w5

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? Visualization of a hemorrhage Aspiration of a brain abscess Access for intravenous (IV) fluids To assess visual acuity

Aspiration of a brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased pulse Increased respirations Widened pulse pressure Decreased body temperature

Widened pulse pressure Explanation: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

A neurologic deficit is best defined as a deficit of the: central and peripheral nervous systems with decreased, impaired, or absent functioning. central nervous system that affects one body system. central nervous system with absent functioning. peripheral nervous system with decreased or impaired functioning.

central and peripheral nervous systems with decreased, impaired, or absent functioning. A client with a neurologic deficit may have decreased, impaired, or absent functioning of the central and peripheral systems.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to control fever. control shivering. dehydrate the brain and reduce cerebral edema. reduce cellular metabolic demand.

dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.

vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 3 6 9 12

3 Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temperature increase from 98.0°F to 99.6°F

Bell's palsy is a paralysis of which of the following cranial nerves? Facial Trigeminal Optic Otic

Facial Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve. Trigeminal neuralgia is a paralysis of the trigeminal nerve (cranial nerve V). The optic nerve (cranial nerve II) functions in vision. The vestibulocochlear nerve (cranial nerve VIII) functions in hearing.

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? Sciatic nerve pain Herniation Paresthesia Paralysis

Paresthesia When a client reports numbness and tingling in an area, he is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: pupillary changes. diminished responsiveness. decreasing blood pressure. elevated temperature.

diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: increase the frequency of the catheterizations. insert an indwelling urinary catheter. place the client on fluid restrictions. use a condom catheter instead of an invasive one.

increase the frequency of the catheterizations. Explanation: As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.

The primary arthropod vector in North America that transmits encephalitis is the tick. horse. mosquito. flea.

mosquito. Arthropod-borne viruses, or arboviruses, are maintained in nature through biologic transmission between susceptible vertebrate hosts by blood feeding arthropods (mosquitoes, psychodidae, ceratopogonids, and ticks). Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because hypothermia can cause death. shivering in hypothermia can increase ICP. hypothermia is indicative of severe meningitis. hypothermia is indicative of malaria.

shivering in hypothermia can increase ICP. Explanation: The nurse should avoid hypothermia in a client with increased ICP because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia in a client with ICP does not indicate malaria or meningitis and is not likely to cause death.

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? "I will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."

"I can apply powder under the liner to help with sweating." Explanation: Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? "In most people, epilepsy is usually synonymous with intellectual disability." "For many people with epilepsy, the disorder is synonymous with mental illness." "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." "Cases of epilepsy are often associated with intellectual level."

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Explanation: Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or mental illness.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? Absence of reflexes along with flaccid extremities Positive Babinski's reflex along with spastic extremities Hyperreflexia along with spastic extremities Spasticity of all four extremities

Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? Brain tumor Epilepsy Trigeminal neuralgia Hypostatic pneumonia

Brain tumor The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?

Change in level of consciousness (LOC) The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Ecchymosis over the mastoid Bruising under the eyes Drainage of cerebrospinal fluid from the nose Drainage of cerebrospinal fluid from the ears

Ecchymosis over the mastoid Explanation: With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Elevate the head of the bed. Complete a head-to-toe assessment. Administer morning dose of anticonvulsant. Administer Percocet as ordered.

Elevate the head of the bed. The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? Lamictal Lamisil Labetalol Lomotil

Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A bounding pulse Bradycardia Hypertension Lethargy and stupor

Lethargy and stupor As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure? Level of consciousness Peripheral pulses Sensory perception Crackles bilaterally

Level of consciousness As the abscess expands, symptoms of increased intracranial pressure such as decreasing level of consciousness and seizures occur. Ongoing neurologic assessment alerts the nurse to changes in intracranial pressure, which may indicate a need for more aggressive intervention.

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Dextrose 5% in water (D5W) Half-normal saline (0.45% NSS) One-third normal saline (0.33% NSS) Mannitol

Mannitol Explanation: With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? 50 to 100 mL/h 100 to 150 mL/h 150 to 200 mL/h More than 200 mL/h

More than 200 mL/h Explanation: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Anemia Osteoarthritis Osteoporosis Obesity

Osteoporosis Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Hepatic Renal

Renal Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Maintaining adequate hydration Administering prescribed antipyretics Restricting fluid intake and hydration Hyperoxygenation before and after tracheal suctioning

Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: Mild TBI. Moderate TBI. Severe TBI. Brain death.

