Question 1

A patient complains of having the "worst headache" ever. What health problem should the nurse suspect is occurring in this patient?

Accepted Answer

1. Intracranial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness and sensory and motor deficits.
2. Ischemic stroke is characterized by confusion, difficulty speaking, visual disturbances, and sensory and motor deficits. Headache does occur.
3. Subarachnoid hemorrhage is the rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically, the bleeding lasts only a few seconds, but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as "the worst headache of my life."
4. The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment.

Question 2

A patient with a brain tumor is prescribed an antiseizure medication. What outcome should the nurse expect to occur with this medication?

Accepted Answer

1. The majority of patients with brain tumors continue with some type of seizure, most commonly a focal seizure.
2. The majority of patients with brain tumors continue with some type of seizure, most commonly a focal seizure.
3. The use of seizure medication in the patient with a brain tumor is not to premedicate for status epilepticus.
4. Seizures after craniotomy are extremely common, and the risk of seizure development is partially dependent on the type of brain tumor. Recurrent seizures post craniotomy continue to cause significant clinical problems. Antiseizure medication is used to control the onset of seizure activity.

Question 3

The nurse plans care for a patient who is recovering from a supratentorial craniotomy. What should be included in this plan of care?

Accepted Answer

1. This patient had surgery involving the supratentorium; therefore, a cervical collar is not necessary.
2. Postoperatively, patients are usually positioned with the head of their bed elevated 30 degrees. This facilitates venous drainage from the head and neck, preventing increases in intracranial pressure and increasing patient comfort.
3. The head of the bed needs to be elevated to 30 degrees in order to facilitate venous drainage from the operative site. This prevents increased intracranial pressure and herniation.
4. If a large tumor was resected, the patient would usually not be permitted to turn the head to the operative side because it may cause a shift in cerebral contents.

Question 4

A patient is diagnosed with a Grade II astrocytoma. What does the nurse realize is this patient's prognosis?

Accepted Answer

1. Grade II tumor cells are less well defined, and there is the possibility that a Grade II tumor will transform to a higher grade. Excellent prognosis is not associated with this type of brain tumor.
2. Astrocytomas are the most common types of primary brain tumor and are graded from I to IV according to tissue histology. Grade I and Grade II tumors are considered to be low-grade tumors, and they have the most favorable survival rates and respond well to early treatment.
3. Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined, and there is the possibility that a Grade II tumor will transform to a higher grade.
4. Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue; therefore, the prognosis is poor.

Question 5

A patient reports an area on the arm that has been getting numb and "feels funny." Why should the nurse consider this information as being important?

Accepted Answer

1. Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one-third of patients with brain tumors. Focal symptoms include hearing problems, such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor.
2. The type and length of treatment of a tumor is based on location, grade, and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy.
3. The neurologic changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality.
4. Treatment would determine length of hospital stay.

Question 6

During an assessment, an older patient asks if "something is burning." What should the nurse suspect is occurring with this patient?

Accepted Answer

1. Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells.
2. Focal symptoms can occur in patients with brain tumors. The nurse should question the patient about any experienced symptoms, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling.
3. The sense of smell decreases as a normal age-related change. It is unlikely that this patient has a good sense of smell.
4. The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness, such as alertness, changes in orientation, and motor and sensory deficits. Seizure activity is a late sign.

Question 7

An older patient is not concerned about having a brain tumor because the only symptom has been a slight increase in forgetfulness, and he has had no headaches. What explanation should the nurse consider about this patient's symptoms?

Accepted Answer

1. The presence of a brain tumor in the elderly often manifests with cognitive changes, such as forgetfulness.
2. The manifestation of forgetfulness is a symptom of the presence of a tumor in the elderly, not in the pediatric population.
3. Because older adults have age-related brain atrophy, they are less likely to present with generalized symptoms of increased intracranial pressure, such as headache and papilledema; instead they are more likely to present with mental changes. Mental and/or personality changes can be caused by the tumor itself, by increased intracranial pressure, or by involvement of the parts of the brain that control personality. These can range from problems with short-term memory, speech, communication, and/or concentration changes to severe intellectual problems and confusion.
4. Alzheimer's disease has many more symptoms other than forgetfulness, such as language problems. A CT scan would be negative for the presence of a tumor.

Question 8

A patient recovering from a glioma has concluded radiation therapy. What should the nurse anticipate as being the next treatment for this patient?

Accepted Answer

1. Standard treatment for malignant gliomas has included primary resection, followed by radiation therapy and temozolomide, which has shown improved prognosis. Recent studies have looked at the addition of bevacizumab (Avastin) for single agent use in recurrent glioblastoma.
2. Additional treatments of radiation have not been shown to decrease morbidity or mortality in the treatment of gliomas. Adjunct treatment of chemotherapy has been proven to improve outcome.
3. Chemotherapy, both systemic and local, is used after the completion of radiation therapy.
4. Antiseizure medications are only used if the patient develops seizures.

Question 9

A patient is diagnosed with an intracerebral hemorrhage. What is the most common cause of this disorder?

Accepted Answer

1. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle and susceptible to cracking and rupture.
2. Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident.
3. Atherosclerosis is the cause of hypertension, which can lead to intracranial hemorrhage.
4. Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension, which may eventually lead to an intracranial hemorrhage. However, this is not a primary cause.

