Question 1

A patient with a severe head injury has a pO₂ of 88 and a pCO₂ of 48. What should be done to support this patient?

Accepted Answer

1. An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients. 2. Oxygen would be provided with a bag-valve mask. 3. Many organizations utilize rapid sequence intubation, which might include supporting the patient's respirations with a 100% O₂ via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present; intubation; confirmation of tube placement; and sedation. 4. Intubation can be a noxious procedure and may increase intracranial pressure. Because of this, routine intubation would not be done.

Question 2

A patient experiencing a fever, stiff neck, and change in mental status has a positive Kernig's sign. What should these findings suggest to the nurse?

Accepted Answer

1. Surgery is not a treatment for a positive Kernig's sign.
2. Intubation is not a treatment for a positive Kernig's sign.
3. Oxygen is not a treatment for a positive Kernig's sign.
4. Signs of meningeal irritation include the Kernig's sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. This sign is an indication of meningitis.

Question 3

When providing care to a patient with increased intracranial pressure, the nurse should be concerned about which clinical finding because it can result in an additional increase in intracranial pressure?

Accepted Answer

1. This is a minor temperature elevation and would not contribute to the patient's increased intracranial pressure.
2. This is a minor respiratory rate increase and would not contribute to the patient's increased intracranial pressure.
3. Hyponatremia is considered a secondary cause that contributes to increases in intracranial pressure. This laboratory value should be reported and treatment started to avoid additional pressure increases.
4. This blood pressure is within parameters that would not affect the patient's cerebral perfusion and is unlikely to contribute to the patient's increased intracranial pressure.

Question 4

What should the nurse do when assessing the motor function of a patient with a head injury?

Accepted Answer

1. Assessing all extremities together would not enable the nurse to compare strength and movement of both sides of the body.
2. The legs are usually assessed separately.
3. Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body.
4. The legs are usually assessed separately.

Question 5

The nurse prepares to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment?

Accepted Answer

1. An electrocardiogram is not a part of an hourly neurologic assessment.
2. On occasion, the nurse might be involved with assessing brainstem functioning; however, this is not a part of an hourly neurologic assessment.
3. Reflexes are not a part of an hourly neurologic assessment.
4. Components of an hourly neurologic assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning.

Question 6

The nurse plans care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient?

Accepted Answer

1. Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team.
2. When a patient engages in a Valsalva maneuver when straining with a bowel movement or pushing up in bed, the ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining.
3. The head of the bed should be elevated to 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation.
4. The patient's ICP may rise when nursing activities are delivered in a traditional "cluster" fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patient's ICP should be permitted to return to baseline before continuing with other activities.

Question 7

A patient with a head injury has a pO₂ of 88 and a pCO₂ of 58. The nurse realizes that which physiologic process will occur in this patient?

Accepted Answer

1. This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels.
2. Autoregulation ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow, such as when there is a drop in cerebral oxygen levels or an increase in cerebral carbon dioxide levels.
3. This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels.
4. This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels.

Question 8

A patient is admitted with a head injury from an acceleration/deceleration motor vehicle crash. Which type of injury did this patient most likely experience?

Accepted Answer

1. Skull fracture is not typically associated with motor vehicle accidents.
2. Penetrating head trauma is not typically associated with motor vehicle accidents.
3. Concussion is not typically associated with motor vehicle accidents.
4. Contusions and axonal injuries often result from acceleration/deceleration injuries from a motor vehicle crash. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma. This is known as a countercoup injury.

Question 9

A patient with a head injury who is being mechanically ventilated needs to be suctioned. What should the nurse do to limit problems related to suctioning?

Accepted Answer

1. The duration of each suctioning pass should be limited to less than 10 seconds.
2. The patient may be premedicated with opiates before suctioning.
3. The flow of oxygen should not be reduced before suctioning.
4. Suctioning the patient's endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure. For both these reasons, suctioning may impact ICP. The nurse should preoxygenate the patient prior to suctioning.

Question 10

The nurse, evaluating the tracing made from a patient's intracranial pressure monitor, notes the presence of many C waves. What does this finding indicate?

