Question 1

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level.The patient is in spinal shock.Following emergent intubation and mechanical ventilation,what is the priority nursing action?
A) Maintain body temperature.
B) Monitor blood pressure.
C) Pad all bony prominences.
D) Use proper hand washing.

Accepted Answer

Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury.Monitoring blood pressure is a priority.

Question 2

The nurse admits a patient to the critical care unit following a motorcycle crash.Assessment findings by the nurse include blood pressure 100/50 mm Hg,heart rate 58 beats/min,respiratory rate 30 breaths/min,and temperature of 100.5°.The patient is lethargic,responds to voice but falls asleep readily when not stimulated.Which nursing action is most important to include in this patient's plan of care?
A) Frequent neurological assessments
B) Side to side position changes
C) Range of motion to extremities
D) Frequent oropharyngeal suctioning

Accepted Answer

Nurses complete neurological assessments based on ordered frequency and the severity of the patient's condition.The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient's plan of care.Side to side position changes,range of motion exercises,and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.

Question 3

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg.The nurse needs to perform an hourly neurological assessment,suction the endotracheal tube,perform oral hygiene care,and reposition the patient to the left side.What is the best action by the nurse?
A) Hyperoxygenate during endotracheal suctioning.
B) Elevate the patient's head of the bed 30 degrees.
C) Apply bilateral heel protectors after repositioning.
D) Provide rest periods between nursing interventions.

Accepted Answer

Sustained increases in ICP lasting longer than 5 minutes should be avoided.This is accomplished by spacing nursing care activities to allow for rest between activities.All other nursing actions are a part of the patient's plan of care; however,spacing out interventions is the priority.

Question 4

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3.Following the administration of mannitol (Osmitrol),which assessment finding by the nurse requires further action?
A) ICP of 10 mm Hg
B) CPP of 70 mm Hg
C) GCS score of 5
D) CVP of 2 mm Hg

Accepted Answer

Osmotic diuretics draw water from normal brain cells,decreasing ICP and increasing CPP and urine output.An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits.A GCS score of 5,while not optimum indicates a slight improvement.A CVP of 2 mm Hg indicates hypovolemia.To ensure adequate cerebral perfusion,further action on the part of the nurse is necessary.

Question 5

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? A) pH 7.38; PaCO₂ 55 mm Hg; HCO₃ 22 mEq/L; PaO₂85 mm Hg B) pH 7.38; PaCO₂ 40 mm Hg; HCO₃ 24 mEq/L; PaO₂ 70 mm Hg C) pH 7.38; PaCO₂ 35 mm Hg; HCO₃ 24 mEq/L; PaO₂ 85 mm Hg D) pH 7.38; PaCO₂ 28 mm Hg; HCO₃ 26 mEq/L; PaO₂ 65 mm Hg

Accepted Answer

Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide.A pH of 7.38,PaCO₂ of 35 mm Hg,and a PaO₂ of 85 mm Hg indicates both.PaCO₂ values greater than normal (35-45)can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP.Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia.Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO₂ above 80 mm Hg.

Question 6

While caring for a patient with a basilar skull fracture,the nurse assesses clear drainage from the patient's left naris.What is the best nursing action?
A) Have the patient blow the nose until clear.
B) Insert bilateral cotton nasal packing.
C) Place a nasal drip pad under the nose.
D) Suction the left nares until the drainage clears.

Accepted Answer

In the presence of suspected cerebrospinal fluid leak,drainage should be unobstructed and free flowing.Small bandages may be applied to allow for fluid collection and assessment.Patients should be instructed not to blow their nose because that action may further aggravate the dural tear.Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

Question 7

Which patient being cared for in the emergency department should the charge nurse evaluate first?
A) A patient with a complete spinal injury at the C5 dermatome level
B) A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula
C) An alert patient with a subdural bleed who is complaining of a headache
D) An ischemic stroke patient with a blood pressure of 190/100 mm Hg

Accepted Answer

A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise.A GCS score of 15 indicates a neurologically intact patient.The patient with a subdural bleed is alert and not in danger of any immediate compromise.The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

Question 8

While caring for a patient with a traumatic brain injury,the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg.What is the best interpretation by the nurse?
A) Both pressures are high.
B) Both pressures are low.
C) ICP is high; CPP is normal.
D) ICP is high; CPP is low.

Accepted Answer

The ICP is above the normal level of 15 mm Hg.The CPP is within the normal range.
All other listed responses are incorrect.

