Question 1

The nurse,assessing a patient with a Glasgow Coma Score of 4,finds the patient's pupils to be pinpoint and nonreactive to light.The nurse takes into consideration that this finding can be due to which situations? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)The patient was given atropine sulfate for bradycardia.
B)The patient has increased blood glucose.
C)The patient may have taken an opioid drug overdose.
D)The patient has sustained compression of the oculomotor nerve.
E)The patient has sustained damage to the pons.

Accepted Answer

Pinpoint and nonreactive pupils can be caused by opioid overdose and damage to the pons.

Question 2

A patient was the unrestrained driver of a car that was struck head on by another vehicle.During initial assessment,the nurse observes another nurse using supraorbital pressure to assess for response.What nursing intervention is indicated?
A)Hold the patient's head still so that the test will be valid.
B)Stop the procedure.
C)Ask the nurse to repeat the procedure on the other orbit.
D)Document the response as 1+,2+,3+,or 4+.

Accepted Answer

Supraorbital pressure is not a recommended or evidence-based method for assessing neurological response. The nurse observing this should stop the procedure and suggest other appropriate methods for neurological assessment, such as Glasgow Coma Scale or pupil response.

Question 3

A nurse is monitoring the intracranial pressure of a patient with a closed-head injury.Which pressure would the nurse evaluate as requiring no additional intervention?
A)12 mm Hg
B)22 mm Hg
C)25 mm Hg
D)30 mm Hg

Accepted Answer

The normal intracranial pressure range is 5-15 mm Hg. A pressure of 12 mm Hg falls within this range and would not require additional intervention. Pressures above 20-25 mm Hg indicate increased intracranial pressure and could be a cause for concern.

Question 4

The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain.The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?
A)There will be an increase in the blood flow to the brain.
B)There is a decrease in the blood-brain barrier.
C)There must be a decrease in another of the intracranial compartments.
D)There will be an increase in the production of cerebrospinal fluid.

Accepted Answer

In order to prevent an increase in intracranial pressure due to swelling of the brain, there must be a decrease in fluid or tissue volume in one of the intracranial compartments to compensate for the increased size of the swollen brain tissue. This can be achieved through the use of medications, such as diuretics, or through surgical interventions, such as a craniotomy or decompressive hemicraniectomy. Increasing blood flow to the brain, decreasing the blood-brain barrier, or increasing production of cerebrospinal fluid would not help to stabilize intracranial pressure in this situation.

Question 5

A patient,admitted with the diagnosis of stroke,has left hemiparesis involving the face,arm,and leg.The nurse explains that this stroke most likely involves which artery?
A)Right vertebral
B)Left posterior communicating
C)Left middle cerebral
D)Right middle cerebral

Accepted Answer

The right middle cerebral artery is most likely involved in a stroke that causes left hemiparesis (weakness on the left side of the body) involving the face, arm, and leg. This is because the right hemisphere of the brain controls motor function on the left side of the body.

Question 6

The nurse is providing care for a patient who sustained a severe head injury.The nurse would intervene to prevent which occurrence that increases cerebral blood flow?
A)Oversedation
B)Hypothermia
C)Fever
D)Paralysis

Accepted Answer

Fever increases metabolic demands and causes vasodilation, which increases cerebral blood flow. This can be harmful to a patient with a severe head injury. Oversedation, hypothermia, and paralysis do not increase cerebral blood flow.

Question 7

Following a stroke a patient is diagnosed with expressive aphasia.What nursing intervention is indicated?
A)Speak slowly and face the patient directly when speaking.
B)Speak at a slightly louder volume.
C)Watch the patient carefully for behavioral clues.
D)Decrease environmental stimuli before attempting to communicate with the patient.

Accepted Answer

The answer of Following a stroke a patient is diagnosed...

Question 8

A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times.What rationale would the nurse provide for this position?
A)The brain will compress the cerebral veins less in this position.
B)The ventricles of the brain will drain better in this position.
C)This position allows for less pain for the patient.
D)The cerebral spinal veins are valveless and drain by gravity.

Accepted Answer

Elevating the head of the bed helps facilitate venous drainage by gravity, as the cerebral spinal veins are valveless.