Accepted Answer

1. Decreased cerebral compliance would be indicated by the presence of A waves.
2. Pending brain herniation would be indicated by the presence of A waves.
3. C waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and do not indicate pathology.
4. Impaired cerebral spinal fluid flow would be indicated by the presence of A waves.

Question 11

The nurse assesses a patient's corneal reflex. Which cranial nerve is being assessed?

Accepted Answer

1. The oculomotor nerve is assessed when the pupils are checked.
2. The optic nerve is assessed when the pupils are checked.
3. Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex.
4. The vagus nerve is assessed by checking for a cough and gag reflex.

Question 12

The blood pressure of a patient with a traumatic brain injury increases from 130/60 to 170/65 mm Hg. How should the nurse respond to this change in blood pressure?

Accepted Answer

1. This change in blood pressure is not due to fluid volume overload.
2. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. The nurse needs to assess the impact of the increased blood pressure on the patient's neurologic status by completing a neurologic assessment.
3. The nurse would need to assess the patient's neurologic status before contacting the physician for treatment.
4. The nurse needs to first assess the patient's neurologic status before medicating for pain or anxiety since these types of medications will dampen neurologic responses.

Question 13

The nurse prepares to assist with the assessment of a patient's oculovestibular reflex. What should be done before this reflex is assessed?

Accepted Answer

1. It is not necessary to ensure that the patient's spinal cord has been found intact.
2. It is not necessary to ensure that the patient has an intact gag reflex before assessing this reflex.
3. The head of the patient's bed is elevated 30 degrees when testing this reflex.
4. The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patient's bed is elevated 30 degrees, and then 50 mL of cool saline is injected into an ear.

Question 14

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. Which of the following will the nurse realize is most likely to be implemented for this patient?

Accepted Answer

1. Prophylactic hypothermia treatment is not recommended for routine use at this time.
2. High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures.
3. Most patients with a traumatic brain injury will be intubated.
4. Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury.

Question 15

The nurse is assigned to a patient with an intracranial pressure monitoring device. What is a priority when caring for this patient?

Accepted Answer

1. Pressure would be monitored every hour.
2. Neurologic assessment checks would be monitored every hour.
3. Clean technique could cause the patient to develop an infection.
4. The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system.

Question 16

A patient with a traumatic brain injury is showing signs of having pain. What would be the medication of choice for this patient?

Accepted Answer

1. Propofol is a sedative-hypnotic anesthetic and not used for this patient.
2. There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury.
3. The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurologic assessment, it can be reversed with Narcan.
4. Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure.

Question 17

A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. What should the nurse realize that the drop in MAP could lead to?

Accepted Answer

1. A decline in mean arterial pressure is not going to cause an increase in intracranial pressure.
2. Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood, or MAP, and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue.
3. A decline in mean arterial pressure is not going to cause an increase in urine output.
4. A decline in mean arterial pressure is not going to cause bradycardia.

Question 18

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating should this patient have for verbal response?

Accepted Answer

1. The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. If the patient is unable to talk because of intubation, the score is a 1.
2. The patient is unable to talk and would not be scored as a 4.
3. The patient is unable to talk and would not be scored as a 2.
4. The patient is unable to talk and would not be scored as a 3.

Question 19

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. What should these assessment findings indicate to the nurse?

Accepted Answer

1. This is not a symptom of a cerebral spinal fluid leak.
2. Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness, and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patients usually develop nonspecific symptoms such as headache, confusion, and speech deficits.
3. Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval and then a sudden loss of consciousness with rapid deterioration in neurologic status.
4. Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm.

Question 20

A patient is admitted with a fracture to the base of the skull. What might the nurse assess in this patient?

Accepted Answer

1. There is no evidence to suggest that the patient will have a depressed respiratory rate with this fracture.
2. Ecchymoses of the neck is not associated with a basilar skull fracture.
3. There is no evidence to suggest that the patient will have increased intracranial pressure with this fracture.
4. Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears.

Quiz 10: Care of the Patient Experiencing an Intracranial Dysfunction

A patient with a severe head injury has a pO2 of 88 and a pCO2 of 48. What should be done to support this patient?