Question 1

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to 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 are all borderline high but require only ongoing monitoring at this time.

Question 2

Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report 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 3

When admitting a patient with a possible coup-contrecoup injury after a car accident to the emergency department, 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 to the ED.

Question 4

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?

Accepted Answer

Since suctioning will cause a transient increase in intracranial pressure, 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 intracranial pressure.

Question 5

A patient admitted with bacterial meningitis and a temperature of 102° F ( 38.8° C ) has orders for all of these collaborative interventions. Which action should the nurse take 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 6

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 7

When caring for a patient who has had a head injury, which assessment information requires the most 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 is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

Question 8

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

Accepted Answer

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

Question 9

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider?

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.

Question 10

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

Accepted Answer

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

Question 11

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit?

Accepted Answer

Experienced NAP 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 RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN.

Question 12

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an 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 postcraniotomy patient, 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 13

A patient is brought to the emergency department ( ED ) by ambulance after being found unconscious on the bathroom floor by the 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 the health and medication history last.

Question 14

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L ( 115 mmol/L ) and a decreasing level of consciousness ( LOC ) and complains of a headache. Which of these prescribed interventions should the nurse implement first?

Accepted Answer

The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and 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 add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

Question 15

Which information about a 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/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO₂

Quiz 57: Nursing Management: Acute Intracranial Problems