Question 10

A patient recovering from a craniotomy is complaining of a headache despite having the head of the bed elevated. The nurse also sees a damp mark on the patient's pillow. What should the nurse do? Select all that apply.

Accepted Answer

1. A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patient's ear or nose and forming a halo as it settles on a pillowcase. The patient will complain of a headache.
2. The nurse should notify the health care provider regarding the presence of cerebrospinal fluid leakage in the event surgical intervention is required to close the tear.
3. Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP, and raising the head of the bed would increase the risk of herniation.
4. The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis.
5. An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure.

Question 11

The nurse applies pneumatic compression boots on a postoperative craniotomy patient. Which complication is the nurse attempting to avoid with this action?

Accepted Answer

1. Prophylaxis to prevent meningitis includes good hand washing; maintaining aseptic technique when handling external ventricular drains, tubes, and surgical sites; and administering antibiotic medications.
2. Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure.
3. Prophylaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at a normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications.
4. Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital.

Question 12

The nurse is assessing a patient with a meningioma. What should the nurse keep in mind when planning this patient's care?

Accepted Answer

1. Other common benign brain tumors arise from nerve sheaths, such as acoustic neuromas, which can lead to a hearing loss.
2. Meningiomas are usually benign and do not affect life expectancy.
3. The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible.
4. Meningiomas are encapsulated and benign, so they do not metastasize to other organs.

Question 13

The nurse prepares a medication to decrease cerebral edema caused by a brain tumor. Which medication is the nurse most likely preparing?

Accepted Answer

1. Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema.
2. Pain medications do not reduce cerebral edema or lower intracranial pressure. These medications can be dangerous in the neurologic patient as they can alter level of consciousness.
3. Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor-associated edema.
4. Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral tissue.

Question 14

A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. Which action should the nurse counsel the patient to avoid performing?

Accepted Answer

1. Blowing the nose or sneezing may cause the patch to dislodge, which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection.
2. Deep breathing is a postoperative activity that all postoperative patients should perform to prevent atelectasis.
3. Drinking 2 liters of fluid per day is a postop activity that helps the body metabolize anesthesia, maintains hydration, and liquefies pulmonary secretions.
4. The head of the bed needs to be elevated at least 30 degrees or higher to reduce postop edema. This also allows for better lung expansion to prevent atelectasis.

Question 15

A patient with a brain tumor is going to have an ablative procedure to treat the mass. What should the nurse consider as a potential reason for this procedure?

Accepted Answer

1. This procedure is not designed to preserve but to destroy blood supply to a tumor.
2. If a tumor is too large, it is initially treated with radiation to shrink to a more manageable size for surgical removal. This is then followed with chemotherapy.
3. The ablation procedure is used for small, nonaccessible tumors.
4. An alternative to surgery would be ablative procedures that cause cell death and necrosis of the tumor over time. They are most appropriate for people with smaller tumors in nonaccessible areas.

Question 16

A patient is recovering from posterior fossa surgery. What should the nurse include in the patient's plan of care?

Accepted Answer

1. The tumor was near the brainstem, which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure, so assessment of level of consciousness is very important.
2. The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure.
3. The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar.
4. This complication is associated with pressure on the pituitary gland and transsphenoidal hypophysectomy.

Question 17

A patient diagnosed with an ischemic stroke developed symptoms within the last 2 hours. What should the nurse anticipate being prescribed for this patient?

Accepted Answer

1. If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to reestablish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endarterectomy may be considered if indicated.
2. In the case of ischemic stroke, intravenous thrombolysis should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria.
3. Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to reestablish blood flow as soon as possible.
4. The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted as to cause dehydration, which would increase blood viscosity, raising the risk of the development of more thromboemboli.

Question 18

A patient with increased intracranial pressure is diagnosed with a brain tumor. What should the nurse suspect that this patient is experiencing?

Accepted Answer

1. Astrocytomas are Grade I and II tumors that grow slowly, and the first symptom is seizures. A late symptom is increased intracranial pressure.
2. Meningiomas are extremely slow-growing tumors. There is a low incidence of the development of increased intracranial pressure.
3. Tumors of less than 1 mm in size do not result in the development of cerebral edema as there is minimal displacement of cerebral tissue.
4. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the development of cerebral edema. Cerebral edema appears to develop once tumors have increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that increase vascular permeability and edema are released.

Question 19

A patient with an embolic stroke is demonstrating urinary incontinence, contralateral weakness, and altered mental status. Where should the nurse suspect the embolism is located?

Accepted Answer

1. Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion.
2. Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence.
3. Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory.
4. Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits.

Question 20

A patient with a brain tumor is scheduled for a diagnostic test to help determine response to therapy. Which test is this patient most likely going to have?

Accepted Answer

1. MRI scans are utilized more often than CT scans because they are more sensitive and capable of detecting tumors too small to be noted on CT scans.
2. Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery.
3. An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses.
4. Functional MRIs may be used to assess the potential clinical outcomes of the tumor.

Quiz 11: Care of the Patient With a Cerebral or Cerbrovascular Disorder