Question 1

The nurse should teach a patient that which is a primary prevention strategy to reduce the occurrence of head injuries?&#10;A) Blood pressure control&#10;B) Smoking cessation&#10;C) Maintaining a healthy weight&#10;D) Violence prevention

Accepted Answer

Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

Question 2

Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment?&#10;A) Blood pressure&#10;B) Cranial nerve function&#10;C) Head circumference&#10;D) Verbal responsiveness

Accepted Answer

Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

Question 3

When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings?&#10;A) Hypertension and bradycardia&#10;B) Hypertension and tachycardia&#10;C) Hypotension and bradycardia&#10;D) Hypotension and tachycardia

Accepted Answer

Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing's triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

Question 4

After shunt procedure, the nurse would monitor the patient's neurologic status by using which test?&#10;A) Electroencephalogram&#10;B) Glasgow Coma Scale&#10;C) National Institutes of Health Stroke Scale&#10;D) Monro-Kellie doctrine

Accepted Answer

The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal fluid, and blood.

Question 5

The nurse preparing to care for a patient after a suspected stroke would question which order?&#10;A) Antihypertensive&#10;B) Antipyretic&#10;C) Osmotic diuretic&#10;D) Sedative

Accepted Answer

Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

Question 6

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?&#10;A) Aligning the neck with the body&#10;B) Clustering many nursing activities&#10;C) Elevating the head of the bed 30 degrees&#10;D) Providing stool softeners or laxatives as ordered

Accepted Answer

It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.

Question 7

Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?&#10;A) Change in level of consciousness&#10;B) Inability to focus visually&#10;C) Loss of primitive reflexes&#10;D) Unequal pupil size

Accepted Answer

A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

Deck 13: Intracranial Regulation