Question 9

A nurse is monitoring a patient who sustained a head injury.The nurse recognizes which finding as the earliest sign of change in neurologic status?
A)The patient cannot remember where he is.
B)The patient's pupil size is increased.
C)The patient's blood pressure has increased.
D)The patient exhibits decorticate posturing when stimulated.

Accepted Answer

The earliest sign of a change in neurologic status, especially following a head injury, is often a change in the level of consciousness or confusion, such as not remembering where one is. This can indicate the brain's response to injury before more severe symptoms, such as changes in pupil size, blood pressure alterations, or abnormal posturing, manifest.

Question 10

A nurse is preparing to conduct a neurological assessment on a patient who is not suspected of having neurological impairment.Which tests should the nurse perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)Observation for level of consciousness
B)Checking pupillary response to light
C)Ability to count by serial 7s
D)Assessing the blood pressure
E)Visual acuity

Accepted Answer

The answer of A nurse is preparing to conduct a...

Question 11

A patient with an intraventricular catheter for the assessment of increased intracranial pressure (ICP)is demonstrating A waves.The nurse would assess for which other findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)Decreasing level of consciousness
B)Pupillary changes
C)Posturing
D)Variations in blood pressure
E)Changes in the wave associated with respiration

Accepted Answer

The answer of A patient with an intraventricular catheter for...

Question 12

A patient who is unconscious following a fall is scheduled for electroencephalography (EEG)testing today.The nurse would provide additional education to a family member making which statement? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)"I hope this test is normal so we will know nothing is wrong with her brain."
B)"I am going to wait in the family room until she comes back from surgery."
C)"If the results of this test are abnormal,I will talk to the rest of the family about organ donation."
D)"This test will let us know if the blood flow to her brain is still intact."
E)"I did tell you that she is allergic to shellfish,didn't I?"

Accepted Answer

A) EEG tests brain activity, not structure, so a normal EEG doesn't rule out all brain issues.  B) EEG is not a surgical procedure; it's a non-invasive test.  D) EEG measures electrical activity, not blood flow.  E) Allergies to shellfish are irrelevant to EEG testing.

Question 13

A nurse is starting an intravenous line in a patient being treated for a head injury.Suddenly the patient extends his legs and demonstrates extreme plantar flexion.What action should be taken by the nurse?
A)Document the presence of decorticate posturing.
B)Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading.
C)Assess the position of the patient's arms.
D)Administer intravenous sedation as quickly as possible after access is obtained.

Accepted Answer

The nurse should assess the position of the patient's arms to determine if the posturing is decerebrate, which involves extension of the arms and legs and is a sign of severe brain injury.

Question 14

A patient who sustained a traumatic brain injury is being sent for a CT scan.Which nursing statements would help the patient's spouse understand the rationale for a CT scan rather than an MRI? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)"CT scans are easier for patients with head injuries because movement is allowed."
B)"We can get results from a CT scan quicker than from an MRI."
C)"MRIs are more costly so the least expensive test is always done first."
D)"CT scans are generally safer."
E)"CT scans show more detail than an MRI."

Accepted Answer

The answer of A patient who sustained a traumatic brain...

Question 15

A nurse is assisting with a patient's oculocephalic and oculovestibular reflex assessment.How should the nurse prepare for this testing? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)Prepare for oculocephalic testing to be done after oculovestibular testing.
B)Ensure that cervical spine injury has been ruled out.
C)Obtain cold water and a syringe.
D)Be certain there is no perforation of the tympanic membrane in the side being tested.
E)Tell the patient she will be asked to report any feeling of numbness or vertigo.

Accepted Answer

B) Before performing these tests, it's crucial to ensure that the patient does not have a cervical spine injury to avoid causing harm during the assessment. C) Cold water and a syringe are needed for the oculovestibular test, which involves irrigating the ear with cold water to observe eye movements. D) Ensuring there is no tympanic membrane perforation is important before performing the oculovestibular test to prevent water from entering the middle ear, which could cause complications.

Question 16

The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever "wake up." The nurse should consider which test when formulating a response to this concern?
A)Evoked potentials
B)CT scan
C)Electroencephalogram
D)Lumbar puncture

Accepted Answer

The answer of The family of a comatose patient asks...

