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Chapter 56: Acute Intracranial Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose

of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? a. “This type of monitoring system is complex and it is managed by skilled staff.” b. “The monitoring system helps show whether blood flow to the brain is adequate.” c. “The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.” d. “This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.” ANS: B

Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members’ anxiety. DIF: Cognitive Level: Analyze (analysis) REF: 1326 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 2. Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse

of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min ANS: A

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. DIF: Cognitive Level: Apply (application) REF: 1316 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,

and flexion of the arms, the nurse reports the response as c. decorticate posturing. d. decerebrate posturing.

a. flexion withdrawal. b. localization of pain.

ANS: C

Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal. DIF: Cognitive Level: Understand (comprehension) REF: 1318 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient.

Which parameter should the nurse monitor to determine the medication’s effectiveness? c. Intracranial pressure d. Hemoglobin and hematocrit

a. Blood pressure b. Oxygen saturation ANS: C

Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve as a result of mannitol administration. DIF: Cognitive Level: Apply (application) REF: 1322 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and

does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient’s Glasgow Coma Scale score as a. 9. c. 13. b. 11. d. 15. ANS: B

The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Apply (application) REF: 1323 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. An unconscious patient is admitted to the emergency department (ED) with a head injury. The

patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Call the family’s pastor or spiritual advisor to take them to the chapel. b. Ask the family to stay in the waiting room until the assessment is completed. c. Allow the family to stay with the patient and briefly explain all procedures to them. d. Refer the family members to the hospital counseling service to deal with their anxiety. ANS: C

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

DIF: Cognitive Level: Analyze (analysis) REF: 1332 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue

swelling. Which nursing intervention will be included in the plan of care? Encourage coughing and deep breathing. Position the patient with knees and hips flexed. Keep the head of the bed elevated to 30 degrees. Cluster nursing interventions to provide rest periods.

a. b. c. d.

ANS: C

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Apply (application) REF: 1319 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A 20-yr-old male patient is admitted with a head injury after a collision while playing football.

After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity. ANS: B

Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Apply (application) REF: 1327 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. Which action will the emergency department nurse anticipate for a patient diagnosed with a

concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation. ANS: B

A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, and surgery are not usually indicated in a patient with a concussion. DIF: Cognitive Level: Apply (application) REF: 1327 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. A patient who is suspected of having an epidural hematoma is admitted to the emergency

department. Which action will the nurse expect to take? Administer IV furosemide (Lasix). Prepare the patient for craniotomy. Initiate high-dose barbiturate therapy. Type and crossmatch for blood transfusion.

a. b. c. d.

ANS: B

The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary. DIF: Cognitive Level: Apply (application) REF: 1329 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 11. The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses

around both eyes and clear drainage from the patient’s nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face. ANS: B

Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders. DIF: Cognitive Level: Apply (application) REF: 1332 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment

information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a. Short-term memory c. Glasgow Coma Scale b. Muscle coordination d. Pupil reaction to light ANS: A

Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. DIF: Cognitive Level: Apply (application) REF: 1327 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may

have a. expressive aphasia. b. impaired judgment. ANS: B

c. right-sided weakness. d. difficulty swallowing.

The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. DIF: Cognitive Level: Apply (application) REF: 1336 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. Which statement by patient who is being discharged from the emergency department (ED)

after a concussion indicates a need for intervention by the nurse? “I will return if I feel dizzy or nauseated.” “I am going to drive home and go to bed.” “I do not even remember being in an accident.” “I can take acetaminophen (Tylenol) for my headache.”

a. b. c. d.

ANS: B

After a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. DIF: Cognitive Level: Apply (application) REF: 1332 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired

physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours. ANS: D

ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. DIF: Cognitive Level: Apply (application) REF: 1338 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will

be included in the plan of care? Encourage family members to remain at the bedside. Apply soft restraints to protect the patient from injury. Keep the room well-lighted to improve patient orientation. Minimize contact with the patient to decrease sensory input.

a. b. c. d.

ANS: A

Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. DIF: Cognitive Level: Apply (application) REF: 1326 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 17. The public health nurse is planning a program to decrease the incidence of meningitis in

teenagers and young adults. Which action is most likely to be effective? Emphasize the importance of hand washing. Immunize adolescents and college freshman. Support serving healthy nutritional options in the college cafeteria. Encourage adolescents and young adults to avoid crowds in the winter.

a. b. c. d.

ANS: B

The Neisseria meningitides vaccination is recommended for children ages 11 and 12 years, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, and good nutrition may increase resistance to infection. but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Analyze (analysis) REF: 1340 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. A patient has been admitted with meningococcal meningitis. Which observation by the nurse

requires action? The patient receives a regular diet tray. The bedrails on both sides of the bed are elevated. Staff have turned off the lights in the patient’s room. Staff have entered the patient’s room without a mask.

a. b. c. d.

ANS: D

Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Apply (application) REF: 1341 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 19. When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following

data. Which finding requires the most immediate intervention? The patient exhibits nuchal rigidity. The patient has a positive Kernig’s sign. The patient’s temperature is 101° F (38.3° C). The patient’s blood pressure is 88/42 mm Hg.

a. b. c. d.

ANS: D

Shock is a serious complication of meningitis, and the patient’s low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig’s sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Analyze (analysis) REF: 1339 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52

mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient’s record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient’s bed to 60 degrees. d. Continue to monitor the patient’s vital signs and ICP. ANS: B

Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] – Diastolic blood pressure [DBP]). Therefore the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient’s therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take. DIF: Cognitive Level: Analyze (analysis) REF: 1327 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient

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

Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP. DIF: Cognitive Level: Analyze (analysis) REF: 1325 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

22. Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a

registered nurse (RN) who has floated from the medical unit? A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy

a. b. c. d.

ANS: A

An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Multiple Patients MSC: NCLEX: Safe and Effective Care Environment

REF: 1341 TOP: Nursing Process: Planning

23. A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116

mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 ...