Deck 57: Nursing Management: Acute Intracranial Problems

Question 1

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?

A) Coordinate the transfer of the patient to the operating room.
B) Provide discharge instructions about monitoring neurologic status.
C) Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
D) Arrange to admit the patient to the neurologic unit for observation for 24 hours.

Answer 1

Provide discharge instructions about monitoring neurologic status.

Question 2

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?

A) Insert nasogastric tube.
B) Turn patient every 2 hours.
C) Keep the head of bed elevated.
D) Apply cold packs for facial bruising.

Answer 2

Insert nasogastric tube.

Question 3

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?

A) Have the patient blow the nose.
B) Check the nasal drainage for glucose.
C) Assure the patient that rhinorrhea is normal after a head injury.
D) Obtain a specimen of the fluid to send for culture and sensitivity.

Answer 3

Check the nasal drainage for glucose.

Question 4

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

A) Elevate the head of the patient's bed to 60 degrees.
B) Document the BP and ICP in the patient's record.
C) Report the BP and ICP to the health care provider.
D) Continue to monitor the patient's vital signs and ICP.

Question 5

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

A) flexion withdrawal.
B) localization of pain.
C) decorticate posturing.
D) decerebrate posturing.

Question 6

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

A) Encourage family members to remain at the bedside.
B) Apply soft restraints to protect the patient from injury.
C) Keep the room well-lighted to improve patient orientation.
D) Minimize contact with the patient to decrease sensory input.

Question 7

After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

A) position the bed flat and log roll the patient.
B) cluster nursing activities to allow longer rest periods.
C) turn and reposition the patient side to side every 2 hours.
D) perform range-of-motion (ROM) exercises every 4 hours.

Question 8

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

A) Hematocrit
B) Blood pressure
C) Oxygen saturation
D) Intracranial pressure

Question 9

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best?

A) "This type of monitoring system is complex and highly skilled staff are needed."
B) "The monitoring system helps show whether blood flow to the brain is adequate."
C) "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure."
D) "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

Question 10

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

A) 9.
B) 11.
C) 13.
D) 15.

Question 11

Which statement by a patient who is being discharged from the emergency department ( ED ) after a head injury indicates a need for intervention by the nurse?

A) "I will return if I feel dizzy or nauseated."
B) "I am going to drive home and go to bed."
C) "I do not even remember being in an accident."
D) "I can take acetaminophen ( Tylenol ) for my headache."

Question 12

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?

A) Muscle resistance
B) Short-term memory
C) Glasgow coma scale
D) Pupil reaction to light

Question 13

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?

A) Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
B) Emphasize the importance of hand washing to prevent spread of infection.
C) Immunize adolescents and college freshman against Neisseria meningitides.
D) Encourage adolescents and young adults to avoid crowded areas in the winter.

Question 14

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

A) Keep the head of the bed elevated to 30 degrees.
B) Position the patient with the knees and hips flexed.
C) Encourage coughing and deep breathing to improve oxygenation.
D) Cluster nursing interventions to provide uninterrupted rest periods.

Question 15

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department ( ED ). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take?

A) Ask the family to stay in the waiting room until the initial assessment is completed.
B) Allow the family to stay with the patient and briefly explain all procedures to them.
C) Call the family's pastor or spiritual advisor to support them while initial care is given.
D) Refer the family members to the hospital counseling service to deal with their anxiety.

Question 16

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

A) judgment changes.
B) expressive aphasia.
C) right-sided weakness.
D) difficulty swallowing.

Question 17

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?

A) The bedrails at the head and foot of the bed are both elevated.
B) The patient receives a regular diet from the dietary department.
C) The nursing assistant goes into the patient's room without a mask.
D) The lights in the patient's room are turned off and the blinds are shut.