Question 9

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache.The nurse assesses a blood pressure of 180/90 mm Hg,heart rate 60 beats/min,respirations 24 breaths/min,and 50 mL of urine via indwelling urinary catheter for the past 4 hours.What is the best action by the nurse?
A) Administer acetaminophen as ordered for the headache.
B) Assess for a kinked urinary catheter and assess for bowel impaction.
C) Encourage the patient to take slow, deep breaths.
D) Notify the physician of the patient's blood pressure.

Accepted Answer

Autonomic dysreflexia,characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli,including a kinked indwelling catheter,which would result in bladder distention.Other causes that should be ruled out prior to pharmacological intervention include fecal impaction.Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia.Treatment must focus on identifying the underlying cause.Slow deep breathes will not correct the underlying problem.Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.

Question 10

While caring for a patient with a closed head injury,the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg,heart rate 60 beats/min,respirations 18 breaths/min,and a temperature of 102° F.To reduce the risk of increased intracranial pressure (ICP)in this patient,what is (are)the priority nursing action(s)?
A) Ensure adequate periods of rest between nursing interventions.
B) Insert an oral airway and monitor respiratory rate and depth.
C) Maintain neutral head alignment and avoid extreme hip flexion.
D) Reduce ambient room temperature and administer antipyretics.

Accepted Answer

In this scenario,the patient's temperature is elevated,which increases metabolic demands.Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP).Cooling measures should be implemented.Insertion of an oral airway in an alert patient is contraindicated.While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP,treatment of the fever is of higher priority.

Question 11

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3.Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg,heart rate 55 beats/min,respiratory rate 10 breaths/min,oxygen saturation (SpO₂)94% on oxygen at 3 L per nasal cannula.What is the priority nursing action? A) Monitor the patient's airway patency. B) Elevate the head of the patient's bed. C) Increase supplemental oxygen delivery. D) Support bony prominences with padding.

Accepted Answer

A GCS score of 3 is indicative of a deep coma.Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3,the nurse must focus on maintaining the patient's airway.There is no evidence to support the need for increased supplemental oxygen.A respiratory rate of 10 breaths/min may result in increased CO₂ retention,which may further increase ICP through dilatation of cerebral vessels.Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however,airway patency is the immediate priority.

Question 12

The nurse is caring for a mechanically ventilated patient with a brain injury.Arterial blood gas values indicate a PaCO₂ of 60 mm Hg.The nurse understands this value to have which effect on cerebral blood flow? A) Altered cerebral spinal fluid production and reabsorption B) Decreased cerebral blood volume due to vessel constriction C) Increased cerebral blood volume due to vessel dilation D) No effect on cerebral blood flow (PaCO₂ of 60 mm Hg is normal)

Accepted Answer

Cerebral vessels dilate when PaCO₂levels increase,increasing cerebral blood volume. Cerebral vessels dilate when CO₂ levels increase,increasing cerebral blood volume.To compensate for increased cerebral blood volume,cerebral spinal fluid may be displaced,but the scenario is asking for the effect of hypercarbia (elevated PaCO₂)on cerebral blood flow.PaCO₂ of 60 mm Hg is elevated,which would cause cerebral vasodilation and increased cerebral blood volume.

Question 13

The nurse is caring for a patient who was hit on the head with a hammer.The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department ( ED )with a GCS score of 15.One hour later,the nurse assesses a GCS score of 3.What is the priority nursing action?
A) Stimulate the patient hourly.
B) Continue to monitor the patient.
C) Elevate the head of the bed.
D) Notify the physician immediately.

Accepted Answer

These are classic symptoms of epidural and acute subdural hematomas: injury,lucid period,and progressive deterioration.The physician must be notified of this neurological emergency so appropriate interventions can be implemented.Although elevating the head of the bed,continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions,notification of the physician is a priority given the severity in change of neurological status.

Question 14

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder.Upon admission,the nurse assesses the patient to be awake,alert,and moving all four extremities.The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare.What is the most appropriate nursing action?
A) Insert bilateral ear plugs.
B) Monitor airway patency.
C) Maintain neutral head position.
D) Apply a small nasal drip pad.

Accepted Answer

Patient assessment findings are indicative of a skull fracture.The presence of straw-colored nasal draining may be indicative of a CSF leak.Drainage should be monitored and allowed to flow freely.Application of a nasal drip pad is the most appropriate action.Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert.Insertion of bilateral ear plugs is not standard of care.