Question 17

A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure.The nurse compares measurements to which critical normal value?
A)50 mm Hg
B)70 mm Hg
C)120 mm Hg
D)30 mm Hg

Accepted Answer

The normal range for cerebral perfusion pressure (CPP) is between 70-100 mm Hg. CPP is calculated by subtracting the intracranial pressure (ICP) from the mean arterial pressure (MAP). Monitoring CPP is crucial for patients with increased ICP, as it provides information about the adequacy of brain perfusion. A CPP less than 50 mm Hg can lead to cerebral ischemia, while a CPP greater than 150 mm Hg may result in cerebral edema and increased ICP. Therefore, the critical normal value for CPP is between 70-100 mm Hg.

Question 18

A nurse is monitoring a patient's Glasgow Coma Scale (GCS).At which point would the nurse document that the patient is comatose?
A)11
B)15
C)7
D)9

Accepted Answer

A GCS score of 7 or less indicates a comatose state. A score of 15 indicates full consciousness, while scores between 9-14 indicate varying degrees of altered mental status. Therefore, the correct choice is C.

Question 19

A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg.Which cerebral perfusion pressure would the nurse document for this patient?
A)50 mm Hg
B)90 mm Hg
C)70/40 mm Hg
D)40/70 mm Hg

Accepted Answer

The cerebral perfusion pressure (CPP) can be calculated by subtracting the intracranial pressure (ICP) from the mean arterial pressure (MAP).

CPP = MAP - ICP

Using the given values: 
CPP = 70 mm Hg - 20 mm Hg = 50 mm Hg

Therefore, the nurse would document a cerebral perfusion pressure of 50 mm Hg for this patient.

Question 20

A patient with a head injury is being monitored with an intraventricular catheter.The nurse would design interventions based on which priority patient problem?
A)There is a risk the patient's brain will be injured by the catheter.
B)Presence of the catheter alters the patient's intracranial adaptation capacity.
C)The catheter is painful for the patient.
D)There is a high risk for infection related to this catheter.

Accepted Answer

Intraventricular catheters, like any invasive device, pose a significant risk for infection, including meningitis or ventriculitis, which can be life-threatening. This risk makes infection prevention a priority in patient care planning.

Quiz 16: Determinants and Assessment of Cerebral Function

A patient was the unrestrained driver of a car that was struck head on by another vehicle.During initial assessment,the nurse observes another nurse using supraorbital pressure to assess for response.What nursing intervention is indicated?

A nurse is monitoring the intracranial pressure of a patient with a closed-head injury.Which pressure would the nurse evaluate as requiring no additional intervention?

The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain.The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?

A patient,admitted with the diagnosis of stroke,has left hemiparesis involving the face,arm,and leg.The nurse explains that this stroke most likely involves which artery?

The nurse is providing care for a patient who sustained a severe head injury.The nurse would intervene to prevent which occurrence that increases cerebral blood flow?

Following a stroke a patient is diagnosed with expressive aphasia.What nursing intervention is indicated?

A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times.What rationale would the nurse provide for this position?

A nurse is monitoring a patient who sustained a head injury.The nurse recognizes which finding as the earliest sign of change in neurologic status?

A nurse is preparing to conduct a neurological assessment on a patient who is not suspected of having neurological impairment.Which tests should the nurse perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient with an intraventricular catheter for the assessment of increased intracranial pressure (ICP) is demonstrating A waves.The nurse would assess for which other findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A nurse is starting an intravenous line in a patient being treated for a head injury.Suddenly the patient extends his legs and demonstrates extreme plantar flexion.What action should be taken by the nurse?

A nurse is assisting with a patient's oculocephalic and oculovestibular reflex assessment.How should the nurse prepare for this testing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever "wake up." The nurse should consider which test when formulating a response to this concern?

A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure.The nurse compares measurements to which critical normal value?

A nurse is monitoring a patient's Glasgow Coma Scale (GCS) .At which point would the nurse document that the patient is comatose?

A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg.Which cerebral perfusion pressure would the nurse document for this patient?

A patient with a head injury is being monitored with an intraventricular catheter.The nurse would design interventions based on which priority patient problem?