Deck 41: Nursing Care of People With Intracranial Disorders

Question 1

The person is hit by a cricket ball. This is an example of what type of injury?

A)A deceleration injury.
B)A deformation head injury.
C)An acceleration injury.
D)An acceleration-deceleration injury.

Answer 1

An acceleration injury.

Question 2

When assessing an adult after a fall, the nurse in the Emergency Department notes a dilated pupil on the right and a haematoma in the right temporal area. What does this most likely mean?

A)The process affecting the pupil is localised on the right side (ipsilateral pupil dilation).
B)The process affecting the pupil is occurring on the opposite side and is unrelated to the right temporal hematoma.
C)The process affecting the right pupil is temporary and soon both pupils will be equal in size.
D)The process causing the right pupil to dilate is a result of brainstem injury.

Answer 2

The process affecting the pupil is localised on the right side (ipsilateral pupil dilation).

Question 3

Decerebrate posturing is present in an unconscious person after a motor vehicle accident. What would the nurse expect to see when assessing a person for decerebrate posturing?

A)The arms and legs are adducted and arms are hyperpronated.
B)The arms are pulled inward and the head is turned to the side.
C)The arms are flexed over the chest and spasms are rhythmic.
D)The arms and legs have tonic-clonic seizure activity.

Answer 3

The arms and legs are adducted and arms are hyperpronated.

Question 4

The nurse is observing a person who is having a seizure that involves a blank stare, unresponsiveness to questions, and eyelid fluttering. The seizure lasts less than a minute. How does the nurse categorise the seizure?

A)Tonic-clonic.
B)Complex partial seizure.
C)Absence.
D)Simple partial seizure.

Question 5

Traumatic brain injury (TBI)is the leading cause of death and disability in Australia. The nurse realises that all of the following are causes of TBI. Place the answers in order from the most frequent to least frequent cause of TBI :
1) Elevated blood alcohol.
2) Motor vehicle accidents.
3) Riding a motorcycle without a helmet.
4) Falls.

Question 6

The nurse anticipates a medication order to halt status epilepticus. Which of the following medications is expected?

A)Phenytoin (Dilantin)orally.
B)Oral glucose.
C)Gabapentin (Neurontin)and sodium valproate (Epilim).
D)Diazepam (Valium)IV.

Question 7

A change in breathing pattern to alternating regular periods of deep, rapid breathing, followed by periods of apnoea, is called ________ and is related to damage in the diencephalon region of the cerebrum.

A)Cheyne-Stokes respirations.
B)Cluster respirations.
C)Apneustic respirations.
D)Central neurogenic hyperventilation.

Question 8

The person has a tonic-clonic seizure. What is the priority for nursing care during the seizure?

A)Protect the person from injury.
B)Hold the person tightly.
C)Insert a bite block to prevent the person from biting their tongue.
D)Perform neurological observations to determine the severity of the seizure.

Question 9

The nurse is caring for a person suspected of brain death. What are the generally recognised criteria to establish brain death? (Select all that apply.)

A)Frequent ocular response to head turning and caloric stimulation.
B)Flat electroencephalogram (EEG)on successive EEGs.
C)Pupils are equal and unreactive to light.
D)Absent motor and reflex movements.

Question 10

The nurse realises that medication ordered to control migraine headaches will be aimed at reducing the frequency and severity and to halt a headache in progress. What is a prophylactic medication for migraine?

A)Sodium valproate (Epilim).
B)Gabapentin (Neurontin).
C)Paracetamol (Panadol).
D)Sumatriptan (Imitrex).

Question 11

The nurse is planning a seminar about headaches for a local community group. What type of headache has a strong familial connection, affects females three-to-one over males, and results in lost productivity?

A)Sinus.
B)Common migraine.
C)Cluster.
D)Tension.

Question 12

The nurse is caring for a person with a head injury from a motor vehicle accident. What should the nurse assess for that would be a sign of increased intracranial pressure?

A)Pupils are reactive to light.
B)Bradycardia.
C)Tachycardia.
D)Change in mental status.

Question 13

What is the most appropriate intravenous fluid for a person with altered level of consciousness (LOC)?

A)Packed cells.
B)Isotonic or slightly hypertonic.
C)Dextrose 5% and 0.45% normal saline.
D)Hypotonic.

Question 14

Which of the following is the most important psychosocial need for a person with a seizure disorder?

A)Altered body image.
B)Risk of trauma.
C)Anxiety.
D)Unilateral neglect.

Question 15

Following a craniotomy, in which position should the nurse place the person? 5)_______

A)Head of bed elevated 20 degrees.
B)Flat.
C)Head of bed elevated 45 degrees.
D)Sitting upright.

Question 16

After a fall, the person is brought to the Emergency Department. There was a momentary loss of consciousness; the person complained of a headache, has vomited twice, has a dilated pupil on the same side as a haematoma over the temporal area and now is having a seizure. What does the nurse anticipate?

A)This is an emergency situation that is likely an epidural haematoma and requires surgery.
B)This is a serious situation in which an intracerebral haematoma is developing and requires surgery.
C)This is a controllable situation once the seizure stops.
D)This is a typical situation seen with most persons who fall and will subside over several hours.

Question 17

The person was driving a car that hit a tree. The person's head hit the windshield (coup), then the brain rebounded within the skull toward the opposite side (contrecoup). This is an example of what type of injury?

A)A deceleration injury.
B)An acceleration injury.
C)A deformation injury.
D)An acceleration-deceleration injury.

Question 18

The nurse is caring for a head-injured person with cerebral oedema and increased intracranial pressure (IICP). To prevent further transient increases from occurring, the nurse should implement which of the following interventions?

A)Implement measures to help the person avoid coughing, sneezing, and straining.
B)Position the person in the supine position.
C)Initiate and monitor an IV with normal saline.
D)Initiate oxygen administration.

Question 19

The nurse is setting up a room for a person coming from the Emergency Department who is unconscious and without a cough reflex. What will this person require?

A)Frequent suctioning with a nasal suction device.
B)Endotracheal intubation.
C)Continuous pulse oximetry instead of intubation.
D)Close observation as they are fed.

Question 20

The nurse is caring for a person on a medical unit who begins a tonic-clonic seizure. The seizure stops after a few minutes, but begins again after another minute. This pattern continues, in which the person is having repeated tonic-clonic seizures, and has lasted for more than 10 minutes. Place the following nursing actions into order from highest priority to lowest:
1) Hang an IV of normal saline to keep a vein open.
2) Call a respiratory physiotherapist stat.
3) Call the doctor stat.
4) Initiate oxygen via the nasal cannula at the bedside.

Question 21

The nurse is caring for a person with vagal nerve stimulation therapy. What instructions should be given to this person?

A)'This therapy should improve your quality of life.'
B)'This treatment will prevent any seizures.'
C)'You will not need to take your antiepileptic medications after this therapy.'
D)'You will need to discharge the stimulator after a seizure.'

Question 22

The nurse is providing preoperative teaching to a client with frequent and severe seizures. What information should be included?

A)'You will get a partial dose of your antiepileptic medication on the morning of surgery.'
B)'You can expect to be unconscious during the surgery.'
C)'You will get double the dose of your antiepileptic medication after surgery.'
D)'This surgery will cure you of any further seizures.'