Deck 42: Nursing Care of Patients with Intracranial Disorders

Question 1

During a motor vehicle accident a patient suffered multiple injuries of the brain. Place an X over the area where the countercoup injury would occur.

Answer 1

Question 2

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

A)anxiety
B)self-care deficit
C)altered activity-exercise
D)altered body image

Answer 2

anxiety

Question 3

The nurse anticipates that unconscious patients without a cough reflex will require

A)continuous pulse oximetry instead of intubation.
B)frequent suctioning with a tonsil-tip suction device.
C)close observation as they are fed.
D)intubation and mechanical ventilation.

Answer 3

intubation and mechanical ventilation.

Question 4

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

A)Cheyne-Stokes respirations
B)apneustic respirations
C)neurogenic hyperventilation
D)ataxic respirations

Question 5

Brain death is the cessation of all brain functions. The criteria to establish brain death varies from state to state but generally recognized criteria include the following: Select all that apply.

A)absent motor and reflex movements
B)flat electroencephalogram (EEG) on successive EEGs
C)no spontaneous respiration
D)pupils are equal and responsive to light
E)criteria present for at least 15 minutes

Question 6

The nurse is monitoring a patient with increased intracranial pressure. What would the patient's mean arterial pressure (MAP) in mmHg be when the patient's blood pressure is 140/80 mmHg? _____ mmHg

Question 7

In the patient with altered level of consciousness (LOC), the most appropriate intravenous fluid is

A)isotonic or hypertonic.
B)0.45% normal saline.
C)dextrose 5% in water.
D)dextrose 5% in 0.45 % normal saline.

Question 8

A patient is in the emergency department following a head injury. The most accurate sign of developing increased intracranial pressure (IICP) is which of the following?

A)decreasing level of consciousness
B)elevated diastolic blood pressure
C)decreasing respiratory rate
D)pupils are equal

Question 9

The patient is hit by a swinging bat. This is an example of

A)an acceleration injury.
B)a deceleration injury.
C)an acceleration-deceleration injury.
D)a penetrating head injury.

Question 10

Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness, the patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. The nurse anticipates which of the following?

A)This is an emergency situation that is likely due to an epidural hematoma and requires surgery.
B)This is a controlled situation once the seizure stops.
C)This is a serious situation in which a subdural hematoma is developing and requires surgery.
D)This is a typical situation seen with most patients who fall and will subside with observation.

Question 11

Traumatic brain injury (TBI) is the leading cause of death and disability in the United States. The nurse realizes that all of the following are causes of TBI. Place the answers in order from the most frequent to least frequent cause of TBI. Click and drag the options below to move them up or down.

A)falls
B)motor vehicle accidents
C)elevated blood alcohol
D)riding a motorcycle without a helmet

Question 12

In a patient diagnosed with a frontal lobe tumor, which of the following would be an appropriate expected outcome? See the accompanying box for the manifestations of a frontal lobe tumor. [Insert Manifestations of Brain Tumors]

A)Uses alternative techniques for communication
B)Can fully verbalize plans for rehabilitation
C)Regains ability to comprehend verbal and written language
D)Expresses understanding that aphasia is permanent

Question 13

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

A)lorazepam (Ativan) IV
B)oral glucose
C)phenytoin (Dilantin) orally
D)gabapentin (Neurontin) and lamotrigine (Lamictal)

Question 14

Following a craniotomy, the nurse should position the patient in which position?

A)low Fowler's (head of bed up 30 degrees)
B)flat
C)high
D)high Fowler's (head of bed up 45 degrees)
E)sitting upright

Question 15

A patient without a history of previous seizures, experiences two tonic-clonic seizures in succession while the nurse is in the patient's room. List in priority order, the actions the nurse should take. Click and drag the options below to move them up or down.

A)Turn the patient on his or her side
B)Protect patient from environmental harm
C)Start oxygen via face mask
D)Reorientation of the patient to time, person, and place

Question 16

The patient was riding in a car that hit a tree. The head hit the windshield (coup) and then the brain rebounded within the skull toward the opposite side (contrecoup). This is

A)an acceleration-deceleration injury.
B)a penetrating head injury.
C)an acceleration injury.
D)a deceleration injury.

Question 17

Reviewing the patient's report of laboratory test results (see accompanying box), the nurse realizes that which of the following critical values are for the patient with a decreased level of consciousness? $$\begin{array} { | l | l | } \hline \text { Laboratory tests } & \text { Results } \\\hline \mathrm { Na } + & 138 \mathrm { mEq } / \mathrm { L } \\\hline \mathrm { K } + & 4.0 \mathrm { mEq } / \mathrm { L } \\\hline \mathrm { WBC } & 10,000 \\\hline \text { Glucose } & 45 \mathrm { mg } / \mathrm { dl } \\\hline \text { Serum osmolality } & \begin{array} { l } 200 \mathrm { mOsm } / \mathrm { kg } \\\mathrm { H } 2 \mathrm { O }\end{array} \\\hline\end{array}$$

A)glucose and serum osmolality
B)sodium and potassium levels
C)sodium and white blood cell count
D)glucose and white blood cell count

Question 18

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which of the following?

