Deck 10: Care of the Patient Experiencing an Intracranial Dysfunction

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?
1) Assess oxygen saturation and plan for intubation if saturation is below 86%.
2) Provide 100% oxygen via face mask.
3) Plan for a rapid sequence intubation.
4) Plan for a routine intubation.

Answer 1

3
Explanation: 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?
1) The patient needs surgery to reduce intracranial pressure.
2) The patient needs to be intubated.
3) The patient should receive 100% oxygen via face mask.
4) The patient has meningeal irritation.

Answer 2

4
Explanation: 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?
1) Temperature of 99°F (37.2°C)
2) Respiratory rate of 24
3) Serum sodium of 110 mEq/L
4) Blood pressure of 150/65

Answer 3

3
Explanation: 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?
1) Assess all four extremities together.
2) Assess the right leg and the right arm together.
3) Assess the arms together and then assess the legs separately.
4) Assess the left leg and the left arm together.

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?
1) ECG
2) Brainstem functioning
3) Reflexes
4) Level of consciousness

Question 6

The nurse plans care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient?
1) Encourage family and physician to discuss patient's care and prognosis in the patient's room.
2) Assess for daily bowel movement and provide intervention as appropriate.
3) Maintain head of bed at a 15-degree angle with knee elevation.
4) Cluster care 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?
1) Cerebral blood vessels will constrict.
2) Cerebral blood vessels will dilate.
3) Blood flow to the cerebral cortex will slow.
4) Blood will be shunted from the cerebral cortex.

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?
1) Skull fracture
2) Penetrating
3) Concussion
4) Coup-countercoup

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?
1) Limit the duration of each suctioning pass to less than 20 seconds.
2) Medicate with opiates after suctioning.
3) Reduce the flow of oxygen prior to suctioning.
4) Preoxygenate before 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?
1) Decreased cerebral compliance
2) Pending brain herniation
3) No evidence of pathology
4) Impaired cerebral spinal fluid flow

Question 11

The nurse assesses a patient's corneal reflex. Which cranial nerve is being assessed?
1) Oculomotor
2) Optic
3) Trigeminal
4) Vagus

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?
1) Weighing the patient to determine if the patient is fluid overloaded
2) Documenting the blood pressure and completing a neurologic assessment
3) Alerting the physician and preparing to administer an antihypertensive agent
4) Providing the patient with immediate pain and/or antianxiety medication

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?
1) Ensure that the patient's spinal cord has been found intact.
2) Ensure that the patient has an intact gag reflex.
3) Determine that the patient can tolerate being in the supine position.
4) Determine that the patient has an intact tympanic membrane.

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?
1) Prophylactic hypothermia treatment
2) High-dose barbiturate therapy
3) Intubation
4) Prophylactic anticonvulsant therapy

Question 15

The nurse is assigned to a patient with an intracranial pressure monitoring device. What is a priority when caring for this patient?
1) Monitor intracranial pressure every 4 hours.
2) Perform neurologic assessment checks every 2 hours.
3) Use clean technique when working with the system.
4) Use 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?
1) Propofol
2) Meperidine
3) Morphine sulfate
4) Fentanyl

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?
1) Increased intracranial pressure
2) Hypoxic cerebral tissue
3) Increased urine output
4) 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?
1) 1
2) 4
3) 2
4) 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?
1) A cerebral spinal fluid leak
2) A subdural hematoma
3) An epidural hematoma
4) A subarachnoid hemorrhage

Question 20

A patient is admitted with a fracture to the base of the skull. What might the nurse assess in this patient?
1) Depressed respiratory rate
2) Ecchymoses of the neck
3) Increased intracranial pressure
4) Cerebral spinal fluid leak from the nose

Question 21

A patient with a traumatic brain injury being mechanically ventilated is prescribed propofol. What should the nurse identify as an advantage of using this medication? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Decreases ICP
2) Reverses cerebral edema
3) Ensures stable electrolyte levels
4) Less need to use benzodiazepines
5) Dose can be lowered to assess neurologic status

Question 22

What might a patient develop if intravenous phenytoin (Dilantin) is administered faster than 50 mg/minute?
1) A severe rash
2) Hypotension
3) Hematologic abnormalities, such as agranulocytosis
4) A pronounced increase in heart rate

Question 23

A patient has been receiving treatment for status epilepticus for the last 20 minutes. What should the nurse prepare to implement at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Prepare for emergency intubation.
2) Insert an indwelling urinary catheter.
3) Monitor body temperature.
4) Obtain an order for a bedside electroencephalogram.
5) Insert an intravenous access line.