Question 15

The nurse admits a patient to the emergency department ( ED )with a suspected cervical spine injury.What is the priority nursing action?
A) Keep the neck in the hyperextended position.
B) Maintain proper head and neck alignment.
C) Prepare for immediate endotracheal intubation.
D) Remove cervical collar upon arrival to the ED.

Accepted Answer

Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury.Hyperextension of the neck is contraindicated with a cervical spine injury.Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient's airway is compromised.The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

Question 16

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness.What is the priority nursing action?
A) Assess for the presence of a headache.
B) Assess the patient's general orientation.
C) Determine the patient's drug allergies.
D) Determine the time of symptom onset.

Accepted Answer

Early intervention for ischemic stroke is recommended.Thrombolytics must be given within 3 hours of the onset of symptoms.Although assessment of allergies,as well accompanying symptoms such as a headache and general orientation,are a part of a complete neurological assessment and should be performed,time of onset of symptoms is critical to the type of treatment.

Question 17

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit.The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure.What is the best nursing action?
A) Assist the patient to the floor and provide soft head support.
B) Insert a nasogastric tube and connect to continuous wall suction.
C) Open the patient's mouth and insert a padded tongue blade.
D) Restrain the patient's extremities until the seizure subsides.

Accepted Answer

To reduce the risk of further injury,a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported.Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration.Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut.Forceful insertion may lead to further injury.Restraining a patient during seizure activity can be traumatizing and is not standard of care.

Question 18

A patient with a head injury has an intracranial pressure (ICP)of 18 mm Hg.Her blood pressure is 144/90 mm Hg,and her mean arterial pressure (MAP)is 108 mm Hg.What is the cerebral perfusion pressure (CPP)?
A) 54 mm Hg
B) 72 mm Hg
C) 90 mm Hg
D) 126 mm Hg

Accepted Answer

CPP = MAP - ICP.In this case,CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg.All other calculated responses are incorrect.

Question 19

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids.The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours.What is the total 24-hour dose for the 70-kg patient?
A) 2478 mg
B) 5000 mg
C) 10,794 mg
D) 12,750 mg

Accepted Answer

The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes,followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours.(30 mg ´ 70 kg)+ (5.4 mg ´ 70 kg)´ 23 hours = 10,794 mg.

Question 20

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated.While performing endotracheal suctioning,the patient reaches up in an attempt to grab the suction catheter.What is the best interpretation by the nurse?
A) The patient is exhibiting extension posturing.
B) The patient is exhibiting flexion posturing.
C) The patient is exhibiting purposeful movement.
D) The patient is withdrawing to stimulation.

Accepted Answer

This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness.Flexion posturing is characterized by rigid flexion and extension of the arms,wrist flexion,and clenched fists.Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet.Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

Quiz 13: Nervous System Alterations

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level.The patient is in spinal shock.Following emergent intubation and mechanical ventilation,what is the priority nursing action?

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg.The nurse needs to perform an hourly neurological assessment,suction the endotracheal tube,perform oral hygiene care,and reposition the patient to the left side.What is the best action by the nurse?

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3.Following the administration of mannitol (Osmitrol) ,which assessment finding by the nurse requires further action?

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

While caring for a patient with a basilar skull fracture,the nurse assesses clear drainage from the patient's left naris.What is the best nursing action?

Which patient being cared for in the emergency department should the charge nurse evaluate first?

While caring for a patient with a traumatic brain injury,the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg.What is the best interpretation by the nurse?

The nurse is caring for a mechanically ventilated patient with a brain injury.Arterial blood gas values indicate a PaCO₂ of 60 mm Hg.The nurse understands this value to have which effect on cerebral blood flow?

The nurse is caring for a patient who was hit on the head with a hammer.The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department ( ED ) with a GCS score of 15.One hour later,the nurse assesses a GCS score of 3.What is the priority nursing action?

The nurse admits a patient to the emergency department ( ED ) with a suspected cervical spine injury.What is the priority nursing action?

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness.What is the priority nursing action?

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit.The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure.What is the best nursing action?

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.Her blood pressure is 144/90 mm Hg,and her mean arterial pressure (MAP) is 108 mm Hg.What is the cerebral perfusion pressure (CPP) ?

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids.The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours.What is the total 24-hour dose for the 70-kg patient?

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated.While performing endotracheal suctioning,the patient reaches up in an attempt to grab the suction catheter.What is the best interpretation by the nurse?