Question 1

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP)who regularly work in the intensive care unit?

Accepted Answer

Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF)color and intracranial pressure (ICP)require registered nurse (RN)-level education and scope of practice. Although repositioning patients is frequently delegated to UAP,repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.

Question 2

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

Accepted Answer

Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

Question 3

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

Accepted Answer

The patient with meningitis has increased fluid needs,so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

Question 4

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Accepted Answer

The PbtO₂ should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP)of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hr. The reason for the sinus tachycardia should be investigated,but the elevated heart rate is not as concerning as the decrease in PbtO₂.

Question 5

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?

Accepted Answer

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.

Question 6

After evacuation of an epidural hematoma,a patient's intracranial pressure (ICP)is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

Accepted Answer

Infection is a serious consideration with ICP monitoring,especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP,arterial pressure,and apical pulse only require ongoing monitoring at this time.

Question 7

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Accepted Answer

Patients who have basilar skull fractures are at risk for meningitis,so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

Question 8

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits?

Accepted Answer

Because the occipital lobe is responsible for visual reception,the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe,cerebellum,and frontal lobe.

Question 9

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C)and a severe headache. Which order should the nurse implement first?

Accepted Answer

Antibiotic therapy should be instituted rapidly in bacterial meningitis,but cultures must be done before antibiotics are started. As soon as the cultures are done,the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

Question 10

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?

Accepted Answer

The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol)will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information,but the low sodium level may lead to seizures unless it is addressed quickly.

Question 11

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP)of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP)as ____ mm Hg.

Accepted Answer

The answer of An unconscious patient with a traumatic head...

Question 12

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse?

Accepted Answer

The change in level of consciousness (LOC)is an indicator of increased intracranial pressure (ICP)and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

Question 13

A 68-yr-old male patient is brought to the emergency department (ED)by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?

Accepted Answer

Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

Question 14

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED),the nurse obtains the following information. Which finding is most important to report to the health care provider?

Accepted Answer

The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

Question 15

During change-of-shift report,the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

Accepted Answer

With decorticate posturing,the patient exhibits internal rotation and adduction of the arms with flexion of the elbows,wrists,and fingers. The other illustrations are of decerebrate,mixed decorticate and decerebrate posturing,and opisthotonic posturing.

Question 16

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

Accepted Answer

Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.

Question 17

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries,which patient should the nurse assess first?

Accepted Answer

The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

Question 18

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?

Accepted Answer

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.

Question 19

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture?

Accepted Answer

Battle's sign (postauricular ecchymosis)and periorbital ecchymoses are associated with basilar skull fracture.

Question 20

The nurse is caring for a patient who has a head injury. Which finding,when reported to the health care provider,should the nurse expect will result in new prescribed interventions?

Accepted Answer

The high urine output indicates that diabetes insipidus may be developing,and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

Quiz 56: Acute Intracranial Problems

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

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?

After evacuation of an epidural hematoma,a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits?

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?

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?

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP)of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP)as ____ mm Hg.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse?

A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED) ,the nurse obtains the following information. Which finding is most important to report to the health care provider?

During change-of-shift report,the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries,which patient should the nurse assess first?

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?

The nurse is caring for a patient who has a head injury. Which finding,when reported to the health care provider,should the nurse expect will result in new prescribed interventions?