Question 24

A patient demonstrates neurologic changes consistent with increasing intracranial pressure. For which primary cause of this pressure increase should the nurse assess at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Cerebral hemorrhage
2) Ischemic stroke
3) Airway obstruction
4) Drop in blood pressure
5) Electrolyte imbalance

Question 25

During an assessment, the nurse notes that the left pupil of a patient with a traumatic brain injury is larger than the right pupil. What action should the nurse take at this time?
1) Ask the patient to cough.
2) Assist the patient into a side-lying position.
3) Increase the head of the bed to a 30-degree angle.
4) Coach the client to bear down against a closed glottis.

Question 26

What action should the nurse take when administering hypertonic saline to a patient with increased intracranial pressure (ICP)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Monitor the patient for renal failure and pulmonary edema.
2) Administer any concentrations greater than 2% through a central line.
3) Monitor serum sodium levels frequently during administration.
4) Expect the patient's neurologic status and ICP will begin to improve within 15 minutes following administration.
5) Monitor the patient's serum osmolarity every 24 hours.

Question 27

A patient with acute meningitis receives antibiotic therapy. The nurse notes that another medication is used as adjuvant therapy. Which medication is being used as an adjuvant for this patient?
1) An anticonvulsant
2) A steroid
3) A barbiturate
4) A pain medication

Question 28

A patient recovering from otitis media develops meningitis. What should the nurse expect to assess in this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Fever
2) Stiff neck
3) Confusion
4) Photophobia
5) Palpitations

Question 29

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What should the nurse expect to assess in this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Loss of consciousness
2) Hemiparesis
3) Dysphagia
4) Confusion
5) Headache

Question 30

The nurse cares for a patient with status epilepticus. What should be the first goal of care for this patient?
1) Determine the patient's medical history.
2) Obtain an EEG.
3) Maintain an airway.
4) Identify the cause of the seizure.

Question 31

The nurse identifies interventions to address the potential problem of increasing intracranial pressure for a victim of a house fire. For which secondary causes is the nurse planning care for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Stroke
2) Hypoxia
3) Hypercarbia
4) Hyperthermia
5) Spinal cord injury

Question 32

While a nasogastric tube is being inserted, a patient begins to cough and gag. What cranial nerves did the nurse inadvertently assess when inserting the nasogastric tube into the patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) IX (glossopharyngeal)
2) X (vagus)
3) V (trigeminal)
4) VII (facial)
5) III (oculomotor)

Question 33

A patient with meningitis develops hypotension and tachycardia. What action should the nurse take? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Notify the health care provider.
2) Complete a neurological assessment.
3) Ensure intravenous fluids are available.
4) Place intubation equipment at the bedside.
5) Prepare to administer adrenal corticosteroids.

Question 34

When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), what action should the nurse take?
1) Expect that any reduction in ICP will begin approximately an hour after the dose is administered.
2) Assess the patient carefully for the development of hypertension.
3) Review lab data to identify the presence of hypernatremia and hyperkalemia.
4) Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered.

Question 35

The nurse is concerned that a patient's intracranial pressure monitor readings are incorrect. What should the nurse do to ensure that the monitor is measuring accurately? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Check the location of the stopcocks.
2) Check the position of the transducer.
3) Check the monitoring line for air.
4) Ensure the catheter is not obstructed.
5) Check to make sure the dressing is dry.

Question 36

A patient diagnosed with a subdural hematoma has an intracranial pressure of 14 mm Hg. What body effect should the nurse expect if this pressure increases? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Displacing cerebrospinal fluid into the lumbar cistern
2) Reabsorbing more cerebrospinal fluid
3) Shunting blood out of venous sinuses
4) Raising the body temperature
5) Increasing the carbon dioxide level

Question 37

The nurse teaches a patient recovering from a mild brain injury about manifestations to expect during the recovery process. What should the nurse instruct this patient to expect while recuperating from this injury? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Headache
2) Dizziness
3) Fatigue
4) Memory loss
5) Nausea

Question 38

The nurse prepares medications for a patient with status epilepticus. What should the nurse identify as the medication of choice for this patient?
1) A barbiturate
2) A steroid
3) An opioid
4) A benzodiazepine