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

Question 19

A patient has suffered a closed head injury due to a car accident. Place an "X" over the area suggestive of a subdural hematoma.

Question 20

When assessing an adult after a fall, the nurse notes a dilated pupil on the right and a hematoma in the right temporal area. The nurse realizes that this likely means that

A)the process affecting the pupil is occurring locally 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 a metabolic process.

Question 21

The nurse arrives on the unit to care for a group of patients who have had strokes. Place these patients in order of highest to lowest priority as to how the nurse should begin care. Click and drag the options below to move them up or down.

A)the patient with dysphagia who is to have his or her first meal following a stroke
B)the patient with increased warmth and redness on the left calf
C)the patient who calls, asking to be turned 45 minutes prior to the next scheduled position change
D)the patient expressing anger over his or her impaired verbal communication

Question 22

The daughter of a patient hospitalized for a stroke asks the nurse "What did the doctor mean when he said that my mother is at risk for strokes because she lives in the stroke belt?" What is the nurse's best response?

A)"People living in the southeastern United States have a higher rate of stroke than other parts of the country but the cause has not been identified."
B)"People with central truncal obesity or fat deposits around the waist are at higher risk for strokes."
C)"The doctor is referring to waist-to-hip ratio, which increases the risk for stroke."
D)"I don't know, but I'll find out and get back to you later this afternoon."

Question 23

The nurse is caring for a patient with an intracranial pressure monitoring device. What is a priority nursing diagnosis for this patient?

A)Risk for Infection
B)Ineffective Tissue Perfusion: Cerebral
C)Risk for Impaired Skin Integrity
D)Impaired Physical Mobility

Question 24

The nurse is observing a patient who is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. The nurse categorizes the seizure as which of the following?

A)absence
B)partial
C)tonic-clonic
D)status epilepticus

Question 25

The nurse realizes that medication ordered to control migraine headaches will be aimed at reducing the frequency and severity and to halt a headache in progress. Prophylactic therapy for migraines includes which of the following?

A)propranolol hydrochloride (Inderal)
B)acetaminophen (Tylenol)
C)zolmitriptan (Zomig)
D)sumatriptan (Imitrex)

Question 26

Place the following stages of a classic migraine headache in the correct order from onset to resolution: Click and drag the options below to move them up or down.

A)premonition of the experience; visual disturbances, spots and flashing; 5-60 minutes in length
B)physiological change of vasoconstriction, numbness and tingling of face or hand, feeling of being nervous or other mood changes
C)physiological change of vasodilation, serotonin levels decline, nausea and vomiting, withdrawal from light and sound
D)sensitivity to touch of the area of the head that is involved, exhaustion, deep aching present

Question 27

A patient with a brain tumor is scheduled for a chest x-ray and says "I don't understand why I'm having a chest x-ray when my problem is in my head!" What is the nurse's most appropriate response?

A)"The physician may be trying to determine if this is a metastatic brain tumor, as the most common source of these tumors is cancer of the lung."
B)"This is just a precautionary measure."
C)"Don't get so upset about this! The doctor will talk to you later."
D)"The escort is here to take you to radiology so we'll discuss this when you return."

Question 28

To prevent stroke and transient ischemic attack (TIA), what medications are used?

A)antiplatelet agents
B)fibrinolytic therapy
C)anticoagulant therapy
D)corticosteroids

Question 29

The nurse is caring for a patient in the postoperative unit following carotid endarterectomy and positions the patient on the

A)unoperated side and either in a flat position or with the head of the bed elevated 30 degrees.
B)operated side and with the head of the bed in semi-Fowler's position.
C)unoperated side with a small towel placed directly against the operative site.
D)operated side with a pressure dressing over the operative site.

Question 30

The nurse is teaching a community education class on warning signs of stroke and transient ischemic attacks (TIAs). What should be included in this presentation? Select all that apply.

A)sudden weakness or numbness of the face, arm, or leg, especially on one side of the body
B)sudden confusion, difficulty speaking, or difficulty understanding speech
C)sudden trouble walking, dizziness, or loss of coordination
D)arrival time at the hospital should be within three hours of onset for drugs to be effective
E)African Americans are a high-risk group for strokes

Question 31

The nurse recognizes the patient's need for clarification regarding therapeutic management of migraine headaches when making the following statement:

A)"I will switch to red wine rather than continuing to drink white wine."
B)"Reading food labels is important since I have to avoid tyramine."
C)"I will need to drink caffeine free soft drinks and coffee from now on."
D)"Stress management classes will be a good approach to take."

Question 32

When giving Mannitol, the following nursing interventions should be implemented: Select all that apply.

A)Use an in-line filter for IV administration.
B)Do not administer the medication if crystals are noted in the solution.
C)Monitor central venous pressure (CVP) and pulmonary artery pressures (PAP) before and every hour throughout administration.
D)Assess patient for signs of fluid retention.
E)Discontinue the drug immediately if the patient complains of a headache.

Question 33

The nurse is caring for a patient who had a craniotomy for a brain tumor and has developed post-operative leakage of cerebrospinal fluid (CSF). What are appropriate nursing interventions for this patient? Select all that apply.

A)Keep patient turned on sign of leakage and keep the head of the bed elevated 20 degrees.
B)Assess the patient for constant swallowing.
C)Observe for thick, yellow, odorous drainage.
D)Insert sterile packing into the area.
E)Encourage the patient to blow his or her nose frequently.

Question 34

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

A)migraine
B)cluster
C)stress
D)sinus

Question 35

The nurse is caring for a head-injured patient with cerebral edema 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 patient avoid coughing, sneezing, and straining.
B)Position the patient in the supine position with the head of the bed at 30 degrees.
C)Initiate oxygen administration.
D)Initiate and monitor an IV with normal saline.

Question 36

The nurse is caring for a patient on a medical unit who begins a tonic-clonic seizure. After a few minutes the seizure stops but repeats again after a minute. This pattern continues in which the patient 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. Click and drag the options below to move them up or down.

A)Initiate oxygen via the nasal cannula at the bedside.
B)Call respiratory therapy stat.
C)Call the physician stat.
D)Hang an IV of normal saline to keep vein open.

Question 37

The nurse completes his or her admission physical assessment (see accompanying chart) of a patient on the neuro unit. These findings are consistent with a patient in which coma state? $$\begin{array} { | l | l | } \hline \text { Physical Assessment } & \\\hline \text { Eyes } & \begin{array} { l } \text { Wandering eye movements present; does not focus on objects or } \\\text { faces }\end{array} \\\hline \text { Head and neck } & \text { Able to chew and swallow } \\\hline \text { Respiratory } & \text { Coughs at intervals but not on command } \\\hline \text { Musculo-skeletal } & \text { Grasps objects but not on command } \\\hline \begin{array} { l } \text { LOC (level of } \\\text { consciousness) }\end{array} & \begin{array} { l } \text { Blinks or smiles when physically stimulated but not on command; } \\\text { does not respond to verbal stimuli; sleep-wake cycles present }\end{array} \\\hline\end{array}$$

A)persistent vegetative
B)stupor
C)locked-in syndrome
D)minimally conscious

Question 38

Which of the following statements correctly describes doll's eye movements characteristic of altered level of consciousness (LOC)?

A)The eyes remain fixed as the head is turned.
B)The eyes appear to move in the direction opposite to the motion of the head, when the head is gently rotated.
C)The eyes open and close when the neck is flexed and extended.
D)The pupils remain fixed and dilated.

Question 39

The patient has a tonic-clonic seizure. During the seizure, the priority for nursing care is to

A)protect the patient from injury.
B)insert a bite block to prevent the patient from swallowing his or her tongue.
C)ask the staff to hold the patient tightly.
D)obtain vital signs.

Question 40

The nurse is completing discharge teaching to a patient following hospitalization for a seizure disorder who is being prescribed phenytoin (Dilantin). What should the nurse include in these instructions?

A)"Maintain good oral hygiene, use a soft toothbrush, massage the gums, and floss daily."
B)"Carry identification indicating the type of seizures for which you are being treated."
C)"You will need to have your sodium level monitored."
D)"If you skip a dose, make sure you double the dose the next day."

Question 41

Which of the following diagrams depicts the tonic phase of a generalized seizure?

A)
B)
C)
D)

Question 42

Mark an "X" on the body diagram below that would depict hemiplegia.

Question 43

An appropriate nursing intervention for a stroke patient with agnosia would be to do the following?

A)Frequently repeat the name of familiar persons and objects in the patient's room when providing care.
B)Help the patient move hands and arms through the motions of combing hair and getting dressed.
C)Speak with a normal tone of voice near the ear on the unaffected side.
D)Talk normally to the patient but allow adequate time for the patient's short responses.

Question 44

Hemorrhagic stroke most often occurs in people with which risk factor for strokes?

A)hypertension
B)sleep apnea
C)sickle cell disease
D)diabetes