Question 1

A patient in a barbiturate coma for increased intracranial pressure (ICP)has audible gurgling through the endotracheal tube.What should the nurse do first before suctioning this patient?

Accepted Answer

Administering 100% oxygen before suctioning is a standard practice to prevent hypoxia during the brief period when the airway is obstructed by the suction catheter.

Question 2

A patient recovering from an ischemic stroke is prescribed verapamil (Calan).In preparation for patient teaching,which medication category will the nurse review?

Accepted Answer

Verapamil (Calan) belongs to the medication category of calcium channel blockers, which are used to treat high blood pressure, angina, and arrhythmias. It works by slowing down the movement of calcium ions into the heart and blood vessels, which results in relaxation of blood vessels and reduction of blood pressure. Therefore, the nurse should review the medication category of calcium channel blockers in preparation for patient teaching.

Question 3

A patient with increased intracranial pressure (ICP)has a body temperature of 100^°F.What action should the nurse take to address this temperature elevation?

Accepted Answer

A body temperature of 101°F or higher can increase the metabolic demands of the body, leading to an increase in cerebral blood flow and thus increasing ICP. Administering an antipyretic medication can help lower the body temperature and reduce the risk of increasing ICP. Placing the head in a neutral position, auscultating lung sounds and increasing fluids, and sending a urine sample for culture and sensitivity do not address the temperature elevation.

Question 4

A patient recovering from a stroke has profound bradycardia.What should the nurse suspect as the cause of this manifestation?

Accepted Answer

The vasomotor center in the brainstem regulates heart rate and blood pressure. A stroke affecting this area can lead to bradycardia.

Question 5

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP).What should the nurse assess to determine this patient's cerebral function?

Accepted Answer

To assess cerebral function in a patient with increased ICP and in a barbiturate coma, the nurse should assess pupillary size and reaction. Changes in pupillary size and reactivity can indicate worsening ICP and a decrease in cerebral function. The gag reflex, Glasgow coma scale, and vital signs can provide additional information, but are not as specific to cerebral function as pupillary assessment.

Question 6

A patient with increased intracranial pressure (ICP)is sensitive to fluid-volume shifts.Which approach would be the safest to reduce this patient's cerebral edema?

Accepted Answer

The answer of A patient with increased intracranial pressure (ICP)is...

Question 7

A patient with a traumatic brain injury is leaking clear fluid from the nose.What action should the nurse take?

Accepted Answer

Clear fluid leaking from the nose after a traumatic brain injury suggests a possible cerebrospinal fluid (CSF) leak. CSF is a clear fluid that surrounds the brain and spinal cord. If there is a leak, it could lead to complications such as infections. Collecting the fluid with a sterile gauze can help determine if it is indeed CSF or not. It is important to notify the healthcare provider immediately if there is suspicion of a CSF leak.

Question 8

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP)monitoring device.What is an advantage of this device?

Accepted Answer

The answer of The nurse is preparing a patient for...

Question 9

A patient with a cerebral vasospasm is receiving triple H therapy.What parameter should the nurse use to determine adequacy of hemodilution?

Accepted Answer

Hemodilution is part of triple H therapy (hypertension, hypervolemia, hemodilution) used to treat cerebral vasospasm. The goal is to reduce blood viscosity to improve cerebral blood flow. Adequacy of hemodilution is determined by monitoring hemoglobin levels, aiming for a lower level to ensure the blood is sufficiently diluted. However, the hemoglobin level of 30 g/dL mentioned in option A is incorrect as it is far too high and likely a typographical error. In clinical practice, a target hemoglobin level would be lower, typically around 30-35% hematocrit or a hemoglobin level of around 10 g/dL, to ensure adequate dilution without compromising oxygen-carrying capacity. The other options (B, C, D) are not direct indicators of hemodilution adequacy.

Question 10

The nurse is caring for a patient with neurogenic shock.What finding should the nurse expect to assess in this patient?

Accepted Answer

Neurogenic shock is characterized by a loss of sympathetic tone, leading to vasodilation and resulting in warm, dry skin due to increased peripheral blood flow.

Question 11

The nurse is preparing materials for the families of patients who have sustained a stroke.What information should the nurse include to reduce the risk for additional strokes?

Accepted Answer

The answer of The nurse is preparing materials for the...

Question 12

The nurse is caring for a patient with a diffuse axonal injury.What treatment plan should the nurse expect to be prescribed for this patient?

Accepted Answer

A diffuse axonal injury typically does not have a surgical treatment option, such as a craniotomy or evacuation of a hematoma. The primary treatment plan for this patient would be to closely monitor and observe their neurological status. Wound debridement would not be indicated for this type of injury.

Question 13

A patient with neurogenic shock is demonstrating vagal stimulation.What should the nurse expect to be prescribed for this patient?

Accepted Answer

Vagal stimulation can cause bradycardia and hypotension. Atropine can block the actions of the vagus nerve and increase heart rate, improving blood pressure. Epinephrine, phenylephrine, and norepinephrine may be prescribed for neurogenic shock, but not specifically for vagal stimulation.

Question 14

The nurse is concerned that a patient is at high risk for having a stroke.What finding did the nurse use to make this clinical decision?

Accepted Answer

A blood pressure reading of 182/90 mm Hg indicates severe hypertension, which is a major risk factor for stroke. BMI, heart rate, and pulse oximetry are not significant risk factors for stroke.

Question 15

A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy.For which procedure should the nurse prepare teaching material for this patient?

Accepted Answer

Aneurysm clipping is often preferred for wide-necked aneurysms with complex anatomy, as it allows for direct access and secure closure of the aneurysm.

Question 16

The nurse is assessing a patient who sustained a traumatic brain injury several years ago.What finding should the nurse expect when completing the assessment?