Question 18

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

A) Blood pressure 156/60, pulse 55, respirations 12
B) Blood pressure 130/72, pulse 90, respirations 32
C) Blood pressure 148/78, pulse 112, respirations 28
D) Blood pressure 110/70, pulse 120, respirations 30

Question 19

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

A) Administer IV furosemide (Lasix).
B) Initiate high-dose barbiturate therapy.
C) Type and crossmatch for blood transfusion.
D) Prepare the patient for immediate craniotomy.

Question 20

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?

A) The patient has a positive Kernig's sign.
B) The patient complains of having a stiff neck.
C) The patient's temperature is 101° F ( 38.3° C ).
D) The patient's blood pressure is 86/42 mm Hg.

Question 21

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?

A) Oral temperature 101.6° F
B) Apical pulse 102 beats/min
C) Intracranial pressure 15 mm Hg
D) Mean arterial pressure 90 mm Hg

Question 22

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?

A) Bruising under both eyes
B) Complaint of severe headache
C) Large ecchymosis behind one ear
D) Temperature of 101.5° F ( 38.6° C )

Question 23

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?

A) The patient takes warfarin (Coumadin) daily.
B) The patient's blood pressure is 162/94 mm Hg.
C) The patient is unable to remember the accident.
D) The patient complains of a severe dull headache.

Question 24

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?

A) Document the increase in intracranial pressure.
B) Assure that the patient's neck is not in a flexed position.
C) Notify the health care provider about the change in pressure.
D) Increase the rate of the prescribed propofol (Diprivan) infusion.

Question 25

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?

A) Administer ceftizoxime ( Cefizox ) 1 g IV.
B) Use a cooling blanket to lower temperature.
C) Swab the nasopharyngeal mucosa for cultures.
D) Give acetaminophen ( Tylenol ) 650 mg PO.

Question 26

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?

A) A patient whose cranial x-ray shows a linear skull fracture
B) A patient who has an initial Glasgow Coma Scale score of 13
C) A patient who lost consciousness for a few seconds after a fall
D) A patient whose right pupil is 10 mm and unresponsive to light

Question 27

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse?

A) The patient is more difficult to arouse.
B) The patient's pulse is slightly irregular.
C) The patient's blood pressure increases from 120/54 to 136/62 mm Hg.
D) The patient complains of a headache at pain level 5 of a 10-point scale.

Question 28

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 ____________________.

Question 29

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?

A) Urine output of 800 mL in the last hour
B) Intracranial pressure of 16 mm Hg when patient is turned
C) Ventriculostomy drains 10 mL of cerebrospinal fluid per hour
D) LICOX brain tissue oxygenation catheter shows PbtO₂of 38 mm Hg

Question 30

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?

A) The staff nurse suctions the patient every 2 hours.
B) The staff nurse assesses neurologic status every hour.
C) The staff nurse elevates the head of the bed to 30 degrees.
D) The staff nurse administers a mild analgesic before turning the patient.

Question 31

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?

A) Monitor cerebrospinal fluid color hourly.
B) Document intracranial pressure every hour.
C) Turn and reposition the patient every 2 hours.
D) Check capillary blood glucose level every 6 hours.

Question 32

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?

A) A 44-year-old receiving IV antibiotics for meningococcal meningitis
B) A 23-year-old who had a skull fracture and craniotomy the previous day
C) A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago
D) A 61-year-old who has increased ICP and is receiving hyperventilation therapy

Question 33

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?

A) Obtain oxygen saturation.
B) Check pupil reaction to light.
C) Palpate the head for hematoma.
D) Assess Glasgow Coma Scale ( GCS ).

Question 34

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?

A) Draw blood for arterial blood gases ( ABGs ).
B) Administer 5% hypertonic saline intravenously.
C) Administer acetaminophen ( Tylenol ) 650 mg orally.
D) Send patient for computed tomography ( CT ) of the head.

Question 35

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

A) Intracranial pressure of 15 mm Hg
B) Cerebrospinal fluid (CSF) drainage of 15 mL/hour
C) Pressure of oxygen in brain tissue (PbtO₂) is 14 mm Hg
D) Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min