Chapter 56 Acute Intracranial Problems PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter56:AcuteIntracranialProblems TestBank 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? 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explanation areeithertoocomplicatedtobeeasilyunderstoodormayincreasethefamilymembersanxiety. DIF:CognitiveLevel:Apply(application)REF:1319 TOP:NursingProcess:ImplementationMSC:NCLEX:PsychosocialIntegrity 2.Admissionvitalsignsforabrain-injuredpatientarebloodpressure128/68,pulse110,andrespirations26. Whichsetofvitalsigns,iftaken1hourafteradmission,willbeofmostconcerntothenurse? a.

Bloodpressure154/68,pulse56,respirations12

b.

Bloodpressure134/72,pulse90,respirations32

c.

Bloodpressure148/78,pulse112,respirations28

d.

Bloodpressure110/70,pulse120,respirations30

ANS:A Systolichypertensionwithwideningpulsepressure,bradycardia,andrespiratorychangesrepresentCushings 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:1318 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

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

a.

flexionwithdrawal.

b.

localizationofpain.

c.

decorticateposturing.

d.

decerebrateposturing.

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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medicationseffectiveness? a.

Bloodpressure

b.

Oxygensaturation

c.

Intracranialpressure

d.

Hemoglobinandhematocrit

ANS:C Mannitolisanosmoticdiureticandwillreducecerebraledemaandintracranialpressure.Itmayinitially reducehematocritandincreasebloodpressure,butthesearenotthebestparametersforevaluationofthe effectivenessofthedrug.Oxygen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46-year-oldpatientwithaheadinjuryopensthe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patientsGlasgowComaScalescoreas a.

9.

b.

11.

c.

13.

d.

15.

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ANS:B Thepatienthasascore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39-year-oldmalepatientisadmittedtotheemergencydepartment(ED)withaheadinjury. Thepatientsspouseandteenagechildrenstayatthepatientssideandaskmanyquestionsaboutthetreatment beinggiven.Whatactionisbestforthenursetotake? a.

Askthefamilytostayinthewaitingroomuntiltheinitialassessmentiscompleted.

b.

Allowthefamilytostaywiththepatientandbrieflyexplainallprocedurestothem.

c.

Referthefamilymemberstothehospitalcounselingservicetodealwiththeiranxiety.

d.

Callthefamilyspastororspiritualadvisortotakethemtothechapelwhilecareisgiven.

ANS:B 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:Apply(application)REF:1333 TOP:NursingProcess:ImplementationMSC:NCLEX:PsychosocialIntegrity 7.A41-year-oldpatientwhoisunconscioushasanursingdiagnosisofineffectivecerebraltissueperfusion relatedtocerebraltissueswelling.Whichnursinginterventionwillbeincludedintheplanofcare? a.

Encouragecoughinganddeepbreathing.

b.

Positionthepatientwithkneesandhipsflexed.

c.

Keeptheheadofthebedelevatedto30degrees.

d.

Clusternursinginterventionstoproviderestperiods.

ANS:C Thepatientwithincreasedintracranialpressure(ICP)shouldbemaintainedinthehead-uppositiontohelp reduceICP.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

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 8.A20-year-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th needtoreturnifneurologicstatusdeteriorates.MRI,hospitaladmission,or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23-year-oldpatientwhoissuspectedofhavinganepiduralhematomaisadmittedtotheemergency department.Whichactionwillthenurseplantotake? a.

AdministerIVfurosemide(Lasix).

b.

Preparethepatientforcraniotomy.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Initiatehigh-dosebarbituratetherapy.

d.

Typeandcrossmatchforbloodtransfusion.

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ANS:B Theprincipaltreatmentforepiduralhematomaisrapidsurgerytoremovethehematomaandprevent herniation.Ifintracranialpressure(ICP)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patients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(CSF)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:1327 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apatientisdevelopingpostconcussionsyndrome? a.

Short-termmemory

b.

Musclecoordination

c.

GlasgowComaScale

d.

