Question 1

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?

Accepted Answer

Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; the temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

Question 2

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), 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?

Accepted Answer

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

Question 3

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to

Accepted Answer

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Question 4

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

Accepted Answer

The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg.

Question 5

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?

Accepted Answer

Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP. The other actions by the staff nurse are appropriate.

Question 6

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of

Accepted Answer

Apneustic breathing is caused by loss of CNS integration in the pons and is not effective in maximizing gas exchange. Crackles on inspiration are abnormal, but they are not an indication of an abnormal breathing pattern. The Glasgow Coma Scale and cerebral perfusion pressure P are not useful in determining or documenting a patient's respiratory patterns.

Question 7

When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

Accepted Answer

A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation. Absent corneal reflexes and nystagmus are not symptoms of herniation. A nonreactive left pupil would be consistent with left-sided damage.

Question 8

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

Accepted Answer

The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

Question 9

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

Accepted Answer

The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and monitoring are inadequate responses to the patient's problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information.

Question 10

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should

Accepted Answer

The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective.

Question 11

The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the medication is effective if

Accepted Answer

Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP. It will not directly affect seizure activity or abnormal EEG activity. A decreased GCS would indicate worsening of the patient's neurologic status.

Question 12

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

Accepted Answer

Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.

Question 13

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess

Accepted Answer

Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

Question 14

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?

Accepted Answer

An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The post-craniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

Question 15

Family members are optimistic about a comatose patient's recovery because the patient's eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?

Accepted Answer

Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to maintain wakefulness even though the damage to the cerebral cortex is severe. The patient's behavior is not a reflex action. The behaviors of eye opening and wakefulness are not indicators of improvement in the comatose condition.

Question 16

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

Accepted Answer

The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

Question 17

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 ml/hr for 3 days. The nurse will anticipate the need to

Accepted Answer

The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and also for healing and immune function. 5% dextrose does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema. A total fluid intake of 1200 ml for 24 hours will not cause cerebral edema. Albumin administration will temporarily increase serum protein, but the patient also requires lipids, carbohydrate, and other nutrients that will be supplied through enteral feeding.

Question 18

A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock while hiking. The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. The nurse's best approach to the patient's family is to

Accepted Answer

The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

Question 19

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

Accepted Answer

LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

Question 20

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

Accepted Answer

The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Quiz 57: Nursing Management: Acute Intracranial Problems

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C) , 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?

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

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?

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of

When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should

The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the medication is effective if

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

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess

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?

Family members are optimistic about a comatose patient's recovery because the patient's eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) , a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 ml/hr for 3 days. The nurse will anticipate the need to

A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock while hiking. The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. The nurse's best approach to the patient's family is to

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

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

Quiz 57: Nursing Management: Acute Intracranial Problems

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C) , 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?

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

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?

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of

When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should

The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the medication is effective if

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

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess

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?

Family members are optimistic about a comatose patient's recovery because the patient's eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) , a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 ml/hr for 3 days. The nurse will anticipate the need to

A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock while hiking. The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. The nurse's best approach to the patient's family is to

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

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 patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 ml/hr for 3 days. The nurse will anticipate the need to