary response are not components of the GSC.
After undergoing surgery for resection of a brain tumor, a patient arrives in the postanesthesia care unit with a temperature of 100° F (37.7° C), blood pressure of 130/76 mm Hg, pulse 64 beats/minute, a urinary catheter in place, and oxygen being administered at a rate of 2 L/min by way of a nasal cannula. One hour later, the nurse assesses the patient. Which assessment finding does the nurse realize should be reported immediately to the surgeon? 1 Presence of a gag reflex 2 Urine output of 50 mL during the past hour 3 Blood pressure of 148/58 mm Hg and pulse 48 beats/minute 4 Temperature of 99.8° F (37.6° C) and pulse of 96 beats/minute
3- A blood pressure with a widening pulse pressure, bradycardia, and irregular respirations are associated with increasing intracranial pressure (ICP). This is known as the Cushing's triad and 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/minute are acceptable assessment findings in a postoperative patient.
A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above how many mm Hg to preserve cerebral perfusion? 1 20 2 40 3 60 4 80
3- Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained above 60 mm Hg to preserve cerebral perfusion.
Following an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which behavior of the patient supports the nurse's conclusion? 1 Movement of the eye in the opposite direction to the turning head 2 Movement of the eye in the upward direction when the neck is flexed 3 Movement of the eye in the sideward direction when the neck is extended 4 Movement of the eye in the downward direction when the neck is extended
3- The oculocephalic reflex is tested by having the patient turn his or her head briskly to the left or right while holding the eyelids open. The eye movement should be in the opposite direction and not in the sideward direction if the neck is extended. The sideward eye movement indicates an intracranial lesion. Movement of the eye in the opposite direction to the turning head is a normal response. Movement of eye in the upward direction if the neck is flexed is normal and does not indicate any abnormality. Movement of the eye in the downward direction if the neck is extended indicates a normal finding.
The patient with increased intracranial pressure (ICP) resulting from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? 1 Administer intravenous (IV) mannitol. 2 Use ventilator to hyperoxygenate the patient. 3 Use strict aseptic technique with dressing changes. 4 Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).
3- 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 prescribed. 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.
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? 1 Free water should be avoided. 2 Sodium restrictions can be managed. 3 Dehydration can be avoided better with feedings. 4 Malnutrition promotes continued cerebral edema.
4- A patient with diffuse axonal injury is unconscious, and with increased ICP 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. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.
A patient with meningitis has adhesions that prevent the normal flow of cerebrospinal fluid from the ventricles. Which complication might be observed first? 1 Cerebral abscess 2 Acute cerebral edema 3 Cranial nerve irritation 4 Noncommunicating hydrocephalus
4- 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.
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? 1 Epidural hematoma 2 Intracerebral hematoma 3 Acute subdural hematoma 4 Chronic subdural hematoma
4- Chronic subdural hematoma is most commonly seen in older adults due to the presence of a potentially larger subdural space caused by brain atrophy. Atrophy increases tension in the brain even though it is attached to the supportive structures, and it is subjected to tearing. Epidural hematoma, intracerebral hematoma, and acute subdural hematoma are common in all age groups.
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? 1 Anxiety 2 Hyperthermia 3 Impaired physical mobility 4 Increased intracranial pressure
4- 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.
The nurse is maintaining a propofol drip in the intensive care unit for a patient on a mechanical ventilator. What does the nurse inform the family about the benefit of the drug regarding managing anxiety and agitation? 1 It reduces blood pressure in the body. 2 It causes fluid replacement effectively. 3 It maintains electrolyte balance effectively. 4 It has a short half-life and rapid onset of action.
4- Intravenous (IV) anesthetic propofol has gained popularity in management of anxiety and agitation because it has a short half-life, which facilitates faster therapeutic action of the drug in the body. The side effect of propofol is hypotension, and it limits the use of propofol in hypotensive patients. Propofol does not have effect on fluid replacement or electrolyte balance in the body.
A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute. Two hours later the nurse assesses the patient. Which finding indicates deterioration in the patient's condition? 1 The patient does not remember what happened. 2 The patient is sleeping but awakens in response to painful stimuli. 3 Blood pressure is 110/80 mm Hg, pulse is 78 beats/minute, and respirations are 20 breaths/minute. 4 Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.
4- Late signs of increased intracranial pressure include an increased systolic blood pressure and decreasing diastolic blood pressure (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a blood pressure of 110/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute do not necessarily indicate deterioration in the patient's condition.
A nurse assesses the intracranial pressure (ICP) of a patient with head trauma. The nurse compares the assessment data with which normative value for ICP? 1 5 to 15 mm Hg 2 25 to 35 mm Hg 3 45 to 60 mm Hg 4 80 to 120 mm Hg
A normal intracranial pressure (ICP) reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention.
A patient has hemianopsia from a brain lesion. Which cranial nerve does the nurse determine is affected in this patient?
Optic nerve- A change in one-half of the visual field resulting from brain lesions is referred to as hemianopsia. Visual fields and acuity assessment will determine the function of the optic nerve.