Accepted Answer

Memory loss is a common consequence of a traumatic brain injury. While dysphagia, hemiparesis, and visual field deficits may also be present, memory loss is the most commonly observed cognitive deficit.

Question 17

The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm.What assessment finding caused the nurse to make this conclusion?

Accepted Answer

A sudden severe headache is a classic symptom of a ruptured cerebral aneurysm and often indicates a hemorrhagic stroke. Slurred speech and visual field deficits may also occur in a stroke, but they are not specific to a hemorrhagic stroke caused by a cerebral aneurysm. Lower extremity weakness may occur in a stroke, but it is also not specific to a hemorrhagic stroke caused by a cerebral aneurysm.

Question 18

A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg.What action should the nurse take?

Accepted Answer

A blood pressure of 90/50 mm Hg may indicate hypotension, which can be harmful to a patient recovering from a hemorrhagic stroke. The nurse should notify the health-care provider to determine if any interventions, such as fluid resuscitation or medication administration, are necessary to maintain hemodynamic stability.

Question 19

The family of a patient with a traumatic brain injury asks why the bed side rails are padded.What should the nurse explain to the family?

Accepted Answer

Patients with traumatic brain injuries are at risk for seizures, and padding the side rails helps prevent injury if a seizure occurs.

Question 20

An adolescent seeks medical care after being in a street fight.Which observation indicates that this patient has sustained a basilar skull fracture?

Accepted Answer

Basilar skull fractures can cause hemotympanum, which is the presence of blood behind the eardrum, resulting in bruising around the ears. Hyperthermia and episodic tachycardia are not specific to a basilar skull fracture. Rapid deterioration to comatose can be a sign of a basilar skull fracture, but bruising around the ears is a more accurate and specific answer.

Quiz 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube.What should the nurse do first before suctioning this patient?

A patient recovering from an ischemic stroke is prescribed verapamil (Calan) .In preparation for patient teaching,which medication category will the nurse review?

A patient with increased intracranial pressure (ICP) has a body temperature of 100^°F.What action should the nurse take to address this temperature elevation?

A patient recovering from a stroke has profound bradycardia.What should the nurse suspect as the cause of this manifestation?

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP) .What should the nurse assess to determine this patient's cerebral function?

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts.Which approach would be the safest to reduce this patient's cerebral edema?

A patient with a traumatic brain injury is leaking clear fluid from the nose.What action should the nurse take?

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device.What is an advantage of this device?

A patient with a cerebral vasospasm is receiving triple H therapy.What parameter should the nurse use to determine adequacy of hemodilution?

The nurse is caring for a patient with neurogenic shock.What finding should the nurse expect to assess in this patient?

The nurse is preparing materials for the families of patients who have sustained a stroke.What information should the nurse include to reduce the risk for additional strokes?

The nurse is caring for a patient with a diffuse axonal injury.What treatment plan should the nurse expect to be prescribed for this patient?

A patient with neurogenic shock is demonstrating vagal stimulation.What should the nurse expect to be prescribed for this patient?

The nurse is concerned that a patient is at high risk for having a stroke.What finding did the nurse use to make this clinical decision?

A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy.For which procedure should the nurse prepare teaching material for this patient?

The nurse is assessing a patient who sustained a traumatic brain injury several years ago.What finding should the nurse expect when completing the assessment?

The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm.What assessment finding caused the nurse to make this conclusion?

A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg.What action should the nurse take?

The family of a patient with a traumatic brain injury asks why the bed side rails are padded.What should the nurse explain to the family?

An adolescent seeks medical care after being in a street fight.Which observation indicates that this patient has sustained a basilar skull fracture?

Quiz 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube.What should the nurse do first before suctioning this patient?

A patient recovering from an ischemic stroke is prescribed verapamil (Calan) .In preparation for patient teaching,which medication category will the nurse review?

A patient with increased intracranial pressure (ICP) has a body temperature of 100°F.What action should the nurse take to address this temperature elevation?

A patient recovering from a stroke has profound bradycardia.What should the nurse suspect as the cause of this manifestation?

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP) .What should the nurse assess to determine this patient's cerebral function?

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts.Which approach would be the safest to reduce this patient's cerebral edema?

A patient with a traumatic brain injury is leaking clear fluid from the nose.What action should the nurse take?

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device.What is an advantage of this device?

A patient with a cerebral vasospasm is receiving triple H therapy.What parameter should the nurse use to determine adequacy of hemodilution?

The nurse is caring for a patient with neurogenic shock.What finding should the nurse expect to assess in this patient?

The nurse is preparing materials for the families of patients who have sustained a stroke.What information should the nurse include to reduce the risk for additional strokes?

The nurse is caring for a patient with a diffuse axonal injury.What treatment plan should the nurse expect to be prescribed for this patient?

A patient with neurogenic shock is demonstrating vagal stimulation.What should the nurse expect to be prescribed for this patient?

The nurse is concerned that a patient is at high risk for having a stroke.What finding did the nurse use to make this clinical decision?

A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy.For which procedure should the nurse prepare teaching material for this patient?

The nurse is assessing a patient who sustained a traumatic brain injury several years ago.What finding should the nurse expect when completing the assessment?

The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm.What assessment finding caused the nurse to make this conclusion?

A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg.What action should the nurse take?

The family of a patient with a traumatic brain injury asks why the bed side rails are padded.What should the nurse explain to the family?

An adolescent seeks medical care after being in a street fight.Which observation indicates that this patient has sustained a basilar skull fracture?

A patient with increased intracranial pressure (ICP) has a body temperature of 100^°F.What action should the nurse take to address this temperature elevation?