Severe TBI. A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Shivering Cool, dry skin Urine output of 100 mL/hr

Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T6 S2 L4 T10

T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: raccoon's eyes and Battle sign. nuchal rigidity and Kernig's sign. motor loss in the legs that exceeds that in the arms. pupillary changes.

raccoon's eyes and Battle sign. Explanation: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? acute chronic subacute intracerebral

Acute Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate? Encourage the client to close his eyes. Alternatively patch one eye every 2 hours. Turn out the lights in the room. Instill artificial tears.

Alternatively patch one eye every 2 hours. Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

Which drug should be available to counteract the effect of edrophonium chloride? Prednisone Atropine Azathioprine Pyridostigmine bromide

Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Increased ICP Exacerbation of uncontrolled hypertension Infection Increase in cerebral perfusion pressure

Increased ICP Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure Look for a halo sign

Look for signs of increased intracranial pressure The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma

Subdural hematoma A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? Take daily weights. Reposition the client frequently. Assess for pupillary response frequently. Assess vital signs frequently.

Take daily weights. Explanation: A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? The client with an open head injury The client with a basilar fracture The client with a concussion The client with a coup injury

The client with a basilar fracture Explanation: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.

Which method is used to help reduce intracranial pressure? Using a cervical collar Keeping the head of bed flat Rotating the neck to the far right with neck support Extreme hip flexion, with the hip supported by pillows

Using a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature

Body temperature Explanation: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? It is the only device that can be applied for stabilization of a spinal fracture. It allows for stabilization of the cervical spine along with early ambulation. It is less bulky and traumatizing for the patient to use. The patient can remove it as needed.

It allows for stabilization of the cervical spine along with early ambulation. Halo devices provide immobilization of the cervical spine while allowing early ambulation.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care? client maintains mechanical ventilation with minimal mucus accumulation client reports no discomfort client's skin remains clean, dry, and intact client regains bowel elimination capacity

client maintains mechanical ventilation with minimal mucus accumulation A client with a lumbar spinal injury would not require mechanical ventilation.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? Subdural Intracerebral Epidural Diffuse axonal

Epidural Explanation: An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A diffuse axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brainstem.

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? Insertion of a nasogastric (NG) tube Urine testing for acetone Serum sodium concentration testing Out of bed to the chair three times a day

Insertion of a nasogastric (NG) tube Explanation: Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? Encouraging oral fluid intake Suctioning the client once each shift Elevating the head of the bed 90 degrees Administering a stool softener as ordered

Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? Flat Turned onto the operative side Elevated no more than 10 degrees Elevated 30 degrees

Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? Keep the client's neck in a neutral position (no flexing). Avoid sedation. Cluster all procedures together. Keep the head of the client's bed flat.

Keep the client's neck in a neutral position (no flexing). To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Monro-Kellie Cushing's Dawn phenomenon Hashimoto's disease

Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action? Inspect the ICP monitor to ensure it is working properly. Administer acetaminophen per orders. Provide ventriculostomy care. Assess for signs and symptoms of infection.

Administer acetaminophen per orders. The nurse needs to control the fever by administering the ordered acetaminophen as the priority action. An increase in the client's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the client has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the dorsal recumbent position. supine position with the head slightly elevated. prone position with the head turned to the unaffected side. Trendelenburg position.

supine position with the head slightly elevated. After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? unequal response equal response rapid response constricted response

unequal response Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the dorsal recumbent position. supine position with the head slightly elevated. prone position with the head turned to the unaffected side. Trendelenburg position.

supine position with the head slightly elevated. Explanation: After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.

The earliest sign of serious impairment of brain circulation related to increased ICP is: A bounding pulse. Bradycardia. Hypertension. A change in consciousness.

A change in consciousness. The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? Treatment with antimicrobial prophylaxis as soon as possible Admission to the nearest hospital for observation No treatment unless the roommate begins to show symptoms Bedrest at home for 72 hours

Treatment with antimicrobial prophylaxis as soon as possible People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? An epidural hematoma An extradural hematoma An intracerebral hematoma A subdural hematoma

An intracerebral hematoma Explanation: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.