Pupilreactiontolight

ANS:A Decreasedshort-termmemoryisoneindicationofpostconcussionsyndrome.Theotherdatamaybeassessed

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butarenotindicationsofpostconcussionsyndrome. DIF:CognitiveLevel:Apply(application)REF:1328 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.

c.

right-sidedweakness.

d.

difficultyswallowing.

ANS:B 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:1334 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 14.Whichstatementbya40-year-oldpatientwhoisbeingdischargedfromtheemergencydepartment(ED) afteraconcussionindicatesaneedforinterventionbythenurse? a.

IwillreturnifIfeeldizzyornauseated.

b.

Iamgoingtodrivehomeandgotobed.

c.

Idonotevenrememberbeinginanaccident.

d.

Icantakeacetaminophen(Tylenol)formyheadache.

ANS:B Following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:1333 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 15.Afterhavingacraniectomyandleftanteriorfossaeincision,a64-year-oldpatienthasanursingdiagnosis of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.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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.

730

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42-year-oldpatientwhohasbacterialmeningitisisdisorientedandanxious.Whichnursingactionwillb includedintheplanofcare? a.

Encouragefamilymemberstoremainatthebedside.

b.

Applysoftrestraintstoprotectthepatientfrominjury.

c.

Keeptheroomwell-lightedtoimprovepatientorientation.

d.

Minimizecontactwiththepatienttodecreasesensoryinput.

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:1341 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 17.Thepublichealthnurseisplanningaprogramtodecreasetheincidenceofmeningitisinadolescentsand youngadults.Whichactionismostimportant? a.

Encourageadolescentsandyoungadultstoavoidcrowdsinthewinter.

b.

Vaccinate11-and12-year-oldchildrenagainstHaemophilusinfluenzae.

c.

ImmunizeadolescentsandcollegefreshmanagainstNeisseriameningitides.

d.

Emphasizetheimportanceofhandwashingtopreventthespreadofinfection.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

731

ANS:C TheNeisseriameningitidesvaccinationisrecommendedforchildrenages11and12,unvaccinatedteens enteringhighschool,andcollegefreshmen.Handwashingmayhelpdecreasethespreadofbacteria,butitis notaseffectiveasimmunization.VaccinationwithHaemophilusinfluenzaeisforinfantsandtoddlers.Because adolescentsandyoungadultsareinschoolortheworkplace,avoidingcrowdsisnotrealistic. DIF:CognitiveLevel:Apply(application)REF:1339 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? a.

Thebedrailsattheheadandfootofthebedarebothelevated.

b.

Thepatientreceivesaregulardietfromthedietarydepartment.

c.

Thelightsinthepatientsroomareturnedoffandtheblindsareshut.

d.

Unlicensedassistivepersonnelenterthepatientsroomwithoutamask.

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-year-oldpatientwithbacterialmeningitis,thenurseobtainsthefollowingdata.Which findingshouldbereportedimmediatelytothehealthcareprovider? a.

Thepatientexhibitsnuchalrigidity.

b.

ThepatienthasapositiveKernigssign.

c.

Thepatientstemperatureis101F(38.3C).

d.

Thepatientsbloodpressureis88/42mmHg.

ANS:D Shockisaseriouscomplicationofmeningitis,andthepatientslowbloodpressureindicatestheneedfor interventionssuchasfluidsorvasopressors.NuchalrigidityandapositiveKernigs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:Apply(application)REF:1340

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

732

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patientsrecord.

b.

ReporttheBPandICPtothehealthcareprovider.

c.

Elevatetheheadofthepatientsbedto60degrees.

d.

Continuetomonitorthepatients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isbelowthenormalof60to100mmHgandapproachingthelevelofischemiaand neuronaldeath.Immediatechangesinthepatientstherapysuchasfluidinfusionorvasopressoradministration areneededtoimprovethecerebralperfusionpressure.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:1315 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 21.Afterendotrachealsuctioning,thenursenotesthattheintracranialpressureforapatientwithatraumatic headinjuryhasincreasedfrom14to17mmHg.Which...