Question 1

A patient with increased intracranial pressure ICP) is being repositioned. The nurse would incorporate which actions into this intervention? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

A,D,E

Question 2

Which neurologic assessment is being performed in the exhibit?

Accepted Answer

The exhibit shows a Brudzinski sign assessment, which is a maneuver used to evaluate the presence of meningitis. In this maneuver, the healthcare provider flexes the patient's neck, and if there is involuntary flexion of the hips and knees, it indicates the presence of meningeal irritation. Kernig's sign involves the inability to fully extend the knee with hip flexion, Babinski reflex involves the extension of the great toe and fanning of the other toes when the bottom of the foot is stroked, and decorticate posturing is a type of abnormal posturing that indicates damage to the brain.

Question 3

A patient is in the emergency department following a head injury. The nurse would assess for which sign indicating early increased intracranial pressure?

Accepted Answer

Decreasing level of consciousness is an early sign of increased intracranial pressure. Elevated diastolic blood pressure, decreasing respiratory rate, and tachycardia are late signs of increased intracranial pressure.

Question 4

Which nursing diagnosis is most applicable to a patient with new-onset seizures?

Accepted Answer

Anxiety is the most applicable nursing diagnosis to a patient with new-onset seizures as they may experience fear, uncertainty, and stress due to the sudden and unexpected nature of the seizures. They may also be anxious about the potential consequences and impact on their daily life.

Question 5

A patient comes to the clinic complaining of repetitive episodes of sudden severe pain on the right side of the face. The nurse anticipates additional testing for which disorder?

Accepted Answer

Trigeminal neuralgia is a disorder characterized by sudden, severe pain on one side of the face. Additional testing, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans, may be needed to confirm the diagnosis and rule out other conditions that may cause similar symptoms. Parkinson's disease, Bell's palsy, and myasthenia gravis do not typically present with sudden, severe pain on one side of the face as a primary symptom.

Question 6

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

Accepted Answer

Decerebrate posturing is characterized by arms and legs being extended and adducted with the arms pronated. It is indicative of severe brain damage or dysfunction, usually at the level of the brainstem.

Question 7

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

Accepted Answer

The priority nursing diagnosis for a patient with an intracranial pressure monitoring device is Risk for Infection, as this device provides a direct route for bacteria to enter the brain. It is essential to monitor the insertion site, ensure proper cleaning and care, and assess for signs and symptoms of infection. The other options, Ineffective Thermoregulation, Risk for Impaired Skin Integrity, and Impaired Physical Mobility, may also be relevant but are not as critical as preventing infection in this patient population.

Question 8

The patient was an unrestrained front-seat passenger in a motor vehicle crash and struck his forehead on the inside of the windshield. Diagnostic testing in the emergency department reveals coup-contrecoup injury. The nurse identifies which area as the contrecoup injury?

Accepted Answer

A coup-contrecoup injury is a type of traumatic brain injury that occurs when the brain is shaken inside the skull, leading to damage to both the area of impact (coup injury) and the area directly opposite it (contrecoup injury). In this case, the patient hit their forehead on the inside of the windshield, leading to a coup injury on the frontal area of the brain and a contrecoup injury on the posterior or occipital part of the brain that is directly opposite. Therefore, the correct answer is B.

Question 9

The patient was riding in a car that hit a tree. The head hit the windshield, and then the brain rebounded within the skull toward the opposite side. This injury represents which mechanism of injury?

Accepted Answer

An acceleration-deceleration injury occurs when the head is set in motion and then suddenly decelerated or stopped, causing the brain inside the skull to move and hit the opposite side. This is consistent with the mechanism of injury described in the question. A penetrating head injury involves an object penetrating the skull and entering the brain. An acceleration injury occurs when the head is set in motion, but there is no subsequent deceleration or stopping. A deceleration injury occurs when the head is suddenly stopped or rapidly decelerated, but there is no initial acceleration.

Question 10

A patient is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. How would the nurse categorize this seizure?

Accepted Answer

The patient's symptoms suggest an absence seizure, also known as a petit mal seizure. These seizures involve brief periods of blank staring and unresponsiveness, often accompanied by repetitive movements like lip smacking. They typically last for only a few seconds to a minute, and the person may not have any memory of the episode afterwards.

Question 11

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 prepares to care for this patient based on which evaluation of this assessment?

Accepted Answer

The patient's symptoms suggest an epidural hematoma, which is a serious emergency situation that requires surgical intervention. The dilated pupil on the same side as the hematoma indicates increased intracranial pressure, and the seizure is a further indication that urgent medical attention is needed. Waiting for the seizure to stop is not an appropriate course of action in this situation. A subdural hematoma may also cause similar symptoms, but the location of the hematoma over the temporal area suggests an epidural hematoma instead. Option D is incorrect as the symptoms are not typical and require immediate medical attention.

Question 12

The nurse anticipates that which medication will be ordered to halt status epilepticus in a patient?

Accepted Answer

Lorazepam (Ativan) IV is the medication of choice for halting status epilepticus as it works quickly to stop seizures. Oral glucose, phenytoin, gabapentin, and lamotrigine are not indicated for stopping status epilepticus.

Question 13

A 25-year-old female is diagnosed with tic douloureux. How should the nurse describe this disorder to the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A 25-year-old female is diagnosed with tic...

Question 14

The patient sustains a subdural hematoma after falling. How would the nurse explain this injury to the patient's family?

Accepted Answer

A subdural hematoma occurs when blood collects between the brain and its outermost covering, which is known as the dura mater. This explanation accurately describes the location of the bleeding in a subdural hematoma.

Question 15

The patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees. The nurse is observing for which finding?

Accepted Answer

The nurse is observing for Brudzinski's sign, which is a positive sign if there is involuntary flexion of the hips and knees during flexion of the patient's neck. Doll's eyes reflex and Babinski reflex both involve eye and foot movements respectively, while Kernig's sign involves pain and resistance in extending the patient's leg with the knee bent. None of these signs are being assessed in this scenario.

Question 16

The nurse is assessing the patient using the technique shown. What is considered a normal finding using this technique?

Accepted Answer

No pain or resistance in either joint is considered a normal finding when using this technique.

Question 17

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. Standard Text: Click and drag the options below to move them up or down.
Choice

Accepted Answer

The answer of A patient without a history of previous...

Question 18

A patient has experienced a subarachnoid hemorrhage and is at risk for increased intracranial pressure ICP) due to the initiation of the vasodilatory cascade. The nurse plans care for this patient to avoid which primary initiating factor?

Accepted Answer

Cerebral tissue ischemia is a primary initiating factor for increased intracranial pressure (ICP) following a subarachnoid hemorrhage. It can lead to a cycle of worsening conditions, including the vasodilatory cascade, which further increases ICP.

Question 19

A patient has just been diagnosed with trigeminal neuralgia. What would the nurse teach this patient about treatment for this disorder?

Accepted Answer

Anticonvulsant drugs like carbamazepine and gabapentin are the first-line treatment for trigeminal neuralgia.

Question 20

Reviewing a patient's report of laboratory test results see accompanying box), the nurse realizes that which values are critical for the patient with a decreased level of consciousness?

Accepted Answer

A patient with a decreased level of consciousness may have altered glucose and serum osmolality levels, indicating the need for immediate medical attention. Sodium and potassium levels are important for overall electrolyte balance, but not necessarily critical for a decreased level of consciousness. White blood cell count is not directly related to a decreased level of consciousness.

Quiz 21: Caring for the Patient With an Acute Brain or Cranial Nerve Disorder

A patient with increased intracranial pressure ICP) is being repositioned. The nurse would incorporate which actions into this